week 9 sherpath Flashcards
Place the steps in the order the nurse would follow when assessing a patient for infection or risk for infection.
Documentation of findings
Head-to-toe examination
Introduction of himself or herself
Collection of subjective data
Introduction of himself or herself
Collection of subjective data
Head-to-toe examination
Documentation of findings
Which question by the nurse specifically assesses the patient for infection or risk for infection?
“When was the last time you took an antibiotic?”
“Have you had a change in activity lately?”
Do you experience urinary pain or frequency?”
“Are you able to finish all of your daily meals?”
Do you experience urinary pain or frequency?”
Match the diagnostic test with the information that it provides.
Provides counts for RBCs, WBCs, platelets, and reticulocytes
Detects causative organism and determines effective antibiotic treatment
Provides the number of each type of WBC
Provides the overall number of all WBCs
Answer choices
White blood cell (WBC) count
Complete blood count (CBC)
Culture and sensitivity (c and S)
White blood cell (WBC) differential
Provides counts for RBCs, WBCs, platelets, and reticulocytes
Complete blood count (CBC)
Detects causative organism and determines effective antibiotic treatment
Culture and sensitivity (c and S)
Provides the number of each type of WBC
White blood cell (WBC) differential
Provides the overall number of all WBCs
White blood cell (WBC) count
Order white blood cells from most prevalent to least prevalent in the absence of infection.
Basophils
Neutrophils
Monocytes
Eosinophils
Lymphocytes
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Which white blood cells are responsible for the signs and symptoms of inflammation?
Neutrophils
Monocytes
Eosinophils
Basophils
Basophils
Match the type of inflammation with its description.
Limited to the area of site of injury
Involves multiple organs or tissues
Quickly severe, lasting only a few days
Prolonged response lasting months to years
Answer choices
Systemic inflammation
Localized inflammation
Chronic inflammation
Acute inflammation
Limited to the area of site of injury
Localized inflammation
Involves multiple organs or tissues
Systemic inflammation
Quickly severe, lasting only a few days
Acute inflammation
Prolonged response lasting months to years
Chronic inflammation
Which factors increase the older adult’s susceptibility to infections?
Select all that apply.
Decreased immune responses
Increased cortisol production
Decreased cough reflex
Incomplete bladder emptying
Reduced vascular supply
Excessive epidermal thickening
Decreased immune responses
Decreased cough reflex
Incomplete bladder emptying
Reduced vascular supply
Which potential infections would a nurse focus on when teaching preventive precautions to an immobile patient being discharged to home?
Select all that apply.
Skin infections
Cardiovascular infections
Urinary tract infections (UTIs)
Respiratory infections
Musculoskeletal infections
Skin infections
Urinary tract infections (UTIs)
Respiratory infections
Match the category of infection with its characteristics and example.
Develops rapidly (e.g., common cold)
Lasts months (e.g., mononucleosis)
Pain (e.g., pressure injury)
High fever (e.g., sepsis)
Answer choices
Acute infection
Chronic infection
Systemic infection
Localized infection
Develops rapidly (e.g., common cold)
Acute infection
Lasts months (e.g., mononucleosis)
Chronic infection
Pain (e.g., pressure injury)
Localized infection
High fever (e.g., sepsis)
Systemic infection
Which patient finding is indicative of a localized infection?
Tachycardia
Fatigue
Abscess
Chills
Abscess
Which techniques can the nurse use for collecting patient assessment data?
Select all that apply.
Performing a general assessment
Speaking with the patient’s family
Consulting the patient’s medical file
Performing the physical assessment
Obtaining a thorough history
Speaking with the patient’s roommate
Performing a general assessment
Speaking with the patient’s family
Consulting the patient’s medical file
Performing the physical assessment
Obtaining a thorough history
Which data collected during the nurse-patient interview is a subjective finding?
Bowel sounds active
Fatigue
Swollen left elbow
Blood pressure of 150/72 mm Hg
Fatigue
Which objective patient findings alert the nurse to the presence of infection or the risk for infection?
Select all that apply.
Pressure injuries
Enlarged lymph nodes
Hyperactive bowel sounds
Reports of pain
Decreased breath sounds
Pressure injuries
Enlarged lymph nodes
Hyperactive bowel sounds
Decreased breath sounds
Which blood test specifically assesses for the presence of an active inflammatory response?
White blood cell (WBC) count
Complete blood count (CBC)
Culture and sensitivity (C&S) test
Erythrocyte sedimentation rate (ESR)
Erythrocyte sedimentation rate (ESR)
Which laboratory finding is abnormal and must be reported to the health care provider?
White blood cell (WBC) count of 10,100 cells/mm3
Erythrocyte sedimentation rate (ESR) 20 mm/hr
Serum complement 140 hemolytic units
C-reactive protein of 0.9 mg/L
Serum complement 140 hemolytic units
Which symptoms are consistent with a chronic inflammatory disorder?
Redness, swelling, and pain to the ankle while playing basketball
Pain and fever from a streptococcal sore throat
Pain and swelling of the knees from arthritis
Discomfort from a strained back muscle
Pain and swelling of the knees from arthritis
Which symptoms are consistent with a chronic inflammatory disorder?
Redness, swelling, and pain to the ankle while playing basketball
Pain and fever from a streptococcal sore throat
Pain and swelling of the knees from arthritis
Discomfort from a strained back muscle
Pain and swelling of the knees from arthritis
Which patient has the most risk factors for developing an infection?
46-year-old recovering from elective noninvasive surgery
30-year-old with newly diagnosed early eating disorder
70-year-old with diabetes and an indwelling urinary catheter
50-year-old smoker who is receiving an intravenous antibiotic
70-year-old with diabetes and an indwelling urinary catheter
Which finding would lead the nurse to conclude that a patient’s surgical incision that was inflamed is now infected?
Greenish drainage
Warm to the touch
Swelling at the edges
Slightly red color
Greenish drainage
Which manifestations indicate systemic infection and warrant further patient assessment?
Select all that apply.
Blood pressure of 164/104 mm Hg
Temperature 101.3°F (38.5°C) orally
Heart rate 122 beats/min
Respiratory rate 16 breaths/min
Skin warm to touch and moist
Temperature 101.3°F (38.5°C) orally
Heart rate 122 beats/min
Which phrase describes medical asepsis?
Absence of all infectious agents
Procedure known as clean technique
Requires use of sterile gloves
Prevents microbial entry into body
Procedure known as clean technique
Which statement is correct regarding hand hygiene in the health care setting?
Soap and water effectively reduce microorganisms on visibly dirty hands.
Infectious agents are killed by soap and water when washing hands.
Washing hands with very hot water helps eliminate a greater number of bacteria.
Non–alcohol-based hand sanitizers inhibit microorganism growth on hands.
Soap and water effectively reduce microorganisms on visibly dirty hands.
An effective alcohol-based hand scrub must contain at least __ percent alcohol.
60
Match the situation to the type of personal protective equipment required.
Head cover
Goggles
Gloves
Gown
Answer choices
Surgery or labor and delivery
Protection from airborne microbes
Patient on transmission precautions
Sprays from respiratory droplets
Direct contact with body fluids
Head cover
Surgery or labor and delivery
Goggles
Sprays from respiratory droplets
Gloves
Direct contact with body fluids
Gown
Patient on transmission precautions
Place the personal protective equipment (PPE) in the order in which the nurse would remove them.
Shoe covers
Gown
Eyewear
Gloves
Mask
Gloves
Eyewear
Gown
Mask
Shoe covers
Which practices would be included by the nurse when teaching about standard precautions?
Select all that apply.
Hand hygiene
Cough etiquette
Patient cleanliness
Safe injection practices
Use of personal protective equipment (PPE)
Hand hygiene
Cough etiquette
Safe injection practices
Use of personal protective equipment (PPE)
Which precaution would the nurse take when handling needles (sharps) to prevent an accidental needlestick?
Recapping the needle after use
Using a needleless system whenever possible
Placing covered intravenous (IV) cannulas securely in the trash
Flushing needles with water before disposing of them
Using a needleless system whenever possible
As a member of the infection control committee, which action would the nurse suggest to help control transmission of respiratory infections among staff during influenza season?
Role model wearing gloves during patient care.
Speak to peers about obtaining their immunizations.
Teach hand hygiene to unlicensed assistive personnel.
Post signs in bathrooms demonstrating cough etiquette.
Post signs in bathrooms demonstrating cough etiquette.
Which transmission-based precaution would the nurse take for a seriously ill patient being admitted for influenza?
Avoid admitting through the reception area.
Admit to an airborne infection isolation room.
Obtain an N95 disposable respirator mask.
Provide a mask for the patient if leaving the room.
Provide a mask for the patient if leaving the room.
Which activities can a nurse easily participate in if interested in slowing infection transmission within the community?
Select all that apply.
Closing schools during influenza pandemics
Changing employer policies regarding sick leave
Participating in local handwashing campaigns
Working locally to encourage immunizations
Avoiding mass gatherings during flu season
Participating in local handwashing campaigns
Working locally to encourage immunizations
Which source is best for the nurse to recommend for patients interested in information about the updated immunization schedule for adults?
Their health care provider’s clinic or office
The Centers for Disease Control and Prevention (CDC) immunization website
Any health care provider at a local pharmacy
The US government website
The Centers for Disease Control and Prevention (CDC) immunization website
Which home care intervention helps reduce the transmission of infections?
Reporting infections as early as recognized
Using disposable dishes and utensils
Soaking clothing in bleach solution
Isolating the infected individual from others
Reporting infections as early as recognized
Which diseases can the federal government order patients to be isolated and/or quarantined for?
Select all that apply.
Smallpox
Human immunodeficiency virus (HIV)/Acquired - - immunodeficiency syndrome (AIDS)
Measles
Cholera
Yellow fever
Diphtheria
Smallpox
Cholera
Yellow fever
Diphtheria
Place in order the steps of establishing a sterile field.
Open sterile packages away from the body.
Do not turn away from the sterile field.
Don a facemask if required.
Perform thorough hand hygiene.
Establish the sterile field above waist level.
Don a facemask if required.
Perform thorough hand hygiene.
Establish the sterile field above waist level.
Open sterile packages away from the body.
Do not turn away from the sterile field.
Match the cleaning method with its use.
Germicide
Chemical sterilization
Physical sterilization
Disinfection
Answer choices
Cleans medical equipment and skin
Uses chlorhexidine
Process that uses steam or radiation
Process that uses gases
Germicide
Uses chlorhexidine
Chemical sterilization
Process that uses gases
Physical sterilization
Process that uses steam or radiation
Disinfection
Cleans medical equipment and skin
Which personal protective equipment (PPE) would the nurse don before observing a sterile procedure in the operating room?
Mask
Gown
Hair cover
Sterile gloves
Mask
Which actions would a nurse take when caring for a patient with cellulitis?
Select all that apply.
Implement wound care
Obtain a wound culture
Implement isolation precautions
Review the complete blood count
Administer antibiotics
Implement wound care
Obtain a wound culture
Review the complete blood count
Administer antibiotics
Which intervention would a nurse anticipate specifically for a patient suspected of meningitis?
Antibiotics
Lumbar puncture
Inputs and outputs
Complete blood count
Lumbar puncture
Which term describes the administration of a medication by a nurse?
Dependent intervention
Independent intervention
Interdependent intervention
Nurse-initiated intervention
Dependent intervention
Which phrases describe the purpose of hand hygiene?
Select all that apply.
Prevents the spread of infection
Breaks the chain of infection
Interrupts organism transmission
Enhances the patient relationship
Kills microorganisms
Prevents the spread of infection
Breaks the chain of infection
Interrupts organism transmission
Which step is first in the sequence for donning personal protective equipment (PPE)?
Hand hygiene
Head cover
Mask
Gown
Hand hygiene
Which infection would require a nurse to don a fitted N95 respiratory mask?
Tuberculosis
Influenza
Pneumonia
Methicillin-resistant Staphylococcus aureus (MRSA)
Tuberculosis
Which statements best describe the purpose for greeting the patient and explaining the need for personal protective equipment (PPE)?
Select all that apply.
Eases fear and misunderstanding
Creates a professional relationship
Builds a trusting relationship
Fulfills legal requirements
Eliminates later confusion
Eases fear and misunderstanding
Creates a professional relationship
Builds a trusting relationship
Which piece of personal protective equipment (PPE) would the nurse consistently don when anticipating that contact with a patient’s body secretions will be possible?
Gloves
Masks
Eyewear
Gown
Gloves
In which situation is it permissible for the nurse to use an alcohol-based hand sanitizer?
Before eating lunch or ingesting food
When hands are not visibly soiled
After use of the bathroom by the nurse
After known exposure to norovirus
When hands are not visibly soiled
Which behavior indicates the need for additional teaching after educating a patient about respiratory etiquette?
Using sanitizer hand wipes after sneezing
Dropping used tissues into a waste receptacle
Reusing tissues for a productive cough
Wearing a mask when leaving the room
Reusing tissues for a productive cough
Which nursing student’s note would the nurse correct?
Standard precautions used during bed, bath, and mouth care.
Education provided to patient about cough etiquette.
Location of site where injection was administered.
Patient performed a return demonstration on wound care using gloves.
Standard precautions used during bed, bath, and mouth care.
Which infection would prompt the nurse to implement contact precautions?
Hepatitis A
Streptococcal pneumonia
Influenza
Chickenpox
Hepatitis A
By which means are pathogens transmitted through droplets, requiring infected patients to be placed on protective precautions?
Select all that apply.
Coughing
Sneezing
Suctioning
Eating
Talking
Coughing
Sneezing
Suctioning
Talking
Which infection would require a patient to be admitted to the airborne infection isolation room?
Pharyngeal diphtheria
Meningococcal sepsis
Staphylococcus aureus
Varicella zoster
Varicella zoster
Match the transmission-based precaution with the mode of transmission it prevents.
Person to person
Coughing, sneezing
Suspended particles
Answer choices
Droplet
Airborne
Contact
Person to person
contact
Coughing, sneezing
droplet
Suspended particles
airborne
Match the type of transmission-based precaution with the infection for which it is implemented.
Herpes simplex virus (HSV)
Rubella
Rubeola
Answer choices
Airborne
Contact
Droplet
Herpes simplex virus (HSV)
Contact
Rubella
Droplet
Rubeola
airborne
Which type of action is the nurse taking to reduce the spread of infections by not going to work when sick?
Personal
Community
Home
Employee
Personal
Which action can communities engage in to help reduce infections among their citizens?
Encouraging and facilitating immunization programs
Providing containers for used needle disposal to patients
Assisting with health care environment modifications
Educating patients about home infection control measures
Encouraging and facilitating immunization programs
Which group(s) does the Centers for Disease Control and Prevention (CDC) apply the term quarantine to?
Select all that apply.
People
Animals
Cargo
Buildings
Institutions
People
Animals
Cargo
Buildings
Match the precaution with its corresponding description.
Separates sick and contagious people from others
Separates people exposed to a contagious disease
Separates people with weak immune systems
Answer choices
Isolation
Protective isolation
Quarantine
Separates sick and contagious people from others
isolation
Separates people exposed to a contagious disease
Quarantine
Separates people with weak immune systems
Protective isolation
Which medical asepsis interventions by the nurse directly protect the patient from infection?
Select all that apply.
Cleaning patient bedside equipment routinely
Disposing of used needles in sharps containers
Placing items wet from body fluids in biohazard bags
Providing leak-proof receptacles at bedside for tissues
Preventing contamination of intravenous sites and ports
Removing excess linens from the patient’s room
Cleaning patient bedside equipment routinely
Disposing of used needles in sharps containers
Providing leak-proof receptacles at bedside for tissues
Preventing contamination of intravenous sites and ports
Which actions are required by the nurse when preparing for a sterile procedure?
Select all that apply.
Keeping sterile surfaces dry
Setting up the sterile field
Leaving the room for supplies
Checking packaging integrity
Monitoring activities of others
Delegating preparations to unlicensed assistive personnel (UAP)
Keeping sterile surfaces dry
Setting up the sterile field
Checking packaging integrity
Monitoring activities of others
Which action would the nurse recognize as a breach in surgical asepsis that contaminated the sterile field?
Health care provider touched sterile field one-half inch from edge
Health care provider reached over sterile field to pick up a towel
Masked assistant talked over the sterile field
Sterile packages opened facing away from body
Health care provider reached over sterile field to pick up a towel
Which procedure is necessary for equipment being used to enter a sterile body cavity?
Sanitization
Disinfection
Sterilization
Decontamination
Sterilization
Which type of infection would a nurse suspect when caring for a patient who has a prescription for a Clostridium difficile test?
Respiratory tract infection
Urinary tract infection
Gastrointestinal infection
Cellulitis
Gastrointestinal infection
A nurse caring for a patient with an infection would anticipate a temperature less than_ _ °F when the infection has resolved.
100.4
Which actions by the nurse would be considered independent nursing interventions?
Select all that apply.
Counseling a patient
Administration of antibiotics
Repositioning a patient to enhance comfort
Participating in a patient care conference
Teaching a postoperative patient how to prevent surgical site infection
Counseling a patient
Repositioning a patient to enhance comfort
Teaching a postoperative patient how to prevent surgical site infection
Which part of the brain maintains a consistent internal body temperature despite environmental extremes?
Thalamus
Brainstem
Cerebellum
Hypothalamus
Hypothalamus
Which internal process provides the primary source of heat production?
Exercise
Hormones
Metabolism
Convection
Metabolism
Which mechanisms primarily enhance heat loss from the body?
Select all that apply.
Radiation
Digestion
Conduction
Convection
Evaporation
Radiation
Conduction
Convection
Evaporation
Infants under the age of
___ months have immature regulatory thermoregulation systems. Record answer as a whole number.
3
Which factors affect body temperature?
Select all that apply.
Stress
Height
Smoking
Hormones
Environment
Circadian rhythms
Stress
Smoking
Hormones
Environment
Circadian rhythms
Which assessment question would the nurse ask a patient prior to measuring temperature?
“Do you have a family history of fevers?”
“Have you exercised in the last 30 minutes?”
“How would you describe your body temperature?”
“At which site would you like me to take your temperature?”
“Have you exercised in the last 30 minutes?”
Match the characteristic with the correct temperature assessment site.
Most common site for measuring temperature
Measures core or deep tissue temperature
Tolerated by infants and young children
Very accurate reading but not preferred by patient
Answer choices
Rectal
Tympanic
Temporal
Oral
Most common site for measuring temperature
Oral
Measures core or deep tissue temperature
Tympanic
Tolerated by infants and young children
Temporal
Very accurate reading but not preferred by patient
Rectal
Which temperature range is expected for an adult patient?
99.4° to 99.7°F (37.4° to 37.6°C)
98° to 98.6°F (36.6° to 37°C)
93.2° to 96.8°F (34° to 36°C)
95.9° to 99.5°F (35.5° to 37.5°C)
95.9° to 99.5°F (35.5° to 37.5°C)
Which areas of the human body are most vulnerable to frostbite?
Select all that apply.
Toes
Wrists
Earlobes
Abdomen
Tip of nose
Toes
Earlobes
Tip of nose
Which cues would the nurse likely observe in a patient who has hyperthermia?
Select all that apply.
Dizziness
Hot skin
Cool, white skin
Rapid heart rate
Increased urinary output
Dizziness
Hot skin
Rapid heart rate
Which cues related to thermoregulation can be found in the medical record?
Select all that apply.
Results of white blood cell count
Presence of growth on a culture
Patient interview
Temperature readings on graphics
Levels of hormones
Results of white blood cell count
Presence of growth on a culture
Temperature readings on graphics
Levels of hormones
Which cues would prompt the nurse to select Fever as a hypothesis?
Select all that apply.
93°F (33.9°C)
Presence of infection
Chills
Anorexia
Dehydration
Cool skin
Presence of infection
Chills
Anorexia
Dehydration
Which patient would the nurse assess first?
One with heatstroke
One who has controlled diabetes
One with anorexia
One who has an infection
One with heatstroke
Which action would the nurse take after developing outcomes for a patient with a fever?
Determine goals with the patient.
Implement care.
Select solutions.
Check the chart for laboratory results.
Select solutions.
Which items would the nurse offer to a patient with a low body temperature?
Select all that apply.
Hot soup
Head coverings
Regular hot tea or coffee
Warmed blankets
Warmed intravenous fluids
Hot soup
Head coverings
Warmed blankets
Warmed intravenous fluids
Match the intervention with its mechanism of action.
Reduce metabolic demands and oxygen use
Identify the most effective antibiotics
Help meet the increased metabolic demands produced by fever
Replace losses from increased respirations and diaphoresis
Answer choices
Oxygen and nutrients
Laboratory tests
Oral and IV fluids
Sleep and rest
Reduce metabolic demands and oxygen use
Sleep and rest
Identify the most effective antibiotics
Laboratory tests
Help meet the increased metabolic demands produced by fever
Oxygen and nutrients
Replace losses from increased respirations and diaphoresis
Oral and IV fluid
Which nonpharmacologic interventions lower a patient’s fever?
Select all that apply.
Ice packs
Acetaminophen
Cooling pads
Cool sponge baths
Warmed blankets
Ice packs
Cooling pads
Cool sponge baths
Which mechanism of action would lower a patient’s temperature when taking antipyretics?
Increase prostaglandin production
Lower the hypothalamus set-point
Reduce heat-loss processes
Transfer of heat as waves or particles of energy
Lower the hypothalamus set-point
Which statement from the nurse indicates a correct interpretation of a higher temperature at 1830 when compared to the temperature at 1600?
“It is normal for temperatures to fluctuate from one hour to the next.”
“I should start taking the temperature every 30 minutes.”
“This is a typical response based on circadian rhythms.”
“This should be reported immediately to the health care provider.”
“This is a typical response based on circadian rhythms.”
Match the mechanism of heat loss to its intervention.
Cooling a patient with a fan
Positioning a patient close to a cold window
Placing a cool rag on the patient’s forehead
Checking the patient with a fever for diaphoresis
Answer choices
Evaporation
Radiation
Conduction
Convection
Cooling a patient with a fan
Convection
Positioning a patient close to a cold window
Radiation
Placing a cool rag on the patient’s forehead
Conduction
Checking the patient with a fever for diaphoresis
Evaporation
Which patient would the nurse monitor closely for alterations in temperature control?
One who requires assistance with activities of daily living
One who just received a series of x-rays for a broken leg during a sports game
One who is undergoing a routine wellness examination prior to an international flight
One who was admitted to the hospital after experiencing a cerebrovascular accident (stroke)
One who was admitted to the hospital after experiencing a cerebrovascular accident (stroke)
Which cues would the nurse likely observe in a patient who has a temperature of 92°F (33.3°C)?
Select all that apply.
Drowsiness
Muscle cramps
Excessive thirst
Pale, cool skin
Decreased urinary output
Drowsiness
Pale, cool skin
Decreased urinary output
Which statements from the nurse indicate a correct understanding of assessment sites for temperature?
Select all that apply.
“Rectal temperature readings are avoided for infants.”
“I can get an accurate tympanic temperature reading on an unconscious patient.”
“A patient who uses an oxygen mask may have an inaccurate temperature measurement - if taken by mouth.”
“I can get an accurate temperature reading by placing the thermometer to the right of the patient’s axilla.”
“I can use temperature-sensitive strips on the forehead for the patient who is diaphoretic.”
“Rectal temperature readings are avoided for infants.”
“I can get an accurate tympanic temperature reading on an unconscious patient.”
“A patient who uses an oxygen mask may have an inaccurate temperature measurement - if taken by mouth.”
Which action would the nurse take immediately after assessing a patient’s temperature to determine whether the patient has heat exhaustion or heatstroke?
Touch the patient’s skin.
Retake the patient’s temperature.
Start the prescribed antibiotic.
Obtain a culture and sensitivity test.
Touch the patient’s skin.
Place the steps in order when caring for a patient who is febrile.
Develop expected outcomes.
Select solutions for Fever.
Gather cues from the temperature assessment.
Reassess temperature to evaluate care for Fever.
Administer antipyretic.
Analyze cues to determine hypothesis of Fever.
Gather cues from the temperature assessment.
Analyze cues to determine hypothesis of Fever.
Develop expected outcomes.
Select solutions for Fever.
Administer antipyretic.
Reassess temperature to evaluate care for Fever.
Which interventions would the nurse select for a patient with hypothermia who was rescued from drowning in a freezing river?
Select all that apply.
Administer prescribed warmed intravenous fluids.
Apply several layers of warmed blankets.
Keep the patient’s wet clothing on to avoid heat loss.
Wrap warm, dry towels around the patient’s head.
Apply a cooling blanket to keep the body accustomed to the cold.
Administer prescribed warmed intravenous fluids.
Apply several layers of warmed blankets.
Wrap warm, dry towels around the patient’s head.
Which action by the nurse supports the hypothesis of Hypothermia when the patient presents with decreased respirations, cool skin, and low body temperature?
Ask the patient about feeling feverish.
Request laboratory work to check the patient’s iron levels.
Check the patient’s urinary output, which is increased.
Take the patient’s blood pressure, which shows hypotension.
Take the patient’s blood pressure, which shows hypotension.
Which statement from the nurse indicates appropriate clinical judgment in choosing a temperature assessment site?
“Because the patient has a low white blood cell count, I will not take a rectal temperature.”
“The unconscious patient will benefit the most from temperature readings taken via the oral route.”
“The older adult patient has been sipping on cool water because of dehydration, but an accurate oral temperature reading is still possible.”
“Because the pediatric patient is slightly perspiring, temperature measurement by the temporal artery on the forehead will be avoided.”
“Because the patient has a low white blood cell count, I will not take a rectal temperature.”
Which actions would the nurse take for a patient who has a fever?
Select all that apply.
Lower the room temperature.
Decrease stress level.
Encourage ambulation.
Monitor red blood cell count.
Review culture and sensitivity reports.
Lower the room temperature.
Decrease stress level.
Review culture and sensitivity reports.
Which patient temperature measurements would cause the nurse to intervene?
Select all that apply.
Newborn: 96°F (35.5°C)
6-year-old: 98.6°F (37°C)
15-year-old: 100°F (37.8°C)
Adult: 97.9°F (36.6°C)
Older adult: 93°F (33.9°C)
15-year-old: 100°F (37.8°C)
Older adult: 93°F (33.9°C)
Which instruction will the nurse give the parent who asks how much aspirin should be given to a 3-year-old with a viral infection?
“Follow the dosing on the label.”
Let the parent know the standard dose.
“Do not give the medication.”
“Use the dosage cup with the medication.”
“Do not give the medication.”
Which outcome would the nurse develop for a patient who is afebrile?
Patient’s temperature will return to expected range within 1 hour of treatment.
Patient’s temperature will be within the expected range until discharge.
Patient’s temperature will increase by 1° until within the expected range.
Patient’s temperature will decrease by 1° until within the expected range.
Patient’s temperature will be within the expected range until discharge.
Match each condition with its proper definition.
Exposure to extreme cold, resulting in low body temperature
Ice crystals form inside cells, causing tissue damage
Rise in body temperature above expected, caused by trauma or illness
High body temperature, caused by prolonged exposure to extreme heat
Answer choices
Hypothermia
Fever
Hyperthermia
Frostbite
Exposure to extreme cold, resulting in low body temperature
Hypothermia
Ice crystals form inside cells, causing tissue damage
Frostbite
Rise in body temperature above expected, caused by trauma or illness
Fever
High body temperature, caused by prolonged exposure to extreme heat
Hyperthermia
Which cues alert the nurse a patient with hypothermia is improving?
Select all that apply.
Temperature decreases.
Temperature increases.
Urinary output increases.
Blood pressure decreases.
Culture growth decreases.
Temperature increases.
Urinary output increases.
Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority.
Young adult with a fever
Older adult patient with a fever
Middle-aged adult with heatstroke
Teenager who is afebrile
Middle-aged adult with heatstroke
Older adult patient with a fever
Young adult with a fever
Teenager who is afebrile
Which cues alert the nurse that a patient with hyperthermia is declining?
Select all that apply.
Temperature increases.
Temperature decreases.
White blood cells decrease.
Heart rate increases.
Dizziness increases..
Temperature increases.
Heart rate increases.
Dizziness increases..
Which action would the nurse take when measuring the tympanic temperature of a 5-year-old?
Pull the ear down and back.
Pull the pinna up and back.
Angle the probe toward the umbilicus.
Angle the probe toward the forehead.
Pull the pinna up and back.
Which action would the nurse take when the unlicensed assistive personnel (UAP) reports an adult patient has a 99.5°F (37.5°C) temperature?
Recognize this is an expected finding.
Immediately notify the health care provider.
Tell the UAP to start taking the temperature every 1 hour.
Inform the family that the patient may be transferred.
Recognize this is an expected finding.
Which instruction would the nurse share with a male patient who calls the clinic and tells the nurse that over a 24-hour period he has taken two extra strength acetaminophen tablets (1000 mg) every 4 hours for a fever?
Acetaminophen is a drug that will reduce your fever.
Continue to take the drug.
This is too much acetaminophen.
You have probably damaged your liver.
This is too much acetaminophen.
When the nurse is reviewing medications, for which patients would the nurse need to notify the health care provider?
Select all that apply.
Patient with liver disease who is receiving acetaminophen
Patient with a fever who is receiving ibuprofen
Patient with an acetaminophen prescription for 3 grams/day
Patient who is taking an anticoagulant and aspirin for fever
Patient who has a bleeding disorder taking ibuprofen
Patient with liver disease who is receiving acetaminophen
Patient who is taking an anticoagulant and aspirin for fever
Patient who has a bleeding disorder taking ibuprofen
Match the intervention to its pathophysiologic cause.
Heat-loss processes outpace heat-generating processes
Heat-generating processes overcome heat-loss processes
Heat-loss processes equal heat-generating processes
Hypothalamus set-point is elevated
Answer choices
Administer antipyretics
Institute cooling measures
Institute rewarming measures
Use measures to maintain expected temperature
Heat-loss processes outpace heat-generating processes
Institute rewarming measures
Heat-generating processes overcome heat-loss processes
Institute cooling measures
Heat-loss processes equal heat-generating processes
Use measures to maintain expected temperature
Hypothalamus set-point is elevated
Administer antipyretics
Which site is the natural pacemaker of the heart?
Sinoatrial node
Atrioventricular node
Purkinje fibers
Internodal pathway
Sinoatrial node
Which explanation would the nurse make when discussing a patient’s cardiac output?
The number of heartbeats in 1 minute
The amount of blood the heart pumps per minute
The amount of time it takes for one cardiac cycle
The number of pulse sites that are palpable
The amount of blood the heart pumps per minute
Which pulse site would the nurse use that is the most definitive site to determine a patient’s cardiac health?
Apical
Radial
Peripheral
Carotid
Apical
Which factors can affect a patient’s heartbeat?
Select all that apply.
Fever
Hunger
Exercise
Medications
Hypovolemia
Fever
Exercise
Medications
Hypovolemia
Which questions would the nurse ask a patient before performing a pulse assessment?
Select all that apply.
Do you smoke?
What medications do you take?
Are your hands or feet swollen?
Do you experience shortness of breath?
Have you engaged in any type of exercise in the past 90 minutes?
Do you smoke?
What medications do you take?
Are your hands or feet swollen?
Do you experience shortness of breath?
In which instances would the nurse listen to an apical pulse?
Select all that apply.
If the patient has a palpable peripheral pulse
If the patient has weak heart contractions
When the patient’s pedal pulse is difficult to palpate
When the patient’s radial pulse is 86 and irregular
When a medication may alter the patient’s cardiac function
If the patient has weak heart contractions
When the patient’s radial pulse is 86 and irregular
When a medication may alter the patient’s cardiac function
Match the pulse site with its location.
Either side of the neck
Either side of the forehead
Inner aspect of the arm
Inside the wrist
Answer choices
Brachial
Radial
Pedal
Temporal
Apical
Carotid
Either side of the neck
Carotid
Either side of the forehead
Temporal
Inner aspect of the arm
Brachial
Inside the wrist
Radial
Match the expected pulse parameters with the appropriate age group.
Newborn (awake or asleep)
6-year-old
15-year-old
Adult
Answer choices
80–180
75–110
50–90
60–100
Newborn (awake or asleep)
80–180
6-year-old
75–110
15-year-old
50–90
Adult
60–100
Which conditions would be likely to cause tachycardia?
Select all that apply.
Beta blocker medication
Sleep
Anemia
Bronchodilator medication
Drop in blood pressure
Athletic fitness level
Anemia
Bronchodilator medication
Drop in blood pressure
Which actions would the nurse perform to obtain patient observation cues for pulse?
Select all that apply.
Interview the patient
Check laboratory results for the patient’s calcium level
Visually inspect the patient for alterations
Review the patient’s baseline on the graphic/flow sheet
Read the nurse’s notes about the patient’s pulse
Interview the patient
Visually inspect the patient for alterations
Which hypothesis would the nurse develop for an adult patient who has a pulse rate of 40 and is sluggish and confused?
Tachycardia
Bradycardia
Risk for Bradycardia
Heart Rate Within Normal Limits
Bradycardia
Which adult patient would the nurse assess first?
One with heart disease
One with tachycardia
One with stable breathing
One with patent (open) airway
One with tachycardia
Which solution would the nurse consider for a patient with bradycardia?
Suggest activities to increase the heart rate.
Administer medications to slow the heart rate.
Encourage measures to stabilize heart rhythm.
Document patient’s pulse rate alteration will resolve.
Suggest activities to increase the heart rate.
Which actions would a nurse take for a patient who has tachycardia from low fluid volume?
Select all that apply.
Administer prescribed fluid replacement.
Administer diuretic medication.
Administer prescribed oxygen.
Prepare patient for an emergency pacemaker insertion.
Prepare patient for an electrocardiogram.
Administer prescribed fluid replacement.
Administer prescribed oxygen.
Prepare patient for an electrocardiogram.
Which treatment option would the nurse anticipate for a patient with bradycardia whose pulse continues to decrease?
Discontinue continuous monitoring.
Prepare patient for an emergency pacemaker.
Transfer patient to a long-term care facility.
Consult a physical therapist.
Prepare patient for an emergency pacemaker.
Teach patient to move extremities periodically
Encourage oral intake
Assess heart sounds
Balance periods of rest and exercise
Answer choices
Tissue perfusion
Fluid volume
Activity
Cardiac output
Teach patient to move extremities periodically
Tissue perfusion
Encourage oral intake
Fluid volume
Assess heart sounds
Cardiac output
Balance periods of rest and exercise
Activity
List the electrical impulse for the conduction cycle in the heart, beginning with the natural pacemaker.
Right and left bundle branches
Bundle of His
Internodal pathway
Atrioventricular node
Purkinje fibers
Sinoatrial node
Sinoatrial node
Internodal pathway
Atrioventricular node
Bundle of His
Right and left bundle branches
Purkinje fibers
Match the numeric value the nurse would document for each pulse description.
Normal pulse, able to palpate with normal pressure
Bounding pulse, may be able to see pulsation
Weak and thready, difficult to palpate
Absent pulse
Answer choices
1+
3+
2+
0
Normal pulse, able to palpate with normal pressure
2+
Bounding pulse, may be able to see pulsation
3+
Weak and thready, difficult to palpate
1+
Absent pulse
0
Which factors would the nurse consider when the patient’s pulse rate is decreased?
Select all that apply.
Age
Stress
Hypoxia
Hypovolemia
Hypothyroidism
Age
Hypothyroidism
At which site would the nurse assess the patient’s apical pulse?
Thumb side of the wrist
Left fifth and sixth intercostal space
Right midclavicular line
Simultaneously on both sides of the neck
Left fifth and sixth intercostal space
Which actions would the nurse take for a patient who develops tachycardia with dizziness and lightheadedness from hypovolemia?
Select all that apply.
Raise the head of the bed.
Slowly ambulate the patient.
Offer noncaffeinated beverages.
Administer fluid replacement.
Monitor potassium and calcium levels.
Offer noncaffeinated beverages.
Administer fluid replacement.
Monitor potassium and calcium levels.
Which action would the nurse take after obtaining a patient’s regular radial pulse rate of 45 in 30 seconds?
Document the appropriate heart rate.
Take the radial pulse for 1 full minute.
Find the point of maximal impulse.
Notify the health care provider immediately.
Document the appropriate heart rate.
Which factors would the nurse consider for an elevated heart rate in a 78-year-old patient who had surgery 1 day prior and currently has a temperature of 102°F (38.9°C) and the nurse is having a difficult time obtaining a blood pressure?
Select all that apply.
Pain
Older age
Fever
Exercise
A drop in blood pressure
pain
fever
A drop in blood pressure
Match the pulse site to when each site is assessed by the nurse.
To check pulse during cardiopulmonary resuscitation (CPR) or cardiac arrest
To measure blood pressure
To determine discrepancies with radial pulse
To assess circulation to the foot
Answer choices
Dorsalis pedis
Brachial
Apical
Carotid
To check pulse during cardiopulmonary resuscitation (CPR) or cardiac arrest
Carotid
To measure blood pressure
Brachial
To determine discrepancies with radial pulse
Apical
To assess circulation to the foot
Dorsalis pedis
Which action would the nurse take to obtain a patient’s apical pulse?
Place a cooled stethoscope on the chest.
Turn the patient to the right side.
Listen at the angle of Louis.
Count “lub-dub” as one beat.
Count “lub-dub” as one beat.
Which patient pulse rates would the nurse report as unexpected (abnormal)?
Select all that apply.
150 for a newborn
52 for an older adult
90 for a 6-year-old
110 for a 15-year-old
180 for a 1-year-old
52 for an older adult
110 for a 15-year-old
180 for a 1-year-old
Which short-term outcome would the nurse develop for a patient experiencing a decreased heart rate?
Patient will exhibit pulse rate within expected range after 12 hours of beginning prescribed interventions.
Patient will maintain capillary refill to fingers/toes, skin color, skin integrity, and skin temperature of extremities at the 2-week follow-up appointment.
Patient will maintain adequate fluid volume within 8 hours.
Patient will exhibit good tissue perfusion.
Patient will exhibit pulse rate within expected range after 12 hours of beginning prescribed interventions.
Which pulse site would the nurse check when an infant appears lifeless?
Carotid
Femoral
Brachial
Popliteal
Brachial
In which patient instances would the nurse use a Doppler unit to assess pulse?
Select all that apply.
34-year-old patient with an irregular heart rhythm
56-year-old morbidly obese patient with hardening of the arteries
45-year-old patient with intestinal problems
62-year-old patient with obstructed blood vessels in the feet
26-year-old patient with poor circulation in the lower extremities
56-year-old morbidly obese patient with hardening of the arteries
62-year-old patient with obstructed blood vessels in the feet
26-year-old patient with poor circulation in the lower extremities
Which actions would the nurse take when the nurse finds the following pulse rates on the flow sheet: 86, 94, 100, 105, 110?
Select all that apply.
Reassess cardiac system.
Perform a head-to-toe assessment.
Review medications.
Notify the health care provider.
Monitor heart rate every 4 hours.
Review electrolyte levels.
Reassess cardiac system.
Perform a head-to-toe assessment.
Review medications.
Notify the health care provider.
Review electrolyte levels.
What heart rate would the nurse record for a patient’s heart rate of 46 beats in 30 seconds?
____ Beats/min
92
Which information would the nurse share about a Holter monitor with a patient who is suffering from arrhythmias and has fainting spells?
This test will monitor your heart rate and rhythm just during sleep.
This test utilizes a portable device attached to the chest by electrodes.
It is an implantable device that is surgically inserted under the skin to continuously monitor the heart’s activity.
It is a device intended to convert life-threatening arrhythmias of the heart to normal sinus rhythm.
This test utilizes a portable device attached to the chest by electrodes.
Which conditions would prompt the nurse to consider a hypothesis of Bradycardia?
Select all that apply.
Hypothermia
Beta blocker administration
Increased intracranial pressure
Hyperthyroidism
Overexertion
Hypothermia
Beta blocker administration
Increased intracranial pressure
Which cues would the nurse assess for in an adult patient with bradycardia?
Select all that apply.
Pulse rate 125
Sluggish
Lethargic
Confused
Bronchodilator prescription
Sluggish
Lethargic
Confused
Which finding would the nurse observe in an adult patient with Bradycardia who is improving?
Pulse rate increases to 110.
Pulse rate decreases from 60 to 50.
Reflexes increase.
Responses decrease.
Reflexes increase.
Which actions would the nurse take for a patient who has Impaired Cardiac Function caused by overhydration and edema?
Select all that apply.
Encourage oral fluid intake.
Elevate legs when at rest.
Check peripheral pulses.
Balance periods of rest and exercise.
Assess heart sounds.
Elevate legs when at rest.
Check peripheral pulses.
Balance periods of rest and exercise.
Assess heart sounds.
Match the pulse site the nurse would use to assess each pulse.
Medial surface of both ankles
Behind both knees
On top of both feet
By the groin on both sides
Answer choice
Popliteal
Posterior tibial
Apical
Pedal
Femoral
Temporal
Medial surface of both ankles
Posterior tibial
Behind both knees
Popliteal
On top of both feet
Pedal
By the groin on both sides
Femoral
Which actions would the nurse take for a patient with tachycardia and atrial fibrillation whose pulse continues to increase?
Select all that apply.
Notify health care provider.
Assist with electrical cardioversion.
Transfer to intensive care unit.
Prepare to insert an emergency pacemaker.
Suggest a consult with a cardiologist.
Initiate cardiopulmonary resuscitation (CPR).
Notify health care provider.
Assist with electrical cardioversion.
Transfer to intensive care unit.
Suggest a consult with a cardiologist.
Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority.
Older adult patient with chronic heart disease
Adult patient with heart rate of 180
Older adult patient with no respirations
Middle-aged patient with a heart rate of 65
Older adult patient with no respirations
Adult patient with heart rate of 180
Older adult patient with chronic heart disease
Middle-aged patient with a heart rate of 65
Which definition of breathing is accurate?
The exchange of oxygen between alveoli and red blood cells
The movement of red blood cells carrying oxygen to tissues and cells
The movement of oxygen in and out of the lungs, or inhaling and exhaling
The active, conscious effort of moving the lungs and chest wall
The movement of oxygen in and out of the lungs, or inhaling and exhaling
Match the stimulus or action to its corresponding physiologic receptor site.
Chemoreceptors in aortic arch, carotid arteries
Receptors in medulla
Receptors in lungs and muscles
Chemoreceptors located throughout the body
Answer choices
React to high levels of carbon dioxide
Stimulate respiratory centers in medulla and pons
Provide stretch input to medulla and pons
React to hypoxemia
Chemoreceptors in aortic arch, carotid arteries
React to hypoxemia
Receptors in medulla
React to high levels of carbon dioxide
Receptors in lungs and muscles
Provide stretch input to medulla and pons
Chemoreceptors located throughout the body
Stimulate respiratory centers in medulla and pons
In which primary area of the lung does carbon dioxide transfer (diffusion) occur?
Nose
Alveoli
Trachea
Bronchioles
Alveoli
Which factors affect respirations?
Select all that apply.
Exercise
Appetite
Diseases
Fear
Acid-base balance
Exercise
Diseases
Fear
Acid-base balance
Which questions would the nurse ask before taking a patient’s respirations?
Select all that apply.
Have you exercised within the last 30 minutes?
Do you vape?
Have you taken any pain medication?
Do you have any shortness of breath?
Have you had anything cold to drink?
Do you vape?
Have you taken any pain medication?
Do you have any shortness of breath?
Match the respiratory rate to its corresponding age group.
Newborn
1-year-old
6-year-old
Older adult
Answer choices
15–20
20–24
24–38
22–30
Newborn
24-38
1-year-old
22-30
6-year-old
20-24
Older adult
15-20
Which breathing pattern would the nurse suspect when a patient is breathing 8 breaths/min?
Hyperventilation
Tachypnea
Bradypnea
Apnea
Bradypnea
Which observation would the nurse observe in a patient who has Cheyne-Stokes respirations?
Absence of breathing
Respirations that are deep, exaggerated, regular, and increased in rate
Rhythmic respirations, going from very deep to very shallow or apneic periods
Respirations that are extremely shallow for two or three breaths, followed by an irregular period of apnea
Rhythmic respirations, going from very deep to very shallow or apneic periods
Which cues would the nurse obtain from the medical records about respiration and oxygenation?
Select all that apply.
Vital signs from the graphics
Medication records
Chronic obstructive pulmonary disease (COPD) from the history
Baselines from the vital signs flow sheet
Answers to questions before taking respirations
Vital signs from the graphics
Medication records
Chronic obstructive pulmonary disease (COPD) from the history
Baselines from the vital signs flow sheet
Match the respiration hypothesis to its cause.
Difficulty breathing
Excess of carbon dioxide exhaled
Respiratory center in the brain shuts down
Alterations in patterns, rate, depth, quality, and/or rhythm
Answer choices
Apnea
Hyperventilation
Impaired Breathing
Dyspnea
Difficulty breathing
Dyspnea
Excess of carbon dioxide exhaled
Hyperventilation
Respiratory center in the brain shuts down
Apnea
Alterations in patterns, rate, depth, quality, and/or rhythm
Impaired Breathing
Which adult patient would the nurse assess first?
Patient’s airway occluded
Patient breathing 32 breaths/min
Patient exhibiting Kussmaul breathing
Patient who is hyperventilating
Patient’s airway occluded
Which goal would the nurse develop for a patient with an elevated respiratory rate?
Patient’s respiratory rate improves.
Patient’s respiratory rate will return to expected levels 1 hour after treatment.
Patient will be taught to use pursed-lip breathing.
Patient’s oxygen saturation level will decrease.
Patient’s respiratory rate improves.
Which finding would indicate to the nurse that an adult patient with Hyperventilation is improving?
Respiratory rate decreasing
Regular respirations on a ventilator
Breaths increasing
Lightheadedness increasing
Respiratory rate decreasing
Which finding would alert the nurse that an adult patient with dyspnea is declining?
Respiratory rate of 18
Oxygen saturation 96%
Painless respirations
Accessory muscle use increasing
Accessory muscle use increasing
Which actions would the nurse take for a disoriented patient who “can’t catch a breath” and has a respiratory rate of 32?
Select all that apply.
Lower the head of the bed.
Apply prescribed oxygen.
Offer emotional support.
Reorient patient.
Monitor vital signs every 4 hours.
Apply prescribed oxygen.
Offer emotional support.
Reorient patient
Which breathing pattern would the nurse assess for in a patient who has a fever, anxiety, and a respiratory disorder?
Bradypnea
Tachypnea
Hypoventilation
Kussmaul breathing
Tachypnea
Which alterations would the nurse anticipate in an older adult patient who is having shortness of breath, can only breathe if in a sitting position, and has a current respiratory rate of 28?
Select all that apply.
Eupnea
Apnea
Dyspnea
Tachypnea
Orthopnea
Dyspnea
Tachypnea
Orthopnea
Which oxygen saturation sites would the nurse select for an adult patient who has decreased perfusion in the fingers and hand?
Select all that apply.
Finger
Earlobe
Foot
Nose
Toe
Earlobe
Nose
Toe
Which expected outcome would the nurse develop for a patient with altered respiration and oxygenation?
Patient is able to perform activities with some shortness of breath.
Patient demonstrates regular rate and depth of respirations before discharge.
Patient demonstrates irregular breathing after treatment.
Patient will have a respiratory rate between 12 and 20 breaths/min.
Patient demonstrates regular rate and depth of respirations before discharge.
What respiratory rate would the nurse document for a rate of 12 breaths in 30 seconds? Record your answer as a whole number.
____ breaths/min
24
Which actions to improve oxygenation would the nurse take for a patient who has dyspnea, confusion, lung secretions, and hypoxia?
Select all that apply.
Reposition the patient to a sitting position.
Suction the patient’s airway.
Apply prescribed supplemental oxygen to the patient.
Encourage the patient to use accessory muscles.
Reposition the pulse oximeter on the patient’s finger
Reposition the patient to a sitting position.
Suction the patient’s airway.
Apply prescribed supplemental oxygen to the patient
Which technique would the nurse use to obtain a patient’s respiratory rate?
Tell the patient, “I am here to count your respirations.”
Count inhalation and exhalation as one breath.
If respirations are irregular, count for 30 seconds.
Remove hand from patient’s wrist.
Count inhalation and exhalation as one breath.
Which factors would the nurse consider are causing a patient’s tachypnea?
Select all that apply.
Afebrile
A smoker
Reports of chest pain
Receiving bronchodilators
Cardiovascular disease
A smoker
Reports of chest pain
Cardiovascular disease
What is the expected respiratory rate (breaths per minute) for an adult patient? Record your answers as whole numbers separated by a hyphen.
___ breaths/min
12-20
Which patient respiratory rates (breaths/minute) would the nurse report as unexpected (abnormal)?
Select all that apply.
Newborn: 30
15-year-old: 26
Older adult: 10
Adult: 28
1-year-old: 50
15-year-old: 26
Older adult: 10
Adult: 28
1-year-old: 50
Which hypothesis would the nurse select for a patient who has ascites, painful breathing, and a subjective feeling of shortness of breath?
Apnea
Dyspnea
Hyperventilation
Impaired Breathing
Dyspnea
Which information would the nurse share with a patient who has rapid, deep breaths, feels faint, and has tingling in fingers?
Inhale through pursed lips.
Take slow, shallow breaths.
Try to make the abdomen move out during inhalation.
Use this continuous positive airway pressure mask.
Try to make the abdomen move out during inhalation.
Which cues would the nurse categorize as irrelevant for a patient’s respiration and oxygenation?
Select all that apply.
Has an irregular, increased respiratory rate
Had prostate surgery 7 years ago
Has trained intensively to run cross country
Has been a teacher for 25 years
Has a history of diabetes
Had prostate surgery 7 years ago
Has been a teacher for 25 years
Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority.
Patient with cessation of breathing and no pulse
Patient with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of 90%
Patient with a respiratory rate of 8
Patient with Kussmaul breathing
Patient with cessation of breathing and no pulse
Patient with a respiratory rate of 8
Patient with Kussmaul breathing
Patient with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of 90%
Which parameter would the nurse assess to determine quality of respirations?
Whether respirations are regular or irregular
Whether respirations are shallow or deep
Whether respirations are labored or nonlabored
Whether respirations are above or below expected ranges
Whether respirations are labored or nonlabored
Which action would the nurse take for a patient with apnea who is not responding to treatment?
Teach diaphragmatic breathing.
Assist with placement on a ventilator.
Consult an occupational therapist.
Monitor respiratory rate every 2 hours.
Assist with placement on a ventilator.
Which conditions would prompt the nurse to observe for Cheyne-Stokes respirations?
Select all that apply.
Increased intracranial pressure
Impending death
Diabetic ketoacidosis
Meningitis
High altitude
Increased intracranial pressure
Impending death
Trace the sequence of events that occurs during the oxygen transport cycle.
Oxygen is released to the body’s cells.
Oxygen is breathed into the lungs.
Oxygen is perfused through the arteries.
Oxygen diffuses across the alveoli.
Oxygen binds to hemoglobin.
Oxygen is breathed into the lungs.
Oxygen diffuses across the alveoli.
Oxygen binds to hemoglobin.
Oxygen is perfused through the arteries.
Oxygen is released to the body’s cells.
Which actions would the nurse take when finding the following respiratory rates on the flow sheet: 20, 16, 12?
Select all that apply.
Reassess respiratory system.
Perform a head-to-toe assessment.
Review medications.
Notify the health care provider.
Monitor respiratory rate every 4 hours.
Obtain an oxygen saturation measurement.
Reassess respiratory system.
Perform a head-to-toe assessment.
Review medications.
Notify the health care provider.
Obtain an oxygen saturation measurement.
Which finding would alert the nurse a newborn with impaired breathing is declining?
Nasal flaring
Pink skin
SpO2 95%
Respiratory rate 35
Nasal flaring
Which outcome would the nurse develop for a patient experiencing bradypnea?
Patient will exhibit an expected respiratory rate within 1 hour of treatment.
Patient will maintain respiratory rate for the next 8 hours.
Patient will maintain skin color, oxygen saturation level, and orientation level at the follow-up appointment.
Patient will exhibit adequate respiration and oxygenation levels.
Patient will exhibit an expected respiratory rate within 1 hour of treatment.
Match the breathing pattern the nurse would report for each patient.
Patient with rapid, deep, regular respirations
Patient with two or three shallow breaths followed by apnea
Patient with decreased respiratory rate
Patient with pattern of deep to shallow to apneic periods that repeats
Answer choices
Biot breathing
Kussmaul breathing
Cheyne-Stokes respirations
Bradypnea
Patient with rapid, deep, regular respirations
Kussmaul breathing
Patient with two or three shallow breaths followed by apnea
Biot breathing
Patient with decreased respiratory rate
Bradypnea
Patient with pattern of deep to shallow to apneic periods that repeats
Cheyne-Stokes respirations
Which factors can compromise an oxygen saturation reading?
Select all that apply.
Jaundice
Respiratory rate
Peripheral edema
Some fingernail polishes
Cold or injury to extremities
Jaundice
Peripheral edema
Some fingernail polishes
Cold or injury to extremities
Which information is accurate about blood pressure?
Blood pressure is measured by subtracting the diastolic from the systolic pressure.
The numerator is the diastolic pressure.
Blood pressure is the force against the venous walls.
The heart exerts maximum pressure during contractions.
The heart exerts maximum pressure during contractions.
Match the blood vessel or mechanism of blood pressure regulation to its function.
Controls delivery of blood to organs, tissues, and cells
Manages mechanisms used for short-term blood pressure regulation
Allows a continuous flow of blood into capillaries
Releases in response to low blood pressure to retain water
Answer choices
Arterioles
Antidiuretic hormone
Arteries
Autonomic nervous system
Controls delivery of blood to organs, tissues, and cells
Arteriole
Manages mechanisms used for short-term blood pressure regulation
Autonomic nervous system
Allows a continuous flow of blood into capillaries
Arteries
Releases in response to low blood pressure to retain water
Antidiuretic hormone
Which factors increase blood pressure?
Select all that apply.
Shock
Head injury
Weight gain
Vasodilation
Acute pain
Head injury
Weight gain
Acute pain
Which area is the most common site for a blood pressure measurement?
Wrist
Lower leg
Upper leg
Upper arm
Upper arm
Which questions would the nurse ask the patient before measuring blood pressure?
Select all that apply.
Are you in pain?
Do you feel stressed?
Have you exercised within the past 5 minutes?
Have you consumed any caffeine in the last 30 minutes?
Have you been to physical therapy within the past 15 minutes?
Do you continuously monitor your blood glucose levels with a device on your arm?
Are you in pain?
Do you feel stressed?
Have you consumed any caffeine in the last 30 minutes?
Have you been to physical therapy within the past 15 minutes?
Do you continuously monitor your blood glucose levels with a device on your arm?
Which blood pressure measurement is an unexpected finding?
Newborn: 70/40
6-year-old: 90/60
15-year-old: 110/68
Adult: 128/84
Adult: 128/84
Match the blood pressure measurement to its classification.
Hypertension stage 1
Elevated
Hypertension stage 2
Answer choices
<80 diastolic with systolic 120–129
<120 systolic
130–139 systolic
≥90 diastolic
Hypertension stage 1
130–139 systolic
Elevated
<80 diastolic with systolic 120–129
Hypertension stage 2
≥90 diastolic
Which cue would alert the nurse that a patient may be experiencing orthostatic hypotension?
Patient feels faint upon position change.
Blood pressure increases when patient stands.
Patient experiences paralysis in legs.
Blood pressure remains constant during transfers.
Patient feels faint upon position change.
Which action would the nurse take to obtain patient observation cues to determine blood pressure alterations?
Question the patient.
Review the patient’s blood pressure on the graphic.
Check the patient’s medication record.
Read the patient’s history in the chart.
Question the patient.
Match the hypothesis to its pathophysiologic cause.
Hypovolemia and decreased cardiac output
Peripheral vasodilation with no compensation
Thickened arteries that reduce compliance
Answer choices
Hypotension
Postural hypotension
Hypertension
Hypovolemia and decreased cardiac output
Hypotension
Peripheral vasodilation with no compensation
Postural hypotension
Thickened arteries that reduce compliance
Hypertension
Which patient situation would the nurse assess first?
Absence of breathing
Hypotension
Hypertension
Orthostatic hypotension
Absence of breathing
Which outcome would the nurse develop for a patient with hypotension?
Patient’s low blood pressure resolves.
Patient’s vital signs will be within expected ranges.
Patient’s blood pressure will return to expected ranges 2 hours after treatment.
Patient will return to previous levels of functioning.
Patient’s blood pressure will return to expected ranges 2 hours after treatment.
Which finding alerts the nurse that a patient with hypertension is improving?
Salt intake increases.
Weight increases.
Nose bleeds decrease.
Exercising decreases.
Nose bleeds decrease.
Which action would the nurse take for a patient with hypotension?
Apply oxygen.
Increase salt intake.
Restrict fluid.
Ambulate patient.
Apply oxygen.
Which patient care strategy would the nurse take for a patient with worsening orthostatic hypotension?
Emphasize the importance of restricting fluids.
Perform a head-to-toe assessment.
Review the white blood cell count.
Prepare to transfer to intensive care unit.
Perform a head-to-toe assessment.
Which description would the nurse use when discussing stroke volume?
The elasticity of the arterial system
The amount of pressure in the arteries in between beats
The numeric difference between systolic and diastolic pressure
The amount of blood injected into the arterial system with each heartbeat
The amount of blood injected into the arterial system with each heartbeat
Which cues would the nurse observe in a patient with a blood pressure of 60/40 and shock?
Select all that apply.
Clammy skin
Thready pulse
Increased urinary output
Confusion
Bradycardia
Clammy skin
Thready pulse
Confusion
Which statements indicate the nurse understands possible errors in blood pressure assessment?
Select all that apply.
“A noisy environment can cause a false low reading.”
“If the cuff is too wide, a false high reading is possible.”
“If pressure is released too slowly, a false high reading is possible.”
“A patient’s arm should be above heart level to avoid a false low reading.”
“Reinflating the cuff bladder before it has completely deflated can cause a false high measurement.”
“A noisy environment can cause a false low reading.”
“If pressure is released too slowly, a false high reading is possible.”
“Reinflating the cuff bladder before it has completely deflated can cause a false high measurement.”
Which factor would the nurse suspect is causing the blood pressure to fall when a patient who experienced a myocardial infarction (heart attack) is becoming cool and clammy?
Extreme vasodilation
Increased blood volume
Decreased cardiac output
Increased peripheral vascular resistance
Decreased cardiac output
Match the type of hypertension to its description.
No known cause
Caused by a specific disease
Systolic blood pressure over 140
Diastolic blood pressure 80–89
Answer choices
Hypertension stage 3
Hypertension stage 1
Primary hypertension
Hypertension stage 2
Secondary hypertension
No known cause
Primary hypertension
Caused by a specific disease
Secondary hypertension
Systolic blood pressure over 140
Hypertension stage 2
Diastolic blood pressure 80–89
Hypertension stage 1
Which action by the nurse when caring for a patient with a left mastectomy would cause the charge nurse to intervene?
Takes the blood pressure in the left arm
Uses a cuff width that is 40% of the circumference of the arm
Listens for the first Korotkoff sound to record as the systolic pressure
Makes sure the cuff bladder is 60% to 80% of the arm circumference
Takes the blood pressure in the left arm
Which interventions would the nurse implement to help an obese adult patient who smokes cigarettes successfully manage hypertension?
Select all that apply.
Arranging for nutritional support
Encouraging cessation of smoking
Monitoring responses to prescribed antihypertensive medications
Comparing current blood pressure readings to original readings
Listening while the patient expresses gratitude for care
Arranging for nutritional support
Encouraging cessation of smoking
Monitoring responses to prescribed antihypertensive medications
Which site would the nurse use to measure blood pressure when the patient’s upper body is severely burned?
Popliteal
Brachial
Radial
Femoral
Popliteal
Which adult patient’s blood pressure reading would the nurse realize is unexpected?
100/60
116/78
96/64 to 118/74
108/70 to 118/79
96/64 to 118/74
What is the patient’s pulse pressure (mm Hg) when the blood pressure is 130/70? Record your answer as a whole number.
__ mm Hg
60
Which actions would the nurse take when manually measuring the patient’s brachial blood pressure?
Select all that apply.
Deflate cuff at a rate of 2 mm Hg/second.
Inflate cuff 30 mm Hg above the previous systolic reading.
Place cuff loosely around the upper arm.
Position cuff 2.5 cm (1 inch) above the antecubital fossa.
Allow the patient to sit and cross legs.
Deflate cuff at a rate of 2 mm Hg/second.
Inflate cuff 30 mm Hg above the previous systolic reading.
Position cuff 2.5 cm (1 inch) above the antecubital fossa.
For which patients would the nurse measure blood pressure with an electronic device?
Select all that apply.
Has a regular heartbeat
Is shivering
Experiences seizure activity
Has a previous systolic blood pressure reading of 86 mm Hg
Has a previous systolic blood pressure reading of 140 mm Hg
Has a regular heartbeat
Has a previous systolic blood pressure reading of 140 mm Hg
Which patient cue would the nurse identify as relevant for blood pressure?
Reports blurred vision
Is married
Had abdominal surgery 5 years ago
Has periods of intense hunger
Reports blurred vision
Which information would the nurse share with a team member about the pathophysiology of hypertension?
Vasoconstriction causes blood to pool in the lower extremities, making the heart pump harder.
Enlarging of the blood vessels with no rise in cardiac output leads to increased blood pressure.
Narrowing of the arteries causes decreased peripheral resistance, leading to higher blood pressure.
Overstimulation of angiotensin and aldosterone causes the blood pressure to increase.
Overstimulation of angiotensin and aldosterone causes the blood pressure to increase.
Place the adult patients in the order in which the nurse would prioritize their care from highest priority to lowest priority.
Patient with chronic hypertension
Patient with an occluded airway
Patient who has a blood pressure of 76/40
Patient with blood pressure of 110/64
Patient with an occluded airway
Patient who has a blood pressure of 76/40
Patient with chronic hypertension
Patient with blood pressure of 110/64
Which hypothesis would the nurse select for a patient with a blood pressure of 130/70 who when sitting up becomes dizzy and the blood pressure is 108/60?
Shock
Postural hypotension
Hypertension stage 1
Hypotension
Postural hypotension
Which actions would the nurse take for a patient with low blood pressure from decreased peripheral vascular resistance?
Select all that apply.
Administer prescribed antihypertensive medications.
Administer prescribed intravenous (IV) fluids.
Administer prescribed oxygen.
Position supine with legs elevated.
Position prone with head on small pillow.
Administer prescribed intravenous (IV) fluids.
Administer prescribed oxygen.
Position supine with legs elevated.
Which factor would the nurse consider is likely causing hypertension in an older adult female who is 5’4”, weighs 100 lbs (45.4 kg), drinks an occasional glass of red wine before bed, and limits salt in her diet?
Age
Obesity
Alcohol use
Salt intake
age
Which finding would alert the nurse that a patient with a blood pressure of 80/40 is improving?
Skin becomes warm and dry.
Blood pressure decreases.
DASH diet is consumed.
Stress level decreases.
Skin becomes warm and dry.
Which actions would the nurse take for a patient with the following blood pressures: 119/74, 125/78, 130/83, and 135/88?
Select all that apply.
Measure oxygen saturation level.
Monitor blood pressure every 4 hours.
Reassess the circulatory system.
Perform a head-to-toe assessment.
Notify health care provider.
Measure oxygen saturation level.
Reassess the circulatory system.
Perform a head-to-toe assessment.
Notify health care provider.
