Download test bank for nursing interventions and clinical skills 5th edition by perry

Test Bank for Nursing Interventions and Clinical Skills 5th Edition by Perry Perry: Nursing Interventions & Clinical Skills, 5th Edition Chapter 06: Vital Signs MULTIPLE CHOICE The patient’s oral temperature is 39° C Which conclusion can the nurse make about the patient on the basis of this information? A The patient is febrile B The patient is afebrile C An infection is present D Inflammation is present ANS: A A temperature of 39° C is above normal, and the patient with an aboveaverage temperature is febrile Afebrile indicates a lack of fever but does not necessarily imply a subnormal temperature An infection often causes a fever in the patient, but a physical examination and laboratory work or culture are necessary before concluding that the patient has an infection A patient with an inflammation can have a fever, but the patient can have an inflammation without being febrile PTS: DIF: REF: Page 84, 95-96 TOP: Cognitive Level: Comprehension MSC: Nursing Process: Diagnosis The nurse is preparing to obtain a set of vital signs Which is the most important factor for the nurse to consider when measuring patient vital signs? A Documentation of vital signs requires timely and accurate recording Test Bank 6-2 B Normal limits are very narrow and are generally the same for all patients C Measuring equipment must suit the patient’s condition and characteristics D Environmental factors play a minor role on patient vital signs ANS: C Suitable measuring equipment for patient condition and characteristics is important because improper equipment distorts the results increasing the risk of patient injury If data are obtained with improper equipment and patient treatment is based on the faulty data, the people who use the improper equipment and the faulty data are liable for the results This is especially important when assessing temperature and blood pressure since a variety of devices are available for measuring these vital signs Documentation is an important part of taking vital signs; however, if the nurse uses improper equipment or technique to obtain vital signs, accurate and prompt recording is to no avail Depending on the parameter, the normal limits are not relatively narrow The benefit of a wider normal range is that the body is able to respond to stress and recover while remaining within normal limits Environmental factors play a significant role on vital signs (e.g., an overly warm room affects patient temperature) PTS: DIF: REF: Page 84-86 TOP: Cognitive Level: Comprehension MSC: Nursing Process: Assessment The patient was hospitalized after a severe closed head injury and has erratic tympanic temperatures Which action should the nurse take when the next temperature is due? A Obtain both the tympanic temperature and the temperature from another site to validate the reading B Watch for increased patient heat loss from vasodilation C Evaluate the vital signs at 4-hour intervals around the clock D Watch for increased intracranial pressure on the hypothalamus ANS: A Test Bank 6-3 Obtain the temperature from another site to validate the reading The most likely causes of the erratic temperatures are variations in the technique, resulting in a high percentage of abnormal results Because of the brain involvement, it is essential that the temperature be watched Vasodilation is not a common result of a closed head injury Taking temperature every hours is normal procedure in hospitals If increased intracranial pressure were the cause of the temperature fluctuations, it is much more likely that the temperature would be at a sustained, abnormal point or trending up or down PTS: Analysis DIF: MSC: REF: Page 84-86 TOP: Cognitive Level: Nursing Process: Planning A patient has a severe upper respiratory and ear infection and has been experiencing diarrhea Assessment of the temperature would be most accurate if the nurse checked the temperature using which site? A The rectum B The axilla C Under the tongue D The tympanic membrane ANS: B The axilla is the only area listed where there is no infection or health issue and where there is no interference to its accuracy The rectum is an inappropriate site because of the diarrhea The oral route, under the tongue, is an inappropriate site because of the severe upper respiratory infection If the patient cannot breathe through the nose, mouth breathing occurs, and the mouth cannot be closed to create a seal for an accurate temperature measurement The tympanic membrane is an inappropriate site because of the ear infection PTS: Analysis MSC: DIF: REF: Page 84-86 TOP: Cognitive Level: Nursing Process: Assessment Test Bank 6-4 The nurse is validating the measurement of an infant’s pulse by a nursing student Which method should the nurse use to obtain the most accurate count? A Compress the bell of the stethoscope over the apex of the heart B Locate the pulsations in the antecubital space C Palpate the superficial artery on the medial side of wrist D Place the thumb and forefinger along the ridge on the outer side of the wrist ANS: B Counting the pulsations in the antecubital fossa from the brachial artery would give the most accurate count Compressing the bell of the stethoscope turns it into a diaphragm; the bell is never compressed during use Placing the thumb and forefinger along the ridge on the outer side of the wrist locates the radial artery, the preferred site for measuring an adult’s pulse PTS: DIF: REF: Page 86-87, 98 TOP: Cognitive Level: Knowledge MSC: Nursing Process: Implementation A patient born without arms needs to have a blood pressure assessment Which artery should the nurse use to most accurately obtain this measurement? A Femoral B Carotid C Brachial D Popliteal ANS: D The nurse can use the popliteal artery to measure blood pressure by applying a properly sized cuff to the patient’s thigh The femoral artery does not provide an area for assessment of the blood pressure The brachial arteries are in the arm The carotid artery, which is in the neck, is impossible to use for blood pressure measurement because applying cuff pressure to temporarily occlude both carotid arteries would stop blood flow to the brain and risk cerebral hypoxia Test Bank 6-5 PTS: DIF: REF: Page 103-105 TOP: Cognitive Level: Comprehension MSC: Nursing Process: Implementation The nurse is running a blood pressure screening clinic at the community health center Which action should the nurse implement to obtain an accurate measurement of a patient’s blood pressure on an upper extremity? A Use a cuff with a cuff width that is 40% wider than the circumference of the arm B Limit the cuff deflation rate to 10 mm Hg per second or heartbeat C Record the second Korotkoff sound as the systolic pressure D Apply the diaphragm of the stethoscope lightly over the brachial artery ANS: A For accurate results, a properly sized blood pressure cuff is at least 40% wider than the circumference of the patient’s arm on which the blood pressure is measured Deflating the cuff at 10 mm Hg is excessively fast The systolic blood pressure is the first Korotkoff sound The diaphragm is placed firmly over the brachial artery to prevent environmental sound from interfering with blood pressure auscultation PTS: DIF: REF: Page 89 TOP: Cognitive Level: Comprehension MSC: Implementation Nursing Process: The patient is unstable; so the nurse is using an electronic blood pressure device to measure blood pressures every 15 minutes What should the nurse to verify the accuracy of the electronic blood pressure measurements? A Check when the device was last calibrated B Know that the device adheres to current medical industry standards C Take a manual blood pressure within several minutes of the electronic reading D Verify that the systolic pressure is within 20% of patient baseline ANS: C Test Bank 6-6 If the blood pressure readings from the electronic blood pressure measurement device are close to the patient’s blood pressure on auscultation using a sphygmomanometer, the nurse assumes that the electronic device is accurate Knowing when the device was calibrated does not guarantee its current accuracy Medical industry standards not exist for electronic blood pressure devices A systolic measurement accurate within 20% of the patient’s baseline is grossly inaccurate, and using such a measurement can potentially lead to catastrophic results PTS: DIF: REF: Page 109 TOP: Cognitive Level: Application MSC: Nursing Process: Evaluation A patient has an electronic blood pressure cuff that inflates every 15 minutes for a reading Which activity by the nursing student would require the nurse to intervene? A The cuff is positioned carefully on the gown sleeve for comfort B The cuff is removed every hours for a skin assessment C The alarm limits on the electronic device are checked frequently D The cuff is rotated to the other extremity every few hours as possible ANS: A The cuff should be directly on the patient’s skin, not over the gown, for an accurate reading All other actions are appropriate PTS: Knowledge MSC: DIF: REF: Page 108 TOP: Cognitive Level: Nursing Process: Planning 10 The nurse delegates temperature measurement to nursing assistive personnel (NAP) For which patient should the nurse instruct the NAP to use the tympanic thermometer? A 10-year-old patient with a left leg fracture B 12-hour-old infant in the newborn nursery C 5-year-old patient with bilateral otitis media D 15-year-old patient with postbilateral tympanoplasties Test Bank 6-7 ANS: A The 10-year-old patient is a suitable candidate for use of the tympanic thermometer if the NAP uses proper technique for positioning the sensor because of the age and condition of the child The anatomy of the ear canal makes it difficult to position the probe accurately in neonates Whenever ear infections are present, a tympanic thermometer can cause injury and record an inaccurate reading because of fluid, wax, or infectious material in the ear Tympanic temperatures are prohibited when ear surgery has just been performed because they increase the risk for injury and infection PTS: DIF: REF: Page 84-85 TOP: Cognitive Level: Comprehension MSC: Nursing Process: Planning 11 The nurse needs to measure the adult patient’s temperature, but the patient has just finished a cup of coffee Which is the best type of temperature for the nurse to obtain accurate results efficiently? A Rectal B Axillary C Tympanic D Disposable ANS: C The nurse obtains a tympanic temperature because the hot coffee will affect an oral reading A tympanic temperature is a more reliable indicator of body temperature than the oral reading because a tympanic temperature is a core temperature Rectal temperatures for adult patients are reserved for occasions when continuous temperature monitoring is required or if no other core temperature site is available; in addition, rectal temperatures are embarrassing for an alert adult patient Axillary temperatures are not as reliable as tympanic temperatures and not reflect core temperature Disposable thermometers are the least accurate method PTS: DIF: REF: Page 84-85 TOP: Cognitive Level: Comprehension MSC: Nursing Process: Test Bank 6-8 Planning 12 The nurse is preparing to obtain a rectal temperature Nursing care is correct if the nurse inserts the thermometer how far into the rectum of an adult? A 1.3 cm (1/2 inch) B 3.5 cm (1 1/2 inches) C 5.1 cm (2 inches) D 6.4 cm (1 1/2 inches) ANS: B The nurse inserts the thermometer 2.5 to 3.5 cm (1 to 1/2 inches) to obtain a rectal temperature on an adult The sensor tip will be deep enough into the rectum to eliminate environmental effects but not too deep to risk penetration or trauma to intestinal tissue 1.3 cm (1/2 inch) is not far enough for an accurate reading 5.1 and 6.4 cm (2 and 1/2 inches) are too far to insert the thermometer into an adult PTS: Knowledge MSC: DIF: REF: Page 92 TOP: Cognitive Level: Nursing Process: Implementation 13 While inserting a rectal thermometer, the nurse encounters resistance What action should the nurse take? A Remove the thermometer immediately B Ask the patient to take a few deep breaths C Apply mild pressure to advance the thermometer D Remove the thermometer and reinsert gently ANS: A If resistance is felt, the nurse should remove the thermometer probe Applying pressure to advance the thermometer is contraindicated to prevent complications such as harm to the mucosa If there is an obstruction or a large amount of stool, having the patient take a few deep breaths is useless Test Bank 6-9 The obstruction or impaction will have to be dealt with first If the nurse removes and then reinserts the thermometer, the stimulation reactivates the sphincter reflex The resistance will more than likely still be present PTS: DIF: REF: Page 93 TOP: Cognitive Level: Application MSC: Planning Nursing Process: 14 The nurse notes that the patient’s tympanic temperature is 37.88° C (100.2° F) at PM on the patient’s second postoperative day What should the nurse initially? A Check the leukocyte count B Collaborate for cultures C Ask the patient to drink some fluid D Offer the patient another blanket ANS: C The nurse should ask the patient to drink more fluid and cough and deep breathe because low-grade temperatures frequently indicate dehydration and atelectasis in postoperative patients; in addition, patient temperatures generally peak in late afternoon The nurse evaluates the patient’s temperature again in hours and expects to obtain a lower temperature If not, the nurse assesses the patient for infection and collaborates with the provider to plan care Until the nurse tries fluid and verifies the temperature, collaborating for specimen cultures is premature; in addition, the provider potentially will not want to culture for a low-grade temperature PTS: DIF: REF: Page 84, 91, 94 TOP: Cognitive Level: Application MSC: Nursing Process: Implementation 15 The nurse is teaching a family member how to check a teenager’s temperature using a tympanic thermometer Which step is most important for the nurse to include obtaining an accurate reading? A Pull the pinna down and back B Move the thermometer in the ear in a figure-eight pattern Test Bank 6-10 C Place the probe loosely into the ear canal D Point the probe toward the nose ANS: B To obtain a tympanic temperature using proper technique, the nurse inserts the thermometer tip into the ear, making a figure-eight pattern to ensure a snug fit The tip must fit securely in the ear canal to block environmental effects The pinna is pulled back, up, and out for an adult The tip of the thermometer should point toward the patient’s chin for proper positioning PTS: Knowledge MSC: DIF: REF: Page 94-95 TOP: Cognitive Level: Nursing Process: Assessment 16 A patient has been experiencing some circulatory issues, and an apical-radial pulse is ordered Nursing care is correct if which procedure is followed? A One nurse counts the apical pulse at the same time another nurse counts the radial pulse B The nurse delegates this procedure to an experienced licensed practical nurse/licensed vocational nurse (LPN/LVN) and nursing assistive personnel (NAP) with 10 years’ experience C The nurse counts the apical pulse for 60 seconds and then the radial pulse for 60 seconds D The apical pulse is counted for 30 seconds, the radial pulse for 30 seconds, and the results are doubled ANS: A The pulse rate must be counted for 60 seconds at the two sites at the same time by two different people If the patient is unstable or experiencing problems, this cannot be delegated to NAP The radial and apical pulses are counted at the same time by two different people The apical and radial pulses are counted for a full minute, not 30 seconds, and the results doubled PTS: DIF: REF: Page 101 TOP: Cognitive Level: Comprehension MSC: Nursing Process: Assessment Test Bank 6-11 17 The nurse is preparing to measure the patient’s blood pressure with an electronic blood pressure device Which concept is most important for the nurse to consider? A Use the extremity closest to the nurse B The cuff size must match the extremity being used C The brachial artery is always the best one to use D The temporal artery is used if neither arm is available ANS: B The cuff must be the appropriate size for the extremity used If the thigh is used, the nurse must use a larger cuff The extremity used has nothing to with proximity to the nurse It depends on the patient’s status In some instances the brachial artery in the upper arm is not available for blood pressure assessment such as after a mastectomy, if the extremity is injured, or if an intravenous line is in place The temporal artery is impossible to use for blood pressure measurement because the temporal arteries are on the lateral aspects of the skull PTS: DIF: REF: Page 89, 104-105 TOP: Cognitive Level: Comprehension MSC: Nursing Process: Planning 18 The nurse is preparing to assess the apical pulse At which location should the nurse listen to obtain an accurate apical pulse on an adult patient? A At the fifth intercostal space at the left sternal border B At the fifth left intercostal space at the midclavicular line C At the second intercostal space at the left midclavicular line D At the second right intercostal space at the midclavicular line ANS: B To auscultate an adult’s apical pulse, the nurse places the stethoscope at the left fifth intercostal space at the midclavicular line directly over the point of maximal impulse and the location for auscultating the mitral valve The fifth left intercostal space at the left sternal border locates the tricuspid valve The second intercostal space at the left midclavicular line locates the pulmonic valve The second right intercostal space at the midclavicular line locates the aortic valve Test Bank PTS: Knowledge MSC: 6-12 DIF: REF: Page 87, 97 TOP: Cognitive Level: Nursing Process: Implementation 19 The nursing assistant reports the following vital signs for four patients just evaluated Which patient should the nurse see first? A 25 respirations per minute for a toddler B 38 respirations per minute for a newborn C 12 respirations per minute for an 8-year-old child D 14 respirations per minute for an adult patient ANS: C The 8-year-old child is the nurse’s priority because the rate is too slow for the patient’s developmental stage The normal range for a child is 20 to 30 breaths per minute The range for respirations for a toddler is 25 to 32 breaths per minute; thus 25 breaths are within the normal limits The range for respirations for a newborn is 35 to 40 breaths per minute; thus 38 breaths are within the normal limits The range for respirations for an adult is 12 to 20 breaths per minute; thus 14 breaths are within the normal limits PTS: DIF: REF: Page 103 TOP: Cognitive Level: Comprehension MSC: Nursing Process: Assessment 20 At what distance above the antecubital fossa does the nurse position a blood pressure (BP) cuff when using the brachial artery to measure BP? A 2.5 cm (1 inch) B 0.6 cm (1/4 inch) C 1.3 cm (1/2 inch) D 5.1 cm (2 inches) ANS: A Test Bank 6-13 The nurse positions the BP cuff 2.5 cm (1 inch) above the antecubital fossa when using the brachial artery This allows proper placement of the stethoscope PTS: Knowledge MSC: DIF: REF: Page 105 TOP: Cognitive Level: Nursing Process: Implementation 21 The patient is morbidly obese and the nurse uses a blood pressure (BP) cuff that is too narrow for the patient’s arm What problem will the nurse encounter because of the cuff used? A The Korotkoff sounds would not be heard B Only a palpable BP could be obtained C The stethoscope could not be positioned correctly D A false high BP reading would occur ANS: D Using a cuff that is too narrow results in a false high BP measurement and makes care planning impossible A properly sized cuff should be obtained as quickly as possible Until it arrives the nurse should continue to measure BP with the smaller cuff and observer the patient to ensure safety Obesity potentially leads to diminished Korotkoff sounds The assessment finding would warrant further investigation such as rechecking the blood pressure in several minutes A palpable BP provides a systolic pressure only; the nurse obtains a palpable BP by inflating the cuff to occlude the artery and then palpating the brachial or radial pulse The point at which the pulse returns is the systolic pressure The nurse should have less difficulty positioning the stethoscope because the narrow cuff exposes more skin PTS: DIF: REF: Page 90, 104, 107 TOP: Cognitive Level: Application MSC: Nursing Process: Evaluation 22 The patient is hypotensive after hemodialysis Which intervention should the nurse implement to prevent complications from hypotension? A Provide warm blankets B Elevate the head of the bed Test Bank 6-14 C Place the patient in the supine position D Place the patient on seizure precautions ANS: C Unusually low BP or hypotension indicates BP may not be adequate for perfusion and oxygenation of tissues The fluid loss during hemodialysis increases the risk of patient hypotension after therapy resulting in patient injury because of orthostatic hypotension and dizziness The nurse should place the patient in the supine position to prevent this problem Providing warm blankets is indicated after hemodialysis despite the patient’s hypotension because the dialysis process involves instilling cold fluid and removing warm body fluids, leading to a decrease in patient temperature; however, increasing the patient’s core temperature facilitates vasodilation and potentially can cause hypotension Elevating the head of the bed in the presence of hypotension is contraindicated because positioning the head in an independent position facilitates venous return to decrease the blood flow to the brain Massive fluid and electrolyte shifts during hemodialysis increase the risk of patient seizures regardless of patient history PTS: DIF: REF: Page 107 TOP: Cognitive Level: Application MSC: Nursing Process: Implementation 23 The primary care nurse measures the patient’s blood pressure and obtains 145/90 mm Hg Which action should the nurse implement next? A Talk with the patient about the use of blood pressure medications B Ask the patient about caffeine, fat, and sodium intake C Ask for the date of the initial hypertension diagnosis D Repeat the blood pressure after the patient sits for a few minutes ANS: D Hypertension is never diagnosed on the basis of one reading At a minimum, the nurse allows the patient to relax for a few minutes and then obtains another blood pressure measurement Talking about antihypertensive therapy is premature because hypertension has not been diagnosed Asking Test Bank 6-15 the patient about sodium, fat, and caffeine intake is a reasonable response after repeating the blood pressure measurement and obtaining similar results Sodium retains water, caffeine vasoconstricts, and fat blocks the arteries Asking for the date when hypertension was originally diagnosed is premature; however, the nurse can ask questions to obtain valuable data about the patient’s blood pressure PTS: DIF: REF: Page 107 TOP: Cognitive Level: Application MSC: Nursing Process: Planning 24 While positioning the patient for a routine blood pressure check, the patient asks the nurse why a support was placed under the arm before the BP cuff was applied Which response by the nurse is most accurate? A “This method prevents any problems in obtaining an accurate reading.” B “This method helps the arm relax so the reading will be correct.” C “I want you to be as comfortable as possible during this time.” D “Just sit back and relax and let me get this reading right now.” ANS: B Supporting the arm assures the muscles are relaxed improving the likelihood for an accurate reading Comfort is important but not the primary reason for providing support There are many variables that can cause an inaccurate reason including the wrong cuff size or improper placement of the stethoscope Telling the patient to just “sit back and relax” ignores the patient’s question and is not an appropriate response PTS: DIF: REF: Page 104 TOP: Cognitive Level: Application MSC: Nursing Process: Planning 25 The nurse assesses the patient’s respirations and sees that they are abnormally shallow (i.e., two to three breaths followed by an irregular period of apnea) Documentation by the nurse would be correct if which phrase were used? A Biot’s respirations Test Bank 6-16 B Cheyne-Stokes respirations C Kussmaul’s respirations D Hyperpneic respirations ANS: A This is an accurate description of Biot’s respirations Cheyne-Stokes respirations have an irregular rate and depth characterized by alternating periods of apnea and hyperventilation Kussmaul’s respirations are abnormally deep but regular Hyperpneic respirations are increased in depth and can often be seen during exercise PTS: Knowledge MSC: DIF: REF: Page 88 TOP: Cognitive Level: Nursing Process: Assessment 26 The nurse is caring for a lethargic, 18-year-old patient with a respiratory rate of 32 breaths per minute What is the first action the nurse should take? A Place the patient in high-Fowler’s position B Assess the remaining vital signs C Reassess the respiratory rate D Notify the health care provider ANS: A The patient’s head should be elevated quickly to promote better lung expansion The remaining vital signs can be assessed after taking actions to improve the patient’s breathing The health care provider will be notified, but the nurse’s first responsibility is to the patient PTS: Synthesis MSC: DIF: REF: Page 102 TOP: Cognitive Level: Nursing Process: Implementation MULTIPLE RESPONSE Test Bank 6-17 The patient’s oral temperature is 37.1° C (98.78° F) at PM Which should the nurse at this time? Select all that apply A Administer acetaminophen (Tylenol) 650 mg by mouth now B Offer the patient an additional blanket C Document that the patient is normotensive D Compare this with the patient’s prior readings E Ask the patient if anything warm was consumed within the past 15 minutes F Ask the patient if the teeth were brushed this morning ANS: D The nurse compares this temperature with the patient’s prior temperature to determine if there is a variation from the patient’s normal temperature This temperature is within normal limits Because the temperature reading is within normal limits, other interventions are not needed The temperature reading would have been higher if the patient had consumed anything warm within the past 15 minutes Brushing teeth in the morning would not affect a reading at PM PTS: DIF: REF: Page 84, 96 TOP: Cognitive Level: Application MSC: Nursing Process: Implementation ... tympanoplasties Test Bank 6-7 ANS: A The 10-year-old patient is a suitable candidate for use of the tympanic thermometer if the NAP uses proper technique for positioning the sensor because of the age and. .. (LPN/LVN) and nursing assistive personnel (NAP) with 10 years’ experience C The nurse counts the apical pulse for 60 seconds and then the radial pulse for 60 seconds D The apical pulse is counted for. . .Test Bank 6-2 B Normal limits are very narrow and are generally the same for all patients C Measuring equipment must suit the patient’s condition and characteristics D Environmental