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Fundamental of Nursing > week 9 sherpath > Flashcards

week 9 sherpath Flashcards

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1
Q

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

A

Introduction of himself or herself

Collection of subjective data

Head-to-toe examination

Documentation of findings

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2
Q

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?”

A

Do you experience urinary pain or frequency?”

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3
Q

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

A

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

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4
Q

Order white blood cells from most prevalent to least prevalent in the absence of infection.

Basophils

Neutrophils

Monocytes

Eosinophils

Lymphocytes

A

Neutrophils

Lymphocytes

Monocytes

Eosinophils

Basophils

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5
Q

Which white blood cells are responsible for the signs and symptoms of inflammation?

Neutrophils

Monocytes

Eosinophils

Basophils

A

Basophils

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6
Q

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

A

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

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7
Q

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

A

Decreased immune responses

Decreased cough reflex

Incomplete bladder emptying

Reduced vascular supply

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8
Q

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

A

Skin infections

Urinary tract infections (UTIs)

Respiratory infections

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9
Q

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

A

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

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10
Q

Which patient finding is indicative of a localized infection?

Tachycardia

Fatigue

Abscess

Chills

A

Abscess

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11
Q

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

A

Performing a general assessment

Speaking with the patient’s family

Consulting the patient’s medical file

Performing the physical assessment

Obtaining a thorough history

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12
Q

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

A

Fatigue

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13
Q

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

A

Pressure injuries

Enlarged lymph nodes

Hyperactive bowel sounds

Decreased breath sounds

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14
Q

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)

A

Erythrocyte sedimentation rate (ESR)

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15
Q

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

A

Serum complement 140 hemolytic units

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16
Q

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

A

Pain and swelling of the knees from arthritis

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16
Q

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

A

Pain and swelling of the knees from arthritis

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17
Q

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

A

70-year-old with diabetes and an indwelling urinary catheter

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18
Q

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

A

Greenish drainage

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19
Q

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

A

Temperature 101.3°F (38.5°C) orally

Heart rate 122 beats/min

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20
Q

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

A

Procedure known as clean technique

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21
Q

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.

A

Soap and water effectively reduce microorganisms on visibly dirty hands.

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22
Q

An effective alcohol-based hand scrub must contain at least __ percent alcohol.

A

60

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23
Q

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

A

Head cover
Surgery or labor and delivery

Goggles
Sprays from respiratory droplets

Gloves
Direct contact with body fluids

Gown
Patient on transmission precautions

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24
Q

Place the personal protective equipment (PPE) in the order in which the nurse would remove them.

Shoe covers

Gown

Eyewear

Gloves

Mask

A

Gloves

Eyewear

Gown

Mask

Shoe covers

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25
Q

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)

A

Hand hygiene

Cough etiquette

Safe injection practices

Use of personal protective equipment (PPE)

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26
Q

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

A

Using a needleless system whenever possible

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27
Q

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.

A

Post signs in bathrooms demonstrating cough etiquette.

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28
Q

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.

A

Provide a mask for the patient if leaving the room.

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29
Q

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

A

Participating in local handwashing campaigns

Working locally to encourage immunizations

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30
Q

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

A

The Centers for Disease Control and Prevention (CDC) immunization website

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31
Q

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

A

Reporting infections as early as recognized

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32
Q

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

A

Smallpox

Cholera

Yellow fever

Diphtheria

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33
Q

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.

A

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.

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34
Q

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

A

Germicide
Uses chlorhexidine

Chemical sterilization
Process that uses gases

Physical sterilization
Process that uses steam or radiation

Disinfection
Cleans medical equipment and skin

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35
Q

Which personal protective equipment (PPE) would the nurse don before observing a sterile procedure in the operating room?

Mask

Gown

Hair cover

Sterile gloves

A

Mask

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36
Q

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

A

Implement wound care

Obtain a wound culture

Review the complete blood count

Administer antibiotics

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37
Q

Which intervention would a nurse anticipate specifically for a patient suspected of meningitis?

Antibiotics

Lumbar puncture

Inputs and outputs

Complete blood count

A

Lumbar puncture

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38
Q

Which term describes the administration of a medication by a nurse?

Dependent intervention

Independent intervention

Interdependent intervention

Nurse-initiated intervention

A

Dependent intervention

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39
Q

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

A

Prevents the spread of infection

Breaks the chain of infection

Interrupts organism transmission

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40
Q

Which step is first in the sequence for donning personal protective equipment (PPE)?

Hand hygiene

Head cover

Mask

Gown

A

Hand hygiene

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41
Q

Which infection would require a nurse to don a fitted N95 respiratory mask?

Tuberculosis

Influenza

Pneumonia

Methicillin-resistant Staphylococcus aureus (MRSA)

A

Tuberculosis

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42
Q

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

A

Eases fear and misunderstanding

Creates a professional relationship

Builds a trusting relationship

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43
Q

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

A

Gloves

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44
Q

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

A

When hands are not visibly soiled

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45
Q

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

A

Reusing tissues for a productive cough

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46
Q

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.

A

Standard precautions used during bed, bath, and mouth care.

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47
Q

Which infection would prompt the nurse to implement contact precautions?

Hepatitis A

Streptococcal pneumonia

Influenza

Chickenpox

A

Hepatitis A

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48
Q

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

A

Coughing

Sneezing

Suctioning

Talking

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49
Q

Which infection would require a patient to be admitted to the airborne infection isolation room?

Pharyngeal diphtheria

Meningococcal sepsis

Staphylococcus aureus

Varicella zoster

A

Varicella zoster

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50
Q

Match the transmission-based precaution with the mode of transmission it prevents.

Person to person

Coughing, sneezing

Suspended particles

Answer choices

Droplet

Airborne

Contact

A

Person to person
contact

Coughing, sneezing
droplet

Suspended particles
airborne

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51
Q

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

A

Herpes simplex virus (HSV)
Contact

Rubella
Droplet

Rubeola
airborne

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52
Q

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

A

Personal

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53
Q

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

A

Encouraging and facilitating immunization programs

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54
Q

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

A

People

Animals

Cargo

Buildings

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55
Q

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

A

Separates sick and contagious people from others
isolation

Separates people exposed to a contagious disease
Quarantine

Separates people with weak immune systems
Protective isolation

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56
Q

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

A

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

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57
Q

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)

A

Keeping sterile surfaces dry

Setting up the sterile field

Checking packaging integrity

Monitoring activities of others

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58
Q

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

A

Health care provider reached over sterile field to pick up a towel

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59
Q

Which procedure is necessary for equipment being used to enter a sterile body cavity?

Sanitization

Disinfection

Sterilization

Decontamination

A

Sterilization

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60
Q

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

A

Gastrointestinal infection

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61
Q

A nurse caring for a patient with an infection would anticipate a temperature less than_ _ °F when the infection has resolved.

A

100.4

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62
Q

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

A

Counseling a patient

Repositioning a patient to enhance comfort

Teaching a postoperative patient how to prevent surgical site infection

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63
Q

Which part of the brain maintains a consistent internal body temperature despite environmental extremes?

Thalamus

Brainstem

Cerebellum

Hypothalamus

A

Hypothalamus

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64
Q

Which internal process provides the primary source of heat production?

Exercise

Hormones

Metabolism

Convection

A

Metabolism

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65
Q

Which mechanisms primarily enhance heat loss from the body?

Select all that apply.

Radiation

Digestion

Conduction

Convection

Evaporation

A

Radiation

Conduction

Convection

Evaporation

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66
Q

Infants under the age of

___ months have immature regulatory thermoregulation systems. Record answer as a whole number.

A

3

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67
Q

Which factors affect body temperature?

Select all that apply.

Stress

Height

Smoking

Hormones

Environment

Circadian rhythms

A

Stress

Smoking

Hormones

Environment

Circadian rhythms

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68
Q

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?”

A

“Have you exercised in the last 30 minutes?”

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69
Q

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

A

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

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70
Q

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)

A

95.9° to 99.5°F (35.5° to 37.5°C)

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71
Q

Which areas of the human body are most vulnerable to frostbite?

Select all that apply.

Toes

Wrists

Earlobes

Abdomen

Tip of nose

A

Toes

Earlobes

Tip of nose

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72
Q

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

A

Dizziness

Hot skin

Rapid heart rate

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73
Q

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

A

Results of white blood cell count

Presence of growth on a culture

Temperature readings on graphics

Levels of hormones

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74
Q

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

A

Presence of infection

Chills

Anorexia

Dehydration

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75
Q

Which patient would the nurse assess first?

One with heatstroke

One who has controlled diabetes

One with anorexia

One who has an infection

A

One with heatstroke

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76
Q

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.

A

Select solutions.

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77
Q

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

A

Hot soup

Head coverings

Warmed blankets

Warmed intravenous fluids

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78
Q

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

A

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

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79
Q

Which nonpharmacologic interventions lower a patient’s fever?

Select all that apply.

Ice packs

Acetaminophen

Cooling pads

Cool sponge baths

Warmed blankets

A

Ice packs

Cooling pads

Cool sponge baths

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80
Q

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

A

Lower the hypothalamus set-point

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81
Q

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.”

A

“This is a typical response based on circadian rhythms.”

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82
Q

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

A

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

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83
Q

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)

A

One who was admitted to the hospital after experiencing a cerebrovascular accident (stroke)

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84
Q

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

A

Drowsiness

Pale, cool skin

Decreased urinary output

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85
Q

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.”

A

“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.”

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86
Q

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.

A

Touch the patient’s skin.

87
Q

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.

A

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.

88
Q

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.

A

Administer prescribed warmed intravenous fluids.

Apply several layers of warmed blankets.

Wrap warm, dry towels around the patient’s head.

89
Q

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.

A

Take the patient’s blood pressure, which shows hypotension.

90
Q

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.”

A

“Because the patient has a low white blood cell count, I will not take a rectal temperature.”

91
Q

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.

A

Lower the room temperature.

Decrease stress level.

Review culture and sensitivity reports.

92
Q

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)

A

15-year-old: 100°F (37.8°C)

Older adult: 93°F (33.9°C)

93
Q

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.”

A

“Do not give the medication.”

94
Q

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.

A

Patient’s temperature will be within the expected range until discharge.

95
Q

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

A

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

96
Q

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.

A

Temperature increases.

Urinary output increases.

97
Q

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

A

Middle-aged adult with heatstroke

Older adult patient with a fever

Young adult with a fever

Teenager who is afebrile

98
Q

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..

A

Temperature increases.

Heart rate increases.

Dizziness increases..

99
Q

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.

A

Pull the pinna up and back.

100
Q

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.

A

Recognize this is an expected finding.

101
Q

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.

A

This is too much acetaminophen.

102
Q

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

A

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

103
Q

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

A

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

104
Q

Which site is the natural pacemaker of the heart?

Sinoatrial node

Atrioventricular node

Purkinje fibers

Internodal pathway

A

Sinoatrial node

105
Q

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

A

The amount of blood the heart pumps per minute

106
Q

Which pulse site would the nurse use that is the most definitive site to determine a patient’s cardiac health?

Apical

Radial

Peripheral

Carotid

A

Apical

107
Q

Which factors can affect a patient’s heartbeat?

Select all that apply.

Fever

Hunger

Exercise

Medications

Hypovolemia

A

Fever

Exercise

Medications

Hypovolemia

108
Q

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?

A

Do you smoke?

What medications do you take?

Are your hands or feet swollen?

Do you experience shortness of breath?

109
Q

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

A

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

110
Q

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

A

Either side of the neck
Carotid

Either side of the forehead
Temporal

Inner aspect of the arm
Brachial

Inside the wrist
Radial

111
Q

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

A

Newborn (awake or asleep)
80–180

6-year-old
75–110

15-year-old
50–90

Adult
60–100

112
Q

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

A

Anemia

Bronchodilator medication

Drop in blood pressure

113
Q

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

A

Interview the patient

Visually inspect the patient for alterations

114
Q

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

A

Bradycardia

115
Q

Which adult patient would the nurse assess first?

One with heart disease

One with tachycardia

One with stable breathing

One with patent (open) airway

A

One with tachycardia

116
Q

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.

A

Suggest activities to increase the heart rate.

117
Q

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.

A

Administer prescribed fluid replacement.

Administer prescribed oxygen.

Prepare patient for an electrocardiogram.

118
Q

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.

A

Prepare patient for an emergency pacemaker.

119
Q

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

A

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

120
Q

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

A

Sinoatrial node

Internodal pathway

Atrioventricular node

Bundle of His

Right and left bundle branches

Purkinje fibers

121
Q

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

A

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

122
Q

Which factors would the nurse consider when the patient’s pulse rate is decreased?

Select all that apply.

Age

Stress

Hypoxia

Hypovolemia

Hypothyroidism

A

Age

Hypothyroidism

123
Q

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

A

Left fifth and sixth intercostal space

124
Q

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.

A

Offer noncaffeinated beverages.

Administer fluid replacement.

Monitor potassium and calcium levels.

125
Q

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.

A

Document the appropriate heart rate.

126
Q

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

A

pain

fever

A drop in blood pressure

127
Q

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

A

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

128
Q

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.

A

Count “lub-dub” as one beat.

129
Q

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

A

52 for an older adult

110 for a 15-year-old

180 for a 1-year-old

130
Q

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.

A

Patient will exhibit pulse rate within expected range after 12 hours of beginning prescribed interventions.

131
Q

Which pulse site would the nurse check when an infant appears lifeless?

Carotid

Femoral

Brachial

Popliteal

A

Brachial

132
Q

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

A

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

133
Q

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.

A

Reassess cardiac system.

Perform a head-to-toe assessment.

Review medications.

Notify the health care provider.

Review electrolyte levels.

134
Q

What heart rate would the nurse record for a patient’s heart rate of 46 beats in 30 seconds?

____ Beats/min

A

92

135
Q

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.

A

This test utilizes a portable device attached to the chest by electrodes.

136
Q

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

A

Hypothermia

Beta blocker administration

Increased intracranial pressure

137
Q

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

A

Sluggish

Lethargic

Confused

138
Q

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.

A

Reflexes increase.

139
Q

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.

A

Elevate legs when at rest.

Check peripheral pulses.

Balance periods of rest and exercise.

Assess heart sounds.

140
Q

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

A

Medial surface of both ankles
Posterior tibial

Behind both knees
Popliteal

On top of both feet
Pedal

By the groin on both sides
Femoral

141
Q

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).

A

Notify health care provider.

Assist with electrical cardioversion.

Transfer to intensive care unit.

Suggest a consult with a cardiologist.

142
Q

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

A

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

143
Q

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

A

The movement of oxygen in and out of the lungs, or inhaling and exhaling

144
Q

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

A

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

145
Q

In which primary area of the lung does carbon dioxide transfer (diffusion) occur?

Nose

Alveoli

Trachea

Bronchioles

A

Alveoli

146
Q

Which factors affect respirations?

Select all that apply.

Exercise

Appetite

Diseases

Fear

Acid-base balance

A

Exercise

Diseases

Fear

Acid-base balance

147
Q

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?

A

Do you vape?

Have you taken any pain medication?

Do you have any shortness of breath?

148
Q

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

A

Newborn
24-38

1-year-old
22-30

6-year-old
20-24

Older adult
15-20

149
Q

Which breathing pattern would the nurse suspect when a patient is breathing 8 breaths/min?

Hyperventilation

Tachypnea

Bradypnea

Apnea

A

Bradypnea

150
Q

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

A

Rhythmic respirations, going from very deep to very shallow or apneic periods

151
Q

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

A

Vital signs from the graphics

Medication records

Chronic obstructive pulmonary disease (COPD) from the history

Baselines from the vital signs flow sheet

152
Q

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

A

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

153
Q

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

A

Patient’s airway occluded

154
Q

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.

A

Patient’s respiratory rate improves.

155
Q

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

A

Respiratory rate decreasing

156
Q

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

A

Accessory muscle use increasing

157
Q

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.

A

Apply prescribed oxygen.

Offer emotional support.

Reorient patient

158
Q

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

A

Tachypnea

159
Q

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

A

Dyspnea

Tachypnea

Orthopnea

160
Q

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

A

Earlobe

Nose

Toe

161
Q

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.

A

Patient demonstrates regular rate and depth of respirations before discharge.

162
Q

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

A

24

163
Q

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

A

Reposition the patient to a sitting position.

Suction the patient’s airway.

Apply prescribed supplemental oxygen to the patient

164
Q

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.

A

Count inhalation and exhalation as one breath.

165
Q

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

A smoker

Reports of chest pain

Cardiovascular disease

166
Q

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

A

12-20

167
Q

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

A

15-year-old: 26

Older adult: 10

Adult: 28

1-year-old: 50

168
Q

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

A

Dyspnea

169
Q

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.

A

Try to make the abdomen move out during inhalation.

170
Q

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

A

Had prostate surgery 7 years ago

Has been a teacher for 25 years

171
Q

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

A

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%

172
Q

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

A

Whether respirations are labored or nonlabored

173
Q

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.

A

Assist with placement on a ventilator.

174
Q

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

A

Increased intracranial pressure

Impending death

175
Q

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.

A

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.

176
Q

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.

A

Reassess respiratory system.

Perform a head-to-toe assessment.

Review medications.

Notify the health care provider.

Obtain an oxygen saturation measurement.

177
Q

Which finding would alert the nurse a newborn with impaired breathing is declining?

Nasal flaring

Pink skin

SpO2 95%

Respiratory rate 35

A

Nasal flaring

178
Q

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.

A

Patient will exhibit an expected respiratory rate within 1 hour of treatment.

179
Q

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

A

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

180
Q

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

A

Jaundice

Peripheral edema

Some fingernail polishes

Cold or injury to extremities

181
Q

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.

A

The heart exerts maximum pressure during contractions.

182
Q

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

A

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

183
Q

Which factors increase blood pressure?

Select all that apply.

Shock

Head injury

Weight gain

Vasodilation

Acute pain

A

Head injury

Weight gain

Acute pain

184
Q

Which area is the most common site for a blood pressure measurement?

Wrist

Lower leg

Upper leg

Upper arm

A

Upper arm

185
Q

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?

A

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?

186
Q

Which blood pressure measurement is an unexpected finding?

Newborn: 70/40

6-year-old: 90/60

15-year-old: 110/68

Adult: 128/84

A

Adult: 128/84

187
Q

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

A

Hypertension stage 1
130–139 systolic

Elevated
<80 diastolic with systolic 120–129

Hypertension stage 2
≥90 diastolic

188
Q

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.

A

Patient feels faint upon position change.

189
Q

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.

A

Question the patient.

190
Q

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

A

Hypovolemia and decreased cardiac output
Hypotension

Peripheral vasodilation with no compensation
Postural hypotension

Thickened arteries that reduce compliance
Hypertension

191
Q

Which patient situation would the nurse assess first?

Absence of breathing

Hypotension

Hypertension

Orthostatic hypotension

A

Absence of breathing

192
Q

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.

A

Patient’s blood pressure will return to expected ranges 2 hours after treatment.

193
Q

Which finding alerts the nurse that a patient with hypertension is improving?

Salt intake increases.

Weight increases.

Nose bleeds decrease.

Exercising decreases.

A

Nose bleeds decrease.

194
Q

Which action would the nurse take for a patient with hypotension?

Apply oxygen.

Increase salt intake.

Restrict fluid.

Ambulate patient.

A

Apply oxygen.

195
Q

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.

A

Perform a head-to-toe assessment.

196
Q

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

A

The amount of blood injected into the arterial system with each heartbeat

197
Q

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

A

Clammy skin

Thready pulse

Confusion

198
Q

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

“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.”

199
Q

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

A

Decreased cardiac output

200
Q

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

A

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

201
Q

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

A

Takes the blood pressure in the left arm

202
Q

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

A

Arranging for nutritional support

Encouraging cessation of smoking

Monitoring responses to prescribed antihypertensive medications

203
Q

Which site would the nurse use to measure blood pressure when the patient’s upper body is severely burned?

Popliteal

Brachial

Radial

Femoral

A

Popliteal

204
Q

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

A

96/64 to 118/74

205
Q

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

A

60

206
Q

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.

A

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.

207
Q

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

A

Has a regular heartbeat

Has a previous systolic blood pressure reading of 140 mm Hg

208
Q

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

A

Reports blurred vision

209
Q

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.

A

Overstimulation of angiotensin and aldosterone causes the blood pressure to increase.

210
Q

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

A

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

211
Q

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

A

Postural hypotension

212
Q

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.

A

Administer prescribed intravenous (IV) fluids.

Administer prescribed oxygen.

Position supine with legs elevated.

213
Q

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

A

age

214
Q

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.

A

Skin becomes warm and dry.

215
Q

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.

A

Measure oxygen saturation level.

Reassess the circulatory system.

Perform a head-to-toe assessment.

Notify health care provider.

Fundamental of Nursing (14 decks)

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