Test bank for clinical nursing skills and techniques 8th edition by perry

Instant download and all chapter: Test Bank for Clinical Nursing Skills and Techniques 8th E Perry https://getbooksolutions.com/download/test-bank-for-clinical-nursing-skills-and-techniques-8thChapter 5: Vital Signs MULTIPLE CHOICE The patient is brought to the emergency department complaining of severe shortness of breath She is cyanotic and her extremities are cold In an attempt to quickly assess the patient’s respiratory status, the nurse should: a remove the patient’s nail polish to get a pulse oximetry reading b use a forehead probe to get a pulse oximetry reading c use a finger probe to get a pulse oximetry reading d check the color of the patient’s nail polish before attempting a reading ANS: B Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacologic vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas For patients with decreased peripheral perfusion, you can apply a forehead sensor Assess for factors that influence measurement of SpO2 (e.g., oxygen therapy; respiratory therapy such as postural drainage and percussion; hemoglobin level; hypotension; temperature; nail polish [Cieck et al., 2010]; medications such as bronchodilators) DIF: Cognitive Level: Analysis REF: Text reference: p 101 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations TOP: Pulse Oximetry KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity A person’s core temperature is considered the most accurate since it is: a reflective of the surrounding environment b the same for everyone c controlled by the hypothalamus d independent of external influences ANS: C The core temperature, or the temperature of the deep body tissues, is under the control of the hypothalamus and remains within a narrow range Skin or body surface temperature rises and falls as the temperature of the surrounding environment changes, and it fluctuates dramatically Body tissues and cells function best within a relatively narrow temperature range, from 36° C to 38° C (96.8° F to 100.4° F), but no single temperature is normal for all people For healthy young adults, the average oral temperature is 37° C (98.6° F) An acceptable temperature range for adults depends on age, gender, range of physical activity, hydration status, and state of health DIF: Cognitive Level: Analysis REF: Text reference: p 67 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations KEY: Nursing Process Step: Assessment TOP: Core Temperature MSC: NCLEX: Physiological Integrity The nurse takes the patient’s temperature using a tympanic electronic thermometer The temperature reading is 36.5 C (97.7 F) The nurse knows that this correlates with: a 37.0 C (98.6 F) rectally b 37.0 C (98.6 F) orally c 36.0 C (97.7 F) axillary d 36.0 C (97.7 F) orally ANS: B It generally is accepted that axillary and tympanic temperatures are usually 0.5 C (0.9 F) lower than oral temperatures It generally is accepted that rectal temperatures are usually 0.5 C (0.9 F) higher than oral temperatures DIF: OBJ: TOP: MSC: Cognitive Level: Analysis REF: Text reference: p 67 Discuss factors involved in selecting temperature measurement sites Temperature Assessment KEY: Nursing Process Step: Implementation NCLEX: Physiological Integrity The patient has an order to be off the floor for 15 minutes every hours to smoke a cigarette The patient has just returned from his “cigarette break.” The nurse is about to take the patient’s temperature orally and should: a wait about 15 minutes before taking his temperature b give him oral fluids to rinse the nicotine away before taking his temperature c give him a stick of chewing gum to chew and then take his temperature d take his oral temperature and record the findings ANS: A The nurse should verify that the patient has not had anything to eat or drink and has not chewed gum or smoked within the 15 minutes before oral temperature is measured Oral food and fluids and smoking and gum can alter temperature measurement DIF: Cognitive Level: Synthesis REF: Text reference: p 71 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations TOP: Oral Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity When evaluating the patient’s temperature levels, the nurse expects the patient’s temperature to be lower: a in the morning b after exercising c during periods of stress d during the postoperative period ANS: A Temperature is lowest during early morning Muscle activity and stress raise heat production Drugs may impair or promote sweating, vasoconstriction, or vasodilation, or may interfere with the ability of the hypothalamus to regulate temperature DIF: Cognitive Level: Comprehension REF: Text reference: p 70 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations TOP: Temperature Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity When inserting a rectal thermometer, the nurse encounters resistance The nurse should: a apply mild pressure to advance b ask the patient to take deep breaths c remove the thermometer immediately d remove the thermometer and reinsert it gently ANS: C If resistance is felt during insertion, withdraw the thermometer immediately Never force the thermometer This prevents trauma to the mucosa With the nondominant hand, separate the patient’s buttocks to expose the anus Ask the patient to breathe slowly and relax This fully exposes the anus for thermometer insertion and relaxes the anal sphincter for easier thermometer insertion DIF: Cognitive Level: Application REF: Text reference: p 72 OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures TOP: Rectal Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity An appropriate procedure for measurement of an adult’s temperature with a tympanic membrane sensor is: a pulling the ear pinna down and back b moving into the ear in a figure-eight pattern c fitting the probe loosely into the ear canal d pointing the probe toward the mouth and chin ANS: B Move the thermometer in a figure-eight pattern Pull the ear pinna backward, up, and out for an adult; fit the speculum tip snugly in the canal and not move; and point the speculum tip toward the nose DIF: Cognitive Level: Application REF: Text reference: p 75 OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures TOP: Rectal Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity The patient is a 1-year-old male infant who is admitted with possible sepsis The patient is irritable and agitates easily What should the nurse to assess the patient’s temperature? a Take an oral temperature before doing anything else b Take an axillary temperature using the upper axilla c Place the child in Sims’ position for a rectal temperature d Take a rectal temperature as the last vital sign ANS: D Critically ill children sometimes have cool skin but a high core temperature because of poor perfusion to the skin Children may assume the prone position for rectal temperature measurement With children who cry or are restless, it is best to take temperature as the last vital sign Use axillary temperatures for screening purposes only, not to detect fevers in infants and young children Use the lower axilla to record temperature in side-lying infants DIF: Cognitive Level: Application REF: Text reference: p 76 OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures TOP: Temperature Assessment in Pediatric Patients KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity The patient is returning from a cardiac catheterization The puncture site is in the right femoral artery The patient is having vital signs assessed every 15 minutes Along with vital signs, the nurse assesses the pedal pulses of the right and left feet Which of the following would be of major concern? a Both pedal pulses were bounding b The femoral artery could be palpated c The right pedal pulse was weaker than the left d The radial artery pulse was 88 ANS: C If a peripheral pulse distal to an injured or treated area of an extremity feels weak on palpation, the volume of blood reaching tissues below the affected area may be inadequate, and surgical intervention may be necessary A full bounding pulse is an indication of increased volume When the pulse wave reaches a peripheral artery, you can feel it by palpating the artery lightly against underlying bone or muscle The pulse is the palpable bounding of the blood flow The usual range for adults is 60 to 100 beats per minute DIF: Cognitive Level: Analysis REF: Text reference: p 77 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations TOP: Pulse Assessment KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 10 The patient has an order to be off the floor for 15 minutes every hours to smoke a cigarette The patient has just returned from his “cigarette break.” The nurse is about to take the patient’s radial pulse and should: a wait about 15 minutes before taking his pulse b use her thumb to detect the pulse and get an accurate count c press hard to detect the pulse and get an accurate count d take his pulse for 15 seconds and multiply by ANS: A If a patient has been smoking, wait 15 minutes before assessing pulse Anxiety, activity, and smoking elevate heart rate Assessing radial pulse rate at rest allows for objective comparison of values Fingertips are the most sensitive parts of the hand for palpating arterial pulsation The nurse’s thumb has pulsation that interferes with accuracy Pulse assessment is more accurate when moderate pressure is used Too much pressure occludes pulse and impairs blood flow If the pulse is regular, count the rate for 30 seconds and multiply the total by If the pulse is irregular, count the rate for a full 60 seconds Assess the frequency and the pattern of irregularity DIF: OBJ: KEY: MSC: Cognitive Level: Analysis REF: Text reference: p 78 Accurately assess a patient’s radial and apical pulses TOP: Pulse Assessment Nursing Process Step: Implementation NCLEX: Physiological Integrity 11 When evaluating the radial pulse measurement technique of the nursing assistant, the nurse identifies appropriate technique when the assistant: a has the patient’s arm elevated b positions the patient supine or sitting c applies significant pressure to the pulse site d counts the pulse for 15 seconds and multiplies by ANS: B Assist the patient to assume a supine or sitting position If the patient is supine, place the patient’s forearm straight alongside or across the lower chest or upper abdomen with the wrist extended straight If the patient is sitting, bend the patient’s elbow 90 degrees and support the lower arm on the chair or on the nurse’s arm Slightly extend or flex the wrist with the palm down until the strongest pulse is noted Lightly compress against the radius, obliterate the pulse initially, and then relax pressure so the pulse becomes easily palpable Pulse is assessed more accurately with moderate pressure Too much pressure occludes the pulse and impairs blood flow If the pulse is regular, count the rate for 30 seconds and multiply the total by If the pulse is irregular, count the rate for 60 seconds Assess frequency and pattern of irregularity DIF: OBJ: TOP: MSC: Cognitive Level: Comprehension REF: Text reference: p 79 Appropriately delegate vital sign measurements to nursing assistive personnel (NAP) Delegation of Pulse Assessment KEY: Nursing Process Step: Assessment NCLEX: Physiological Integrity 12 The nurse is caring for an infant in the NICU While taking vital signs, the nurse finds that the baby’s heart rate is 195 The nurse calls the physician, knowing that the normal heart rate should be: a 60 to 100 beats per minute b 100 to 160 beats per minute c 90 to 140 beats per minute d 220 beats per minute or higher ANS: B The infant’s heart rate at birth ranges from 100 to 160 beats per minute at rest By adolescence, the heart rate varies between 60 and 100 beats per minute and remains so throughout adulthood By age 2, the pulse rate slows to 90 to 140 beats per minute DIF: Cognitive Level: Analysis REF: Text reference: p 82 OBJ: Accurately assess a patient’s radial and apical pulses TOP: Assessing Apical Pulse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13 The patient has been in the hospital for several days for urosepsis He has been responding favorably to treatment, and his vital signs have been “normal” for days When the nurse takes his vital signs, however, the patient’s apical pulse is 152 and regular The nurse suspects that the: a b c d patient is having a reaction to his narcotic medication patient may be suffering from hypothermia patient’s fever may have returned patient may be an athlete ANS: C Fever or exposure to warm environments increases heart rate Large doses of narcotic analgesics and hypothermia can slow heart rate A well-conditioned patient may have a slower than usual resting heart rate, which returns more quickly to resting rate after exercise DIF: Cognitive Level: Synthesis REF: Text reference: p 82 OBJ: Accurately assess a patient’s radial and apical pulses TOP: Assessing Apical Pulse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14 What steps should the nurse take to conduct an assessment of a possible pulse deficit? a A nurse measures the pulse after the patient exercises b Two nurses check the same pulse on opposite sides of the body c Two nurses assess the apical and radial pulses and determine the difference d The current pulse is compared with previous pulse measurements for differences ANS: C Locate apical and radial pulse sites One nurse auscultates the apical pulse, and one nurse palpates the radial pulse Both nurses count the pulse rate for 60 seconds simultaneously Subtract the radial rate from the apical rate to obtain the pulse deficit The pulse deficit reflects the number of ineffective cardiac contractions in minute If a pulse deficit is noted, assess for other signs and symptoms of decreased cardiac output DIF: OBJ: KEY: MSC: Cognitive Level: Application REF: Text reference: p 85 Explain the implications of a pulse deficit TOP: Pulse Deficit Nursing Process Step: Implementation NCLEX: Physiological Integrity 15 An appropriate method of assessing a patient’s respirations is for the nurse to: a place the bed flat b remove all supplemental oxygen sources from documentation c explain to the patient that respirations are being assessed d gently place the patient’s hand in a relaxed position over the upper abdomen ANS: D Place the patient’s arm in a relaxed position across the abdomen or lower chest, or place the nurse’s hand directly over the patient’s upper abdomen Be sure the patient is in a comfortable position, preferably sitting or lying with the head of the bed elevated 45 to 60 degrees Sitting erect promotes full ventilatory movement A position of discomfort may cause the patient to breathe more rapidly Documentation should include any supplemental oxygen that the patient is receiving Inconspicuous assessment of respirations immediately after pulse assessment prevents the patient from consciously or unintentionally altering the rate and depth of breathing DIF: Cognitive Level: Application REF: Text reference: p 88 OBJ: Accurately assess a patient’s respirations TOP: Respiratory Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16 The nurse is about to take vital signs on a newborn patient in the nursery She should: a assess respiratory rate after taking a rectal temperature b observe the child’s chest while the child is sleeping c call the physician if the rate is over 40 d expect that the child will have short periods of apnea ANS: D An irregular respiratory rate and short apneic spells are normal for newborns Assess respiratory rate before other vital signs or assessments are taken Children up to age breathe abdominally, so respirations are observed by abdominal movement Average respiratory rate (breaths per minute) for newborns is 30 to 60; for infants (6 months to year), 30 to 50; for toddlers (2 years), 25 to 32; and for children from to 12 years, 20 to 30 DIF: OBJ: KEY: MSC: Cognitive Level: Analysis REF: Text reference: p 90 Accurately assess a patient’s respirations TOP: Pediatric Considerations Nursing Process Step: Implementation NCLEX: Physiological Integrity 17 The nurse should report an assessment of _ respirations per minutes for a(n) _ a 14; adult patient b 16; 8-year-old patient c 25; toddler d 38; newborn ANS: B Acceptable average respiratory rate (breaths per minute) for newborns is 35 to 40; for infants (6 months), 30 to 50; for toddlers (2 years), 22 to 32; and for children, 20 to 30 Adults average 12 to 20 respirations per minute DIF: OBJ: TOP: MSC: Cognitive Level: Application REF: Text reference: p 90 Identify ranges of acceptable vital sign values for infant, child, and adult Respiratory Assessment KEY: Nursing Process Step: Assessment NCLEX: Physiological Integrity 18 During the normal cardiac cycle, blood pressure reaches a peak, followed by a trough, in the cycle What is the peak known as? a Pulse pressure b Systole c Diastole d Korotkoff phase ANS: B Blood pressure is the force exerted by blood against the vessel walls During a normal cardiac cycle, blood pressure reaches a peak, followed by a trough, or low point, in the cycle The peak pressure occurs when the heart’s ventricular contraction, or systole, forces blood under high pressure into the aorta The difference between systolic pressure and diastolic pressure is the pulse pressure When the ventricles relax, the blood remaining in the arteries exerts a minimum or diastolic pressure Diastolic pressure is the minimal pressure exerted against the arterial wall at all times As the sphygmomanometer cuff is deflated, the five different sounds heard over an artery are called Korotkoff phases DIF: Cognitive Level: Knowledge REF: Text reference: p 90 OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation TOP: Systolic Blood Pressure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19 The patient is complaining of a severe headache The nurse takes the patient’s blood pressure and finds it to be 240/110 What is the pulse pressure? a 110 b 240 c 130 d 350 ANS: C The difference between systolic pressure and diastolic pressure is the pulse pressure For a blood pressure of 240/110, the pulse pressure is 130 The diastolic pressure is 110 The systolic pressure is 240 The sum of the systolic and diastolic pressures is 350 DIF: OBJ: TOP: MSC: Cognitive Level: Analysis REF: Text reference: p 90 Accurately assess a patient’s blood pressure using techniques of auscultation and palpation Pulse Pressure KEY: Nursing Process Step: Implementation NCLEX: Physiological Integrity 20 During his initial screening, the patient’s blood pressure was noted to be elevated Two months after the first assessment, he was noted to have a blood pressure of 150/92 and 166/96 at different times during the visit It is now a month and a half later, and the nurse is concerned because the patient’s initial blood pressure on this visit was 154/94 She is preparing to take a second blood pressure, understanding that another reading in this range could lead to a diagnosis of: a hypotension b prehypertension c hypertension d orthostatic hypotension ANS: C Hypertension is defined as systolic blood pressure (SBP) of 140 mm Hg or greater, diastolic blood pressure (DBP) of 90 mm Hg or greater, or taking antihypertensive medication (NHBPEP, 2003) One blood pressure recording revealing a high SBP or DBP does not qualify as a diagnosis of hypertension However, if you assess a high reading (e.g., 150/90 mm Hg), encourage the patient to return for another checkup within months The diagnosis of hypertension in adults requires an average of two or more readings taken at each of two or more visits after an initial screening Hypotension occurs when the systolic blood pressure falls to 90 mm Hg or below Prehypertension is a designation for patients at high risk for developing hypertension In these patients, early intervention through adoption of healthy lifestyles reduces the risk of or prevents hypertension Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., lightheadedness, dizziness) and low blood pressure when rising to an upright position DIF: OBJ: TOP: MSC: Cognitive Level: Synthesis REF: Text reference: p 91 Accurately assess a patient’s blood pressure using techniques of auscultation and palpation Hypertension KEY: Nursing Process Step: Evaluation NCLEX: Physiological Integrity 21 The patient is an 86-year-old woman who is being admitted for dehydration and pneumonia The patient is lying in bed but tells the nurse that she needs to go to the bathroom The nurse tells the patient that she will stay with her and will help her get there The patient states, “That’s OK I can make it on my own.” The nurse should: a help the patient to the bathroom and stay with her b allow the patient to get up on her own and go to the bathroom c allow the patient to go to the bathroom and call for help if needed d insert a Foley catheter ANS: A Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., lightheadedness, dizziness) and low blood pressure when rising to an upright position Orthostatic changes in vital signs are good indicators of blood volume depletion In severe cases of orthostatic hypotension, loss of consciousness may occur Foley catheters are believed to be a major source or urinary tract infection DIF: OBJ: TOP: MSC: Cognitive Level: Synthesis REF: Text reference: p 91 |Text reference: p 98 Accurately assess a patient’s blood pressure using techniques of auscultation and palpation Orthostatic Hypotension KEY: Nursing Process Step: Evaluation NCLEX: Physiological Integrity 22 The nurse chooses a sphygmomanometer that has a circular gauge and a needle that registers the millimeter calibrations This type of device is known as a(n) _ manometer a mercury b electronic c aneroid d direct (invasive) ANS: C The aneroid manometer has a glass-enclosed circular gauge containing a needle that registers millimeter calibrations Metal parts in the aneroid manometer are subject to temperature expansion and contraction and must be recalibrated at least every months to verify their accuracy Before using the aneroid manometer, make sure the needle is pointing to zero With mercury manometers, pressure created by inflation of the compression cuff moves the column of mercury up the tube against the force of gravity Millimeter calibrations mark the height of the mercury column Electronic or automatic blood pressure machines consist of an electronic sensor positioned inside a blood pressure cuff attached to an electronic processor You measure arterial blood pressure either directly (invasively) or indirectly (noninvasively) The direct method requires electronic monitoring equipment and the insertion of a thin catheter into an artery The risks associated with invasive blood pressure monitoring require use in an intensive care setting DIF: OBJ: TOP: MSC: Cognitive Level: Knowledge REF: Text reference: p 91 Accurately assess a patient’s blood pressure using techniques of auscultation and palpation Manometers KEY: Nursing Process Step: Diagnosis NCLEX: Physiological Integrity 23 The nurse is working on the general surgical unit and is caring for a patient who has a right total mastectomy To take the patient’s vital signs and to accurately assess the patient’s blood pressure, it will be necessary to: a place the blood pressure cuff on the left upper arm b place the blood pressure cuff on the right upper arm c place the blood pressure cuff on the right lower arm d use direct (invasive) blood pressure measurement ANS: A Determine the best site for blood pressure assessment Avoid applying the cuff to an extremity when intravenous fluids are infusing, an arteriovenous shunt or fistula is present, or breast or axillary surgery has been performed on that side The risks associated with invasive blood pressure monitoring require use in an intensive care setting DIF: OBJ: TOP: MSC: Cognitive Level: Application REF: Text reference: p 93 Describe factors involved in selecting an extremity to measure blood pressure Manometers KEY: Nursing Process Step: Implementation NCLEX: Physiological Integrity 24 Which site is used to auscultate blood pressure? a Radial b Ulnar c Brachial d Temporal ANS: C Place the stethoscope over the brachial artery to measure blood pressure Use the radial site for the radial pulse, the ulnar site for the ulnar pulse, and the temporal site for the temporal pulse DIF: OBJ: TOP: MSC: Cognitive Level: Application REF: Text reference: p 77 Describe factors involved in selecting an extremity to measure blood pressure Brachial Pulse KEY: Nursing Process Step: Implementation NCLEX: Physiological Integrity 25 The nurse is caring for a 2-year-old child who is admitted with croup and crying To take the child’s vital signs, the nurse should: a place the pediatric blood pressure cuff on the left arm b place the blood pressure cuff on the right thigh c skip the blood pressure measurement d place the blood pressure cuff on the left thigh ANS: C Blood pressure is not a routine part of assessment in children younger than years The right arm is preferred for blood pressure measurement in children older than Thigh blood pressure is the least preferred and the most uncomfortable method for children DIF: OBJ: TOP: MSC: Cognitive Level: Analysis REF: Text reference: p 98 Describe factors involved in selecting an extremity to measure blood pressure Teaching Considerations KEY: Nursing Process Step: Implementation NCLEX: Physiological Integrity 26 When the benefits of the different types of blood pressure monitoring devices are compared, which of the following patients would be the best candidate for noninvasive electronic blood pressure measurement? a A 49-year-old postsurgical patient with no history of heart disease on q15min vital signs b A 22-year-old patient undergoing active grand mal seizures c A 68-year-old patient with diagnosed peripheral vascular disease d A 54-year-old patient with chronic atrial fibrillation ANS: A These devices are used when frequent assessment is required, as in critically ill or potentially unstable patients; during or after invasive procedures; or when therapies require frequent monitoring Patients with irregular heart rate, peripheral vascular disease, seizures, tremors, and shivering are not candidates for this device DIF: OBJ: TOP: KEY: Cognitive Level: Analysis REF: Text reference: p 99 Discuss the benefits and disadvantages of using an automatic blood pressure machine Noninvasive Electronic Blood Pressure Measurement Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 27 The patient was found in an alley on a cold winter night and is admitted with hypothermia from environmental exposure She is elderly and is having difficulty breathing Her breath sounds are diminished, and the tip of her nose is cyanotic The nurse wants to assess the oxygen level in the patient’s blood She decides to use the pulse oximeter The best way to apply this to this patient would be with a(n): a finger probe b earlobe sensor c forehead sensor d toe sensor ANS: C In adults, you can apply reusable and disposable oximeter probes to the earlobe, finger, toe, bridge of the nose, or forehead For patients with decreased peripheral perfusion, you can apply a forehead sensor Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacologic vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas DIF: OBJ: TOP: MSC: Cognitive Level: Analysis REF: Text reference: p 101 Accurately assess a patient’s oxygenation status using pulse oximetry Oxygen Saturation KEY: Nursing Process Step: Implementation NCLEX: Physiological Integrity 28 The patient is admitted in a near comatose state with a blood glucose level of 750 His respiratory rate is 42 breaths per minute, and his respiratory pattern is deep and regular What is this type of breathing known as? a Cheyne-Stokes respiration b Biot’s respiration c Bradypnea d Kussmaul’s respiration ANS: D Respirations are abnormally deep, regular, and increased in rate This is common in diabetic ketoacidosis With Cheyne-Stokes respirations, respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation The respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth The pattern reverses, and breathing slows and becomes shallow, climaxing in apnea before respiration resumes With Biot’s respirations, respirations are abnormally shallow for two to three breaths followed by an irregular period of apnea With bradypnea, the rate of breathing is regular but abnormally slow (fewer than 12 breaths per minute) DIF: Cognitive Level: Analysis REF: Text reference: p 89 OBJ: Accurately assess a patient’s respirations TOP: Breathing Patterns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29 What is a disadvantage of using the disposable sensor pad for pulse oximetry? a It is less restrictive b It contains latex c It is less expensive to use d It is available in different sizes ANS: B A disposable sensor pad can be applied to a variety of sites, including the earlobe of an adult and the nose bridge, palm, or sole of an infant It is less restrictive for continuous SpO2 monitoring It is expensive and contains latex, which some patients may not be able to tolerate The skin under the adhesive may become moist and may harbor pathogens It is available in a variety of sizes, and the pad can be matched to infant weight DIF: OBJ: TOP: MSC: Cognitive Level: Application REF: Text reference: p 101 Accurately assess a patient’s oxygenation status using pulse oximetry Oxygen Saturation KEY: Nursing Process Step: Implementation NCLEX: Physiological Integrity MULTIPLE RESPONSE The nurse is preparing to take the patient’s temperature Which of the following may cause the temperature to fluctuate? (Select all that apply.) a Age b Stress c Hormones d Medications ANS: A, B, C, D Older adults have a narrower range of temperature than younger adults A temperature within an acceptable range in an adult may reflect a fever in an older adult Undeveloped temperature control mechanisms in infants and children cause temperature to rise and fall rapidly Stress elevates temperature Women have wider temperature fluctuations than men because of menstrual cycle hormonal changes; body temperature varies during menopause Some drugs impair or promote sweating, vasoconstriction, or vasodilation, or interfere with the ability of the hypothalamus to regulate temperature DIF: Cognitive Level: Analysis REF: Text reference: p 70 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations TOP: Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity Which of the following processes are involved in respiration? (Select all that apply.) a Ventilation b Diffusion c Oximetry d Perfusion ANS: A, B, D Three processes are involved in respiration: ventilation, mechanical movement of gases into and out of the lungs; diffusion, movement of O2 and CO2 between the alveoli and the red blood cells; and perfusion, distribution of red blood cells to and from the pulmonary capillaries DIF: Cognitive Level: Comprehension REF: Text reference: p 86 OBJ: Accurately assess a patient’s respirations TOP: Respiratory Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity The nurse is about to teach the patient about risk factors for hypertension Which of the following are risk factors for hypertension? (Select all that apply.) a Obesity b Cigarette smoking c High blood cholesterol d Renal disease ANS: A, B, C, D Persons with a family history of hypertension, premature heart disease, lipemia, or renal disease are at significant risk Obesity, cigarette smoking, heavy alcohol consumption, high blood cholesterol and triglyceride levels, and continued exposure to stress from psychosocial and environmental conditions are factors linked to hypertension DIF: Cognitive Level: Knowledge REF: Text reference: p 93 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations TOP: Teaching Considerations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity The nurse is about to take a patient’s blood pressure Which of the following conditions would cause the nurse to obtain a false high reading? (Select all that apply.) a Bladder or cuff too narrow b Bladder or cuff too wide c Patient’s arm below the level of the heart d Inflating the cuff too slowly ANS: A, C, D Bladder or cuff too narrow or too short, arm below heart level, or inflating the cuff too slowly will give a false high reading A bladder or cuff too wide will give a false low reading DIF: Cognitive Level: Analysis REF: Text reference: p 92 OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation TOP: Common Mistakes in Blood Pressure Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION _, a subjective symptom, is also referred to as a vital sign, along with the physiological signs ANS: Pain Pain, a subjective symptom, is also referred to as a vital sign, along with the physiological signs DIF: Cognitive Level: Comprehension REF: Text reference: p 66 OBJ: Identify when it is appropriate to assess each vital sign TOP: Pain as a Vital Sign KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity When heat loss mechanisms are unable to keep pace with heat production, is the result ANS: fever Fever occurs when heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature DIF: Cognitive Level: Analysis REF: Text reference: p 67 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations TOP: Core Temperature KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity The nurse is taking a rectal temperature on an adult patient She expects to insert the thermometer inches ANS: 1.5 Gently insert the thermometer into the anus in the direction of the umbilicus 3.5 cm (1.5 inches) for an adult Do not force the thermometer DIF: Cognitive Level: Application REF: Text reference: p 72 OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures TOP: Rectal Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity The patient has been sleeping and has been lying on his right side The nurse is ready to take his temperature using a tympanic thermometer She needs to insert the thermometer into his _ ear ANS: left If the patient has been lying on one side, use the upper ear Heat trapped in the ear facing down will cause a false high temperature reading DIF: Cognitive Level: Application REF: Text reference: p 74 OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures TOP: Tympanic Membrane Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity An irregular heartbeat, often found in children, that speeds up with inspiration and slows down with expiration is known as a sinus _ ANS: dysrhythmia Children often have a sinus dysrhythmia, which is an irregular heartbeat that speeds up with inspiration and slows down with expiration DIF: OBJ: TOP: KEY: Cognitive Level: Analysis REF: Text reference: p 80 Accurately assess a patient’s radial and apical pulses Pulse Assessment—Pediatric Considerations Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity _ is the sound of the tricuspid and mitral valves closing at the end of ventricular filling ANS: S1 S1 is the sound of the tricuspid and mitral valves closing at the end of ventricular filling, just before systolic contraction begins DIF: Cognitive Level: Application REF: Text reference: p 81 OBJ: Accurately assess a patient’s radial and apical pulses TOP: Assessing Apical Pulse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity _ is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction ANS: S2 S2 is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction DIF: Cognitive Level: Application REF: Text reference: p 81 OBJ: Accurately assess a patient’s radial and apical pulses TOP: Assessing Apical Pulse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a ANS: pulse deficit An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit Pulse deficits frequently are associated with dysrhythmias and warn of potentially decreased cardiac function DIF: Cognitive Level: Comprehension REF: Text reference: p 85 OBJ: Accurately assess a patient’s radial and apical pulses TOP: Pulse Deficit KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity To take a manual blood pressure, the nurse places the cuff of the _ around the patient’s upper arm ANS: sphygmomanometer The most common technique of measuring blood pressure is auscultation using a sphygmomanometer and stethoscope DIF: OBJ: TOP: MSC: Cognitive Level: Comprehension REF: Text reference: p 90 Accurately assess a patient’s blood pressure using techniques of auscultation and palpation Sphygmomanometer KEY: Nursing Process Step: Implementation NCLEX: Physiological Integrity 10 After applying the sphygmomanometer to the patient’s upper arm, the nurse inflates the cuff to the proper level, and then, using a stethoscope, listens for the sounds ANS: Korotkoff The most common technique used for measuring blood pressure is auscultation with a sphygmomanometer and stethoscope As the sphygmomanometer cuff is deflated, the five different sounds heard over an artery are called Korotkoff phases The sound in each phase has unique characteristics Blood pressure is recorded with the systolic reading (first Korotkoff sound) before the diastolic reading (beginning of the fifth Korotkoff sound) DIF: OBJ: TOP: MSC: Cognitive Level: Application REF: Text reference: p 90 Accurately assess a patient’s blood pressure using techniques of auscultation and palpation Korotkoff Sounds KEY: Nursing Process Step: Implementation NCLEX: Physiological Integrity 11 _ occurs when the systolic blood pressure falls to 90 mm Hg or below ANS: Hypotension Hypotension occurs when the systolic blood pressure falls to 90 mm Hg or below Although some adults normally have a low blood pressure, for most people, low blood pressure is an abnormal finding associated with illness DIF: OBJ: TOP: MSC: Cognitive Level: Knowledge REF: Text reference: p 91 Accurately assess a patient’s blood pressure using techniques of auscultation and palpation Hypotension KEY: Nursing Process Step: Evaluation NCLEX: Physiological Integrity 12 The percent to which hemoglobin is filled with oxygen is known as _ ANS: arterial blood oxygen saturation Pulse oximetry is the noninvasive measurement of arterial blood oxygen saturation—the percent to which hemoglobin is filled with oxygen DIF: OBJ: TOP: MSC: Cognitive Level: Knowledge REF: Text reference: p 101 Accurately assess a patient’s oxygenation status using pulse oximetry Oxygen Saturation KEY: Nursing Process Step: Assessment NCLEX: Physiological Integrity ... pulse and impairs blood flow If the pulse is regular, count the rate for 30 seconds and multiply the total by If the pulse is irregular, count the rate for a full 60 seconds Assess the frequency and. .. observed by abdominal movement Average respiratory rate (breaths per minute) for newborns is 30 to 60; for infants (6 months to year), 30 to 50; for toddlers (2 years), 25 to 32; and for children... nondominant hand, separate the patient’s buttocks to expose the anus Ask the patient to breathe slowly and relax This fully exposes the anus for thermometer insertion and relaxes the anal sphincter for