Exam 2 study questions

Question 1

The nurse has just measured an adult client’s oral temperature and obtained a result of 102.4ºF (39.1ºC). The client states, “I just finished my coffee right before you came in. Can I have another cup?” Which response by the nurse is most appropriate?

A) “I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return.”
B) “Before you drink another hot beverage, drink some cool water so I can obtain an accurate oral temperature.”
C) “I’ll be right back with your coffee and a different thermometer. I’m not sure this one measured your temperature correctly.”
D) “You will need to remain n.p.o. until I notify your primary health care provider about your increased temperature.”

Answer 1

Answer: A
“I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return.”

Question 2

During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant, true or false

Answer 2

True

Question 3

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will do what? 
A)  Decrease the blood glucose.  
B)  Decrease the respiratory rate.  
 C) Decrease the apical pulse.  
 D) Decrease the blood volume.

Answer 3

Answer: C

Decrease the apical pulse

Question 4

The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant’s pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant’s pulse rate?
A) The parents will not be able to check the pulse accurately, the nurse will need to have home health check on this infant on a periodic basis.
B) This infant will need a home cardiac monitor set up.
C) The parents should be encouraged to get a neighbor or family member to help them check their infant’s pulse.
D) The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant’s apical pulse.

Answer 4

Answer: D
The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant’s apical pulse.

Question 5

The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next?
A) Connect the client to the oxygen saturation monitoring device.
B) Ask another student nurse to check it for him.
C) Use the Doppler ultrasound device.
D) Use the Bell side of the stethoscope to listen.

Answer 5

Answer: C

Use the Doppler ultrasound device

Question 6

A client presents to the Emergency Department with a temperature of 100.6F and BP of 108/60 mm Hg. What intervention does the nurse anticipate providing?

A) cooling blanket
B) acetaminophen
C) oral fluids
D) ibuprofen

Answer 6

Answer: C

Oral Fluids

Question 7

A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?

A) “Dizziness can occur when baroreceptors overreact to the changes in BP.”
B) “Dizziness is caused by very low blood pressure when you lay down.”
C) “Dizziness when you change position can occur when fluid volume in the body is decreased.”
D) “Dizziness can occur due to changes in the hospital environment.”

Answer 7

Answer: C

“Dizziness when you change position can occur when fluid volume in the body is decreased.”