Ramont2e Rev TIF Ch21

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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank

Chapter 21Question 1

Type: MCSA

The nurse would measure vital signs more frequently than every 4 hours for which of the following clients?

1. The client with a diagnosis of terminal cancer admitted for palliative care

2. The client who is 6 days postoperative and is to be discharged tomorrow

3. The client admitted as an outpatient for ! hours while receiving a blood transfusion

. The client who is "6 hours postoperative and stable

Corre!t "ns#er: "

Rationa$e 1# A client receiving blood transfusions requires vital signs before beginning the transfusion$ %

minutes after starting the transfusion and then hourly from that point onward until the transfusion is completed&

The other clients would require vital signs every 4 hours unless a complication or change in condition arose&

Rationa$e 2# A client receiving blood transfusions requires vital signs before beginning the transfusion$ %

minutes after starting the transfusion and then hourly from that point onward until the transfusion is completed&


Rationa$e 3# A client receiving blood transfusions requires vital signs before beginning the transfusion$ %minutes after starting the transfusion and then hourly from that point onward until the transfusion is completed&


Rationa$e # A client receiving blood transfusions requires vital signs before beginning the transfusion$ %

minutes after starting the transfusion and then hourly from that point onward until the transfusion is completed&The other clients would require vital signs every 4 hours unless a complication or change in condition arose&

%$o&a$ Rationa$e:

Cogniti'e (e'e$: Applying

C$ient Need: 'hysiological (ntegrityC$ient Need )u&:

Nursing*+ntegrated Con!epts: )ursing 'rocess# 'lanning

(earning ut!ome: (dentify times when vital signs should be measured&

Question 2

Type: MCSA

*amont$ )iedringhous$ Comprehensive Nursing Care !nd +dition ,pdate Test -an.

Copyright !/! by 'earson +ducation$ (nc&



3. The client is hypertensive$ and the physician should be notified&

. The pulse is borderline low$ and requires further assessment&

Corre!t "ns#er: 4

Rationa$e 1# The client2s pulse is borderline low$ and further assessment is needed$ as this could be normal for the

child$ or the child could have a problem& *emaining vital signs are within normal limits&





Rationa$e # The client2s pulse is borderline low$ and further assessment is needed$ as this could be normal for the


%$o&a$ Rationa$e:


C$ient Need: 'hysiological (ntegrity

C$ient Need )u&:

Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment

(earning ut!ome: (dentify normal ranges for each vital sign by age&

Question

Type: MCSA

The nursing student is ta.ing blood pressures at a health3screening fair in the local mall& A !63year3old woman

who is seven months pregnant has a blood pressure reading of 46:99& 0hich of the following actions does the

nursing student ta.e?

1. Tell the client that she has a normal blood pressure&

2. Call 9 for an ambulance because the blood pressure is dangerously high&

3. Advise the client to notify her physician immediately of the results&

. Advise the woman to go home$ rest$ and put her feet up&

Corre!t "ns#er: "

Rationa$e 1# The blood pressure for this client is too high$ and the client is advised to contact her physicianimmediately& There is no evidence that the client is in any distress$ so calling 9 is unnecessary& The blood

pressure$ however$ is too high to send the client home to rest& The pregnant client might run a slightly higher

pressure than normal for her age$ but$ this blood pressure is an indication of problems for the client and her baby&





Rationa$e 3# The client is e<hibiting all the signs of hypothermia& 1ital signs are all decreased$ so the client is note<periencing pyre<ia >fever$ or a remittent fever$ which would occur with an elevated temperature& There is no

such thing as vital sign crisis&

Rationa$e # The client is e<hibiting all the signs of hypothermia& 1ital signs are all decreased$ so the client is not

e<periencing pyre<ia >fever$ or a remittent fever$ which would occur with an elevated temperature& There is nosuch thing as vital sign crisis&

%$o&a$ Rationa$e:

Cogniti'e (e'e$: Analy@ing


C$ient Need )u&:


(earning ut!ome: ;escribe factors that affect temperature and its accurate measurement&

Question

Type: MCSA

0hen measuring temperature on a client who comes to the clinic drin.ing coffee$ the nurse would use what route

1. ral

2. *ectal

3. Tympanic

. A<illary

Corre!t "ns#er: "

Rationa$e 1# The best route for measuring temperature would be tympanic& ral is contraindicated because the

client is drin.ing hot coffee& A<illary would be less accurate than would tympanic& *ectal would be embarrassing

for the client$ and is not required in order to get an accurate temperature&

Rationa$e 2# The best route for measuring temperature would be tympanic& ral is contraindicated because theclient is drin.ing hot coffee& A<illary would be less accurate than would tympanic& *ectal would be embarrassing


Rationa$e 3# The best route for measuring temperature would be tympanic& ral is contraindicated because theclient is drin.ing hot coffee& A<illary would be less accurate than would tympanic& *ectal would be embarrassingfor the client$ and is not required in order to get an accurate temperature&

Rationa$e # The best route for measuring temperature would be tympanic& ral is contraindicated because the

client is drin.ing hot coffee& A<illary would be less accurate than would tympanic& *ectal would be embarrassing






%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: ;escribe factors that affect temperature and its accurate measurement&

Question /

Type: MCSA

The nurse measures pulse rate on a young adult male and obtains a rate of 44 per minute& The nurse would

consider this pulse rate normal if which of the following data were assessed?

1. The client is on Bano<in >digo<in for heart disease&

2. The client is an athlete&

3. The client has awasa.i2s disease&

. The client has a congenital cardiac defect&

Corre!t "ns#er: !

Rationa$e 1# 0hen all other vital signs and assessments are normal$ and the client has no signs or symptoms of

reduced perfusion$ the nurse would consider the pulse rate acceptable if the client were an athlete& Athletes

strengthen their cardiac muscle$ resulting in increased stro.e volume$ requiring a lower pulse rate to meet tissuedemands& A heart rate of 44 would be considered abnormal and potentially dangerous for all of the other options&







Rationa$e # 0hen all other vital signs and assessments are normal$ and the client has no signs or symptoms ofreduced perfusion$ the nurse would consider the pulse rate acceptable if the client were an athlete& Athletes


%$o&a$ Rationa$e:






The nurse is wor.ing in the )(C, and is caring for an infant who weighs %// grams& The child is being

monitored$ and has several electrodes on the chest& The nurse is unable to hear the apical pulse through the

electrodes$ and does not want to remove the electrodes and damage the infant2s s.in& The nurse chec.s the infant2s

pulse at which of the following sites?

1. -rachial artery

2. *adial artery

3. 'edal artery

. Dugular artery

Corre!t "ns#er:

Rationa$e 1# The brachial artery would be the best choice for this infant if the apical pulse were not an option&

The radial and pedal arteries might not have enough pressure to adequately assess& The Eugular is a vein$ not an

artery&

Rationa$e 2# The brachial artery would be the best choice for this infant if the apical pulse were not an option&The radial and pedal arteries might not have enough pressure to adequately assess& The Eugular is a vein$ not an

artery&

Rationa$e 3# The brachial artery would be the best choice for this infant if the apical pulse were not an option&

The radial and pedal arteries might not have enough pressure to adequately assess& The Eugular is a vein$ not anartery&

Rationa$e # The brachial artery would be the best choice for this infant if the apical pulse were not an option&

The radial and pedal arteries might not have enough pressure to adequately assess& The Eugular is a vein$ not anartery&

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: 'oint to the nine sites commonly used to assess the pulse and state the reasons each sitemight be used&

Question 1

Type: MCSA

The nurse is caring for a 5/3year3old client who suddenly becomes confused and tells the nurse she has to go

catch the bus& The nurse assesses which of the following before notifying the physician?

1. 'resence of an apical pulse rate





2. The strength of the radial artery

3. 'resence of carotid pulses bilaterally

. The femoral pulses

Corre!t "ns#er: "

Rationa$e 1# The client might be e<periencing decreased blood flow to the brain as a result of reduced carotid

perfusion& The nurse would lightly palpate for the carotid arteries$ ta.ing care to palpate only one side at a time$

before notifying the physician& 'resence of an apical pulse is indicated by the client2s spea.ing$ and radial arterystrength and femoral pulses would not apply to the situation&

Rationa$e 2# The client might be e<periencing decreased blood flow to the brain as a result of reduced carotid

perfusion& The nurse would lightly palpate for the carotid arteries$ ta.ing care to palpate only one side at a time$


Rationa$e 3# The client might be e<periencing decreased blood flow to the brain as a result of reduced carotid perfusion& The nurse would lightly palpate for the carotid arteries$ ta.ing care to palpate only one side at a time$


Rationa$e # The client might be e<periencing decreased blood flow to the brain as a result of reduced carotid

perfusion& The nurse would lightly palpate for the carotid arteries$ ta.ing care to palpate only one side at a time$ before notifying the physician& 'resence of an apical pulse is indicated by the client2s spea.ing$ and radial artery

strength and femoral pulses would not apply to the situation&

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: 'oint to the nine sites commonly used to assess the pulse and state the reasons each site

might be used&

Question 11

Type: MCMA

The nurse assesses the client2s pulse for which of the following? Select all that apply&

)tandard Tet: Select all that apply&

1. *ate

2. *hythm





3. Strength

. -ilateral equality

-. Stro.e volume

Corre!t "ns#er: $!$"$4

Rationa$e 1# Stro.e volume cannot be determined by assessing the pulse& All other options should be included

when assessing pulse&

Rationa$e 2# Stro.e volume cannot be determined by assessing the pulse& All other options should be includedwhen assessing pulse&

Rationa$e 3# Stro.e volume cannot be determined by assessing the pulse& All other options should be included


Rationa$e # Stro.e volume cannot be determined by assessing the pulse& All other options should be included


Rationa$e -# Stro.e volume cannot be determined by assessing the pulse& All other options should be included


%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: (dentify normal ranges for pulse rate and quality when assessing a client2s pulse&

Question 12

Type: MCMA

0hen assessing the apical3radial pulse using the two3nurse method$ the nurses include which of the following?

Select all that apply&


1. 'lace the client supine with the =- elevated "/ degrees&

2. Bocate the 'M( and radial pulses&

3. Bocate the femoral pulses&

. +ach nurse counts for "/ full seconds&





. ;iminished breath sounds

Corre!t "ns#er: !

Rationa$e 1# At a higher altitude$ there is less o<ygen in the atmosphere$ requiring faster respirations to obtain the

same o<ygen acquired at lower elevations& The respirations would increase to try to obtain more o<ygen& See3saw

respirations are uneven breathing$ and diminished breath sounds are not a part of counting respirations&

Rationa$e 2# At a higher altitude$ there is less o<ygen in the atmosphere$ requiring faster respirations to obtain thesame o<ygen acquired at lower elevations& The respirations would increase to try to obtain more o<ygen& See3saw


Rationa$e 3# At a higher altitude$ there is less o<ygen in the atmosphere$ requiring faster respirations to obtain the

same o<ygen acquired at lower elevations& The respirations would increase to try to obtain more o<ygen& See3sawrespirations are uneven breathing$ and diminished breath sounds are not a part of counting respirations&

Rationa$e # At a higher altitude$ there is less o<ygen in the atmosphere$ requiring faster respirations to obtain the

same o<ygen acquired at lower elevations& The respirations would increase to try to obtain more o<ygen& See3saw


%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: ;escribe factors that affect respiration and its accurate measurement&

Question 1

Type: MCSA

The nurse assesses respirations on a postoperative client receiving morphine every four hours$ and anticipates

which of the following?

1. Morphine could cause a decrease in respirations&

2. The client could be in pain and have increased respirations&

3. The client might have increased respirations due to an<iety&

. The client will have normal respirations&

Corre!t "ns#er:

Rationa$e 1# Morphine is a narcotic$ and affects the respiratory center of the brain$ resulting in decreased

respirations& The effects of the morphine are li.ely to overcome any increase in respirations caused by pain$ and





morphine usually reduces client an<iety& (t would not be abnormal to find a normal respiratory rate$ but theanticipation would be for a slower rate&


respirations& The effects of the morphine are li.ely to overcome any increase in respirations caused by pain$ and

morphine usually reduces client an<iety& (t would not be abnormal to find a normal respiratory rate$ but theanticipation would be for a slower rate&


respirations& The effects of the morphine are li.ely to overcome any increase in respirations caused by pain$ andmorphine usually reduces client an<iety& (t would not be abnormal to find a normal respiratory rate$ but the

anticipation would be for a slower rate&

Rationa$e # Morphine is a narcotic$ and affects the respiratory center of the brain$ resulting in decreased

respirations& The effects of the morphine are li.ely to overcome any increase in respirations caused by pain$ andmorphine usually reduces client an<iety& (t would not be abnormal to find a normal respiratory rate$ but the

anticipation would be for a slower rate&

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: ;escribe factors that affect respiration and its accurate measurement&

Question 1-

Type: MCSA

The nurse assesses the infant2s respirations as normal when which of the following is noted?

1. (ntercostal retractions

2. Substernal retractions

3. ,se of accessory muscles when breathing

. Abdominal breathing

Corre!t "ns#er: 4

Rationa$e 1# (nfants have immature chest muscles$ and rely more on abdominal breathing during respirations as

the result of the wor. of the diaphragm& *etractions of any .ind are always abnormal$ indicating respiratory

distress$ and occur because the infant uses accessory muscles to draw in more air&





Rationa$e 2# (nfants have immature chest muscles$ and rely more on abdominal breathing during respirations asthe result of the wor. of the diaphragm& *etractions of any .ind are always abnormal$ indicating respiratory

distress$ and occur because the infant uses accessory muscles to draw in more air&

Rationa$e 3# (nfants have immature chest muscles$ and rely more on abdominal breathing during respirations as

the result of the wor. of the diaphragm& *etractions of any .ind are always abnormal$ indicating respiratorydistress$ and occur because the infant uses accessory muscles to draw in more air&

Rationa$e # (nfants have immature chest muscles$ and rely more on abdominal breathing during respirations as

the result of the wor. of the diaphragm& *etractions of any .ind are always abnormal$ indicating respiratorydistress$ and occur because the infant uses accessory muscles to draw in more air&

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: ;escribe the mechanics of breathing and identify the components of a respiratory

assessment&

Question 1

Type: MCSA

The nurse is preparing to assess blood pressure on the client& 0hen the nurse enters the room$ the client is being

assisted bac. to bed by the physical therapist following therapy& The nurse does which of the following?

1. Measures blood pressure quic.ly so the client can rest&

2. 0aits for the therapist to get the client in bed and measure vital signs&

3. *equests permission from the client to measure vital signs&

. *eturns to measure vital signs in /3% minutes&

Corre!t "ns#er: 4

Rationa$e 1# The client2s blood pressure will be elevated after e<ercise$ so the nurse should allow the client to res

and return in /3% minutes to measure blood pressure&









Rationa$e # The client2s blood pressure will be elevated after e<ercise$ so the nurse should allow the client to resand return in /3% minutes to measure blood pressure&

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: ;escribe factors that affect blood pressure and its accurate measurement&

Question 1/

Type: MCSA

The nursing student is practicing blood pressure s.ills at a screening clinic& After ta.ing a client2s blood pressure

several times$ the student tells the instructor that the orot.off2s sounds cannot be heard& 'rior to the instructor2s

measuring blood pressure$ the nurse should do which of the following to improve accuracy?

1. =ave the instructor apologi@e to the client for repeated cuff inflation&

2. =ave the client pump his fist to improve volume of orot.off2s sounds&

3. Move the cuff to the other arm&

. =ave the client elevate his arm&

Corre!t "ns#er: "

Rationa$e 1# *epeated inflation of the cuff causes false elevation of blood pressure due to repeated engorgementof the artery& The cuff should be moved to the other arm before performing another measurement& The studentshould have been the one to apologi@e to the client$ and fist pumping will not alter orot.off2s sounds$ although i

could have an adverse effect on accuracy of the measurement& -lood pressures should be measured with the

brachial pulse at heart level$ and elevation of the arm will create a falsely low reading&

Rationa$e 2# *epeated inflation of the cuff causes false elevation of blood pressure due to repeated engorgementof the artery& The cuff should be moved to the other arm before performing another measurement& The student

should have been the one to apologi@e to the client$ and fist pumping will not alter orot.off2s sounds$ although i

could have an adverse effect on accuracy of the measurement& -lood pressures should be measured with the


Rationa$e 3# *epeated inflation of the cuff causes false elevation of blood pressure due to repeated engorgement

of the artery& The cuff should be moved to the other arm before performing another measurement& The student

should have been the one to apologi@e to the client$ and fist pumping will not alter orot.off2s sounds$ although icould have an adverse effect on accuracy of the measurement& -lood pressures should be measured with the






Rationa$e # *epeated inflation of the cuff causes false elevation of blood pressure due to repeated engorgementof the artery& The cuff should be moved to the other arm before performing another measurement& The student

should have been the one to apologi@e to the client$ and fist pumping will not alter orot.off2s sounds$ although i

could have an adverse effect on accuracy of the measurement& -lood pressures should be measured with the brachial pulse at heart level$ and elevation of the arm will create a falsely low reading&

%$o&a$ Rationa$e:


C$ient Need: 'sychosocial (ntegrity

C$ient Need )u&:


(earning ut!ome: ;escribe factors that affect blood pressure and its accurate measurement&

Question 10

Type: MCSA

0hen measuring blood pressure$ the nurse identifies the systolic blood pressure at the pressure when which of thefollowing occurs?

1. orot.off2s sounds develop a muffled whooshing quality&

2. The first of at least two tapping sounds are heard in phase &

3. The first sound is heard during phase &

. A muffled blowing quality

Corre!t "ns#er: !

Rationa$e 1# The nurse listens for at least two consecutive tapping sounds to ensure that they are not e<traneous

sounds$ and then labels the first sound as the systolic blood pressure& A muffled whooshing sound is heard in phase !$ while a muffled blowing quality develops in phase 4&


sounds$ and then labels the first sound as the systolic blood pressure& A muffled whooshing sound is heard in

phase !$ while a muffled blowing quality develops in phase 4&


sounds$ and then labels the first sound as the systolic blood pressure& A muffled whooshing sound is heard in phase !$ while a muffled blowing quality develops in phase 4&

Rationa$e # The nurse listens for at least two consecutive tapping sounds to ensure that they are not e<traneoussounds$ and then labels the first sound as the systolic blood pressure& A muffled whooshing sound is heard in

phase !$ while a muffled blowing quality develops in phase 4&

%$o&a$ Rationa$e:







C$ient Need )u&:


(earning ut!ome: ;ifferentiate systolic from diastolic blood pressure and describe five phases of orot.off2ssounds&

Question 1

Type: MCMA

The nurse measures a clientFs vital signs according to agency policy$ as well as#>Select all that apply


1. -efore discharge

2. At least every si< hours if the client has had an elevated temperature within the past !4 hours

3. -efore calling the physician

. -efore transfer to a new unit

-. n admission to a facility

Corre!t "ns#er: $"$4$%

Rationa$e 1# The nurse measures the clientFs vital signs prior to discharge to ensure the clientFs condition has not

changed

Rationa$e 2# The clientFs vitals signs should be measured at least every 4 hours if the client has had an eleveated

temperature within the past !4 hours

Rationa$e 3# The nurse measures the clientFs vital signs before calling the physician as part of the data collection

Rationa$e # The nurse measures the clientFs vital signs prior to transferring the client to another unit to determin

any change in condition$ as well as having the data to report to the receiving unit

Rationa$e -# The nurse measures the clientFs vital signs on admission to a facility to determine a baseline

measurement

%$o&a$ Rationa$e:



C$ient Need )u&:






(earning ut!ome:

Question 2

Type: MCMA

The nursing assistant reports vital signs from a 4"3year3old client to the nurse$ who reports the abnormal

measurements to the physician& The following measurements are normal for the 4"3year3old client#>Select all that

apply


1. Temperature of 96&7G oral

2. 'ulse rate of /4

3. Temperature of "57C oral

. -lood pressure of /:%/

-. *espirations of 5:minute

Corre!t "ns#er: "$4$%

Rationa$e 1# The normal temperature for a 4"3year3old is 9&6



Rationa$e # The normal temperature for a 4"3year3old is 9&6

Rationa$e -# The normal temperature for a 4"3year3old is 9&6

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 21

Type: G(-





The neonatal nurse is measuring the vital signs of a !3day3old infant& The mother e<presses concern about the

babyFs blood pressure& The nurse e<plains that the neonates diastolic blood pressure is normally HHHHHHH mm=g

less than the normal adults&

)tandard Tet:

Corre!t "ns#er:

Rationa$e # The normal neonatal blood pressure is 5":%%8 the normal adult blood pressure is !/:/

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 22

Type: MCMA

A client returns to the nursing unit after laporoscopic surgery& The nurse prepares to ta.e the clientFs vital signs at

several intervals$ including#>Select all that apply


1. +very % minutes for first hour

2. +very "/ minutes for second and third hours

3. +very hour for fourth through seventh hours

. +very "/ minutes for three hours

-. +very four hours from return from surgery

Corre!t "ns#er: $!$"

Rationa$e 1# The nurse ta.es vital signs every % minutes for hour after surgery$ if vital signs remain stable



Rationa$e # The nurse ta.es vital signs every % minutes for hour after surgery$ if vital signs remain stable

Rationa$e -# The nurse ta.es vital signs every % minutes for hour after surgery$ if vital signs remain stable





%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 23

Type: MCSA

The nurse modifies her schedule to be certain to ta.e a clientFs vital signs before and after routine administration

of which of the following types of medications?

1. Antipyretics

2. Antibiotics

3. Anticoagulants

. Antihelmintics

Corre!t "ns#er:

Rationa$e 1# The nurse measures vital signs before and after administration of a medication that can impact vital

signs8 an antipyretic is meant to reduce temperature





Rationa$e # The nurse measures vital signs before and after administration of a medication that can impact vital


%$o&a$ Rationa$e:




(earning ut!ome:

Question 2

Type: S+I





There are several sites for assessing a clientFs temperature& The nurse understands that each method has benefits$

and that accuracy of each method is different& *an. the methods of temperature measurement from most to least

accurate

)tandard Tet: Clic. and drag the options below to move them up or down&

Choi!e 1. *ectal

Choi!e 2. Tympanic

Choi!e 3. ral

Choi!e . A<illary


Rationa$e 1# The most accurate means of measuring temperature is rectally because this is a measurement of the

core temperature

Rationa$e 2# The most accurate means of measuring temperature is rectally because this is a measurement of thecore temperature


core temperature

Rationa$e # The most accurate means of measuring temperature is rectally because this is a measurement of the

core temperature

%$o&a$ Rationa$e:

Cogniti'e (e'e$:

C$ient Need:

C$ient Need )u&:

Nursing*+ntegrated Con!epts:

(earning ut!ome:

Question 2-

Type: MCMA

The nurse is caring for a client with hyperthyroidism$ who has been e<periencing fevers& The nurse understandsthat a number of factors affect the bodyFs heat production$ including#>Select all that apply


1. -asal metabolic rate

2. Thyro<ine output





3. Sympathetic stimulation

. Jender

-. Jenetics


Rationa$e 1# The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essential

activities such as breathing

Rationa$e 2# The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essentialactivities such as breathing



Rationa$e # The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essential


Rationa$e -# The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essential


%$o&a$ Rationa$e:

Cogniti'e (e'e$:

C$ient Need:

C$ient Need )u&:


(earning ut!ome:

Question 2

Type: MCMA

0hen ma.ing initial rounds$ the nurse notes a clientFs shivering& 0hish of the following processes are stimulated

by the hypothalamus to increase the body temperature#>Select all that apply


1. Shivering

2. Sweating

3. 1asoconstriction

. 1asodilation





-. (ncreased respiratory rate

Corre!t "ns#er: $"

Rationa$e 1# The hypothalamus stimulates shivering to increase heat production



Rationa$e # The hypothalamus stimulates shivering to increase heat production

Rationa$e -# The hypothalamus stimulates shivering to increase heat production

%$o&a$ Rationa$e:

Cogniti'e (e'e$:

C$ient Need:

C$ient Need )u&:


(earning ut!ome:

Question 2/

Type: MCSA

0hen planning to assess a clientFs temperature$ the nurse reali@es that the safest$ least invasive method of

temperature measurement is#

1. *ectal

2. ral

3. A<illary

. Tympanic membrane

Corre!t "ns#er: "

Rationa$e 1# 0hile rectal temperature measurement is the most reliable$ it is the most invasive$ and can cause

inEury to rectum


inEury to rectum

Rationa$e 3# 0hile rectal temperature measurement is the most reliable$ it is the most invasive$ and can causeinEury to rectum





Rationa$e # 0hile rectal temperature measurement is the most reliable$ it is the most invasive$ and can causeinEury to rectum

%$o&a$ Rationa$e:


C$ient Need: Safe +ffective Care +nvironment

C$ient Need )u&:


(earning ut!ome:

Question 20

Type: MCMA

'rior to delegating temperature measurement to assistive personnel$ the nurse determines the appropriate method

of measuring the clientFs temperature& Safety considerations include#>Select all that apply


1. Gorcing the thermometer into place to ma.e sure it is accurate

2. Ma.ing sure the client .nows not to roll over when a rectal thermometer is in place

3. ,sing the blue tipped thermometer for an oral temperature

. ,sing a site other than oral if the client is .nown to have frequent sei@ures

-. ,sing probe covers e<cept for a<illary temperatures

Corre!t "ns#er: "$4

Rationa$e 1# Thermometers should never be forced into place8 if it does not enter easily$ reassess the site$ andconsider a different location

Rationa$e 2# Thermometers should never be forced into place8 if it does not enter easily$ reassess the site$ and

consider a different location

Rationa$e 3# Thermometers should never be forced into place8 if it does not enter easily$ reassess the site$ andconsider a different location

Rationa$e # Thermometers should never be forced into place8 if it does not enter easily$ reassess the site$ and


Rationa$e -# Thermometers should never be forced into place8 if it does not enter easily$ reassess the site$ and


%$o&a$ Rationa$e:






C$ient Need: Safe +ffective Care +nvironment

C$ient Need )u&:

Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation

(earning ut!ome:

Question 2

Type: MCMA

0hen ta.ing a %!3year3oldFs pulse rate$ the nurse considers which of the following factors that might increase the

clientFs pulse?>Select all that apply


1. Age

2. Stress

3. Gever

. Morning vital signs

-. =emorrhage

Corre!t "ns#er: !$"$%

Rationa$e 1# As age increases$ the pulse rate gradually decreases

Rationa$e 2# (n response to stress$ sympathetic nervous stimulation increases the rate as well as the force of the

heartbeat

Rationa$e 3# The pulse rate increases in response to the lowered blood pressure that results from peripheral

vasodilation associated with elevated body temperature and because of the increased metabolic rate

Rationa$e # 'ulse rate is lower in the morning and rises later in the day

Rationa$e -# Boss of blood from the vascular system normally increases pulse rate

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:





Question 3

Type: MCMA

The nurse measures a !/3year3oldFs pulse at %6 beats:minute at 5pm& 0hich of the following factors may be

responsible for a lower pulse rate?>Select all that apply


1. Age

2. +<ercise

3. Time of day

. +pinephrine

-. Standing up

Corre!t "ns#er: $!

Rationa$e 1# 'ulse rates increase as age increases8 the !/3year3old would usually have a pulse on the lower end o

normal

Rationa$e 2# Athletes normally have slower resting heart rates because of greater cardiac si@e$ strength and

efficiency

Rationa$e 3# 'ulse rate is higher later in the day and lower in the morning

Rationa$e # +pinephrine containing medications would normally cause an increase in the heart rate

Rationa$e -# 'ostural changes after sitting cause a transient decrease in venous blood return to the heart and a

subsequent reduction in blood pressure

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 31

Type: MCMA

0hen ta.ing the pulse of a child under three years of age$ the nurse will use which of the following sites#>Select

all that apply






1. *adial

2. Apical

3. Carotid

. -rachial

-. 'edal

Corre!t "ns#er: !$"$4

Rationa$e 1# *adial is not routinely used for infants

Rationa$e 2# Apical pulse is routinely used for infants and children up to " years of age

Rationa$e 3# Carotid pulse is used for infants if brachial pulse is not accessible

Rationa$e # -rachial pulse is used during cardiac arrest for infants

Rationa$e -# 'edal pulses are assessed to determine circulation to the foot

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 32

Type: G(-

The nurse .nows that the pulse is commonly ta.e in any of HHHH sites&

)tandard Tet:

Corre!t "ns#er: 9

Rationa$e # The pulse is commonly measured from one of the following 9 sites# temporal$ carotid$ apical$

brachial$ radial$ femoral$ popliteal$ posterior tibial$ pedal

%$o&a$ Rationa$e:

Cogniti'e (e'e$:






C$ient Need )u&:


(earning ut!ome:

Question 33

Type: MCMA

The nurse is preparing to measure a clientFs pulse& 0hich of the following are appropriate to use?>Select all that

apply


1. Thumb and inde< finger

2. Stethoscope

3. Three middle fingers

. ;oppler ultrasound stethoscope

-. Two last fingers


Rationa$e 1# The thumb is not



Rationa$e # The thumb is not

Rationa$e -# The thumb is not

%$o&a$ Rationa$e:



C$ient Need )u&:Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment

(earning ut!ome:

Question 3

Type: MCSA





Corre!t "ns#er: $"$%

Rationa$e 1# Thoracic >costal breathing involves the use of e<ternal intercostal muscles

Rationa$e 2# Abdominal breathing involves the contraction and rela<ation of the diaphragm

Rationa$e 3# Thoracic>costal breathing involves the use of accessory muscles

Rationa$e # ;iaphragmatic breathing involves contraction and rela<ation of the diaphragm

Rationa$e -# Costal breathing can be observed by the movement of the chest upward and outward

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 3

Type: MCMA

The nurse is assessing a clientFs respiratory status& (ndicators of normal respiratory status include#>Select all that

apply


1. +upnea

2. ,se of e<ternal intercostal muscles

3. Suprasternal retraction

. rthopnea

-. Apnea

Corre!t "ns#er: $!

Rationa$e 1# +upnea describes normal adult respirations$ !3!4 rpm depending on baseline

Rationa$e 2# The use of e<ternal intercostal muscles is a characteristic of normal thoracic respirations

Rationa$e 3# Suprasternal retraction$ the indrawing above the clavicles and sternum is not characteristic of norma

respirations





Rationa$e # rthopnea$ the ability to breathe only in upright sitting or standing positions is not characteristic ofnormal respirations

Rationa$e -# Apnea$ the cessation of breathing$ is not characteristic of normal respirations

%$o&a$ Rationa$e:

Cogniti'e (e'e$: ApplyingC$ient Need: 'sychosocial (ntegrity

C$ient Need )u&:


(earning ut!ome:

Question 3/

Type: MCMA

The nurse measures a clientFs respiratory rate at "4 rpm& The nurse reviews the clients chart and discovers the

following factors that may be causing the increase in respirations#>Select all that apply


1. Client is febrile

2. The client was Eust told about a poor prognosis

3. The client has been diagnosed with increased intracranial pressure

. The client was Eust medicated for pain

-. The clientFs body temperature is 967G

Corre!t "ns#er: $!

Rationa$e 1# The client who is febrile will often have an increased respiratory rate

Rationa$e 2# The client who is undergoing stress may have an increased respiratory rate as the body readies for

Kfight or flightL

Rationa$e 3# The client with increased intracranial pressure will show a decrease in respiratory rate

Rationa$e # Certain medications$ such as narcotics and analgesics will decrease the respiratory rate

Rationa$e -# The client with a decreased body temperature will show a decreased respiratory rate

%$o&a$ Rationa$e:







C$ient Need )u&:


(earning ut!ome:

Question 30

Type: MCMA

0hile assessing a clientFs respirations as abnormal$ the nurse notes the following#>Select all that apply


1. The rate of respirations

2. The depth of respirations

3. The clientFs normal breathing patterns

. The relationship of respirations to cardiovascular function

-. Bac. of sound when breathing


Rationa$e 1# The nurse notes the rate of respirations$ by number$ as well as terms such as tachypnic$ bradypnic

Rationa$e 2# The nurse notes the depth of the clientFs respirations by watching the movement of the chest

Rationa$e 3# A change in the clientFs normal breathing pattern should be noted

Rationa$e # A client with compromised cardiovascular status is li.ely to have alterations in his or her respiratory

pattern$ with increased or decreased breath sounds$ respiratory rate or depth

Rationa$e -# )ormal breathing is silent

%$o&a$ Rationa$e:



C$ient Need )u&:Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation

(earning ut!ome:

Question 3

Type: MCMA





The nurse is e<plaining the basic physiology and significance of blood pressure to a client who has been

hospitali@ed for hypertension& (nformation that is important to discuss includes#>Select all that apply


1. 1enous blood pressure is a measure of the force e<erted by the blood as it flows through the arteries

2. The systolic pressure is the pressure of the blood as a result of contraction of the ventricles

3. The diastolic blood pressure is the lower pressure that is present at all times within the arteries

. -lood pressure is static

-. -lood pressure is recorded as a fraction


Rationa$e 1# Arterial blood pressure is a measure of the force e<erted by the blood as it flows through the arteries

Rationa$e 2# The systolic pressure is the result of contraction of the ventricles8 the pressure at the height of the

blood wave

Rationa$e 3# The diastolic pressure it the pressure when ventricles are at rest

Rationa$e # -lood pressure is not static and normally changes from minute to minute

Rationa$e -# -lood pressure is measured in millimeters of mercury$ recorded as a fraction with the systolic pressure written above the diastolic pressure

%$o&a$ Rationa$e:


C$ient Need:

C$ient Need )u&:


(earning ut!ome:

Question

Type: MCMA

As the nurse assesses a clientFs blood pressure$ he or she understands that blood pressure is a result of#>Select all

that apply


1. The volume of blood pumped into the arteries by the heart





Rationa$e 1# Age is a non3modifiable factor8 blood pressure increases with age from the newborn$ to the pea. atthe onset of puberty8 in older people$ the elasticity of the arteries is decreased which yields elevated systolic and

diastolic pressures

Rationa$e 2# -lood pressure is generally higher in overweight and obese people8 weight can be lost through diet

and e<ercise modification

Rationa$e 3# -lood pressure is usually lowest early in the morning$ when the metabolic rate is lowest

Rationa$e # 'hysical activity increases the cardiac output and the blood pressure

Rationa$e -# Many medications may increase of decrease the blood pressure$ and should be review if abnormal

measurements are determined

%$o&a$ Rationa$e:


C$ient Need:

C$ient Need )u&:


(earning ut!ome:

Question 2

Type: MCSA

The community health nurse is holding a blood pressure chec. at a community center& 0hich of the following

measurements indicates Stage hypertension?

1. %:56

2. "6:

3. %4:9/

. 6!:9/

Corre!t "ns#er: "

Rationa$e 1# This blood pressure is within normal limits$ and should be rechec.ed in year

Rationa$e 2# This blood pressure indicates prehypertension$ and should be rechec.ed within 63! months

Rationa$e 3# This blood pressure indicates Stage hypertension$ and should be rechec.ed within month

Rationa$e # This blood pressure indicates a split category$ between stage and !$ and should be evaluated or

referred to a source of care within wee.





%$o&a$ Rationa$e:


C$ient Need:

C$ient Need )u&:


(earning ut!ome:

Question 3

Type: MCSA

The nurse is caring for a client who has been on bedrest for several wee.s& The nurse ta.es precaution when

assisting the client to the chair due to the ris. of

1. =ypotension

2. =ypertension

3. rthostatic hypertension

. rthostatic hypotension

Corre!t "ns#er: 4

Rationa$e 1# =ypotension is a condition base on blood pressure that is below normal combined with the presence

of symptoms8 the information given does not support this answer





Rationa$e # =ypotension is a condition base on blood pressure that is below normal combined with the presence


%$o&a$ Rationa$e:


C$ient Need:C$ient Need )u&:


(earning ut!ome:

Question

Type: S+I





orot.offFs sounds can be differentiated into five phases& Correlate the phase from 3% with the appropriate

choice&


Choi!e 1. Systolic blood pressure

Choi!e 2. Sounds have muffled$ whooshing$ swishing quality

Choi!e 3. Sounds become crisper$ more intense

Choi!e . Sounds become muffled$ soft blowing quality

Choi!e -. ;iastolic blood pressure

Corre!t "ns#er: $!$"$4$%

Rationa$e 1# 'hase is the pressure level at which the first faint$ clear tapping or thumping sounds are heart8 thefirst tapping sound heard during deflation of the cuff is the systolic blood pressure

Rationa$e 2# 'hase ! is the period during deflation when the sounds have a muffled$ whooshing$ or swishing

quality

Rationa$e 3# 'hase " is the period during which the blood flows freely through an increasingly open artery andthe sounds become crisper and more intense and again assume a thumping quality$ but softer than in phase

Rationa$e # 'hase 4 is the time when the sounds become muffled and have a soft$ blowing quality

Rationa$e -# 'hase % is the level when the last sound is heard8 the pressure at which the last sound is heard is the

diastolic blood pressure in adults

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question -Type: MCMA

The nurse identifies factors that can cause errors in blood pressure measurement that yield higher results$ such as

>Select all that apply






1. ,se of an electronic blood pressure device

2. ,se of an aneroid sphygmomanometer

3. ,se of a ;oppler ultrasound stethoscope

. A blood pressure cuff that is too small for the diameter of the clientFs arm

-. A blood pressure cuff that is too long

Corre!t "ns#er: $4

Rationa$e 1# *esearch indicates that automated electronic devices produce higher values than manual readings

Rationa$e 2# The manual sphygmomanometer will yield the most accurate measurement

Rationa$e 3# The use of a ;S is indicated when orot.offFs sounds are difficult to hear

Rationa$e # (f the bladder of the blood pressure cuff is too narrow for the clientFs arm the blood pressure readingwill be erroneously elevated

Rationa$e -# (f the blood pressure cuff is too long for the client$ the blood pressure reading will be erroneously

low

%$o&a$ Rationa$e:

Cogniti'e (e'e$:


C$ient Need )u&:


(earning ut!ome:

Question

Type: MCMA

The nurse is choosing the appropriate blood pressure cuff for a client& The following consideration affect the

decision#>Select all that apply


1. A small cuff may be used for a normal adult

2. The bladder of the blood pressure cuff must be 4/ of the arm circumference

3. A large cuff may be used to measure the blood pressure on the leg of an infant

. The same cuff may be used to measure the blood pressure of an infant or toddler





-. A small cuff may be used with a frail adult

Corre!t "ns#er: !$%

Rationa$e 1# A small cuff is used for an infant$ small child or frail adult



Rationa$e # A small cuff is used for an infant$ small child or frail adult

Rationa$e -# A small cuff is used for an infant$ small child or frail adult

%$o&a$ Rationa$e:

Cogniti'e (e'e$:


C$ient Need )u&:


(earning ut!ome:

Question /

Type: MCMA

0hen preparing to assess a clientFs blood pressure$ the nurse observes for indications to using the clientFs thigh

for and standard stethoscope$ such as#>Select all that apply


1. ,nilateral mastectomy

2. (ntravenous infusions in both arms

3. -urns on upper body$ including shoulders or hands

. -ilateral mastectomy

-. Arteriovenous fistula


Rationa$e 1# The client with a unilateral mastectomy should have the blood pressure measured on the not3affecte

arm

Rationa$e 2# The client with (1s in both arms should have the blood pressure measured on the thigh





Rationa$e 3# The client with burns or trauma affecting the upper body$ including shoulders or hands >bilaterallyshould have the blood pressure measured on the thigh

Rationa$e # The client with bilateral mastectomies should have the blood pressure measured on the thigh

Rationa$e -# The client with an arteriovenous fistula should have the blood pressure measured on the non3affecte

arm

%$o&a$ Rationa$e:

Cogniti'e (e'e$:


C$ient Need )u&:


(earning ut!ome:

Question 0

Type: S+I

The nurse uses the two3step palpatory blood pressure measurement to ensure accurate results& The steps are as

follows# 'lace the steps in the appropriate order


Choi!e 1. The blood pressure cuff is inflated until the brachial or radial pulse is occluded

Choi!e 2. The nurse notes the reading$ deflates the cuff

Choi!e 3. The nurse waits "/36/ seconds

Choi!e . Cuff is inflated !/3"/ mm=g higher than number noted


Rationa$e 1# The blood pressure cuff is inflated while palpating the radial or brachial pulse$ until the artery is

occluded and the pulse cannot be palpated

Rationa$e 2# The nurse notes the reading and deflates the cuff

Rationa$e 3# The nurse waits "/36/ seconds prior to reinflating cuff to allow blood flow to normali@e

Rationa$e # The cuff is inflated !/3"/ mm=g higher than the number noted on palpation$ and the rest of the procedure is the same as the auscultatory method

%$o&a$ Rationa$e:

Cogniti'e (e'e$:






C$ient Need )u&:


(earning ut!ome:

Question

Type: MCMA

The nurse measures a clientFs vital signs according to agency policy$ as well as#


1. -efore discharge&

2. At least every 6 hours if the client has had an elevated temperature within the past !4 hours&

3. -efore calling the physician&

. -efore transfer to a new unit&

-. n admission to a facility&

Corre!t "ns#er: $"$4$%

Rationa$e 1# The nurse measures the clientFs vital signs prior to discharge to ensure that the clientFs condition hasnot changed&

Rationa$e 2# The clientFs vital signs should be measured at least every 4 hours if the client has had an elevated

temperature within the past !4 hours&

Rationa$e 3# The nurse measures the clientFs vital signs before calling the physician as part of data collection&

Rationa$e # The nurse measures the clientFs vital signs prior to transferring the client to another unit to determinany change in condition$ as well as to have the data to report to the receiving unit&

Rationa$e -# The nurse measures the clientFs vital signs on admission to a facility to determine a baseline

measurement&

%$o&a$ Rationa$e:

Cogniti'e (e'e$: ApplyingC$ient Need: 'hysiological (ntegrity

C$ient Need )u&:


(earning ut!ome:

Question -

Type: MCMA





The nursing assistant reports vital signs from a 4"3year3old client to the nurse$ who reports the abnormalmeasurements to the physician& The following measurements are normal for the 4"3year3old client#


1. Temperature of 96&7G oral

2. 'ulse rate of /4

3. Temperature of "57C oral

. -lood pressure of /:%/

-. *espirations of 5:minute

Corre!t "ns#er: "$4$%

Rationa$e 1# The normal temperature for a 4"3year3old is 9&67G&



Rationa$e # The normal temperature for a 4"3year3old is 9&67G&

Rationa$e -# The normal temperature for a 4"3year3old is 9&67G&

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question -1

Type: G(-

The neonatal nurse is measuring the vital signs of a !3day3old infant& The mother e<presses concern about the

babyFs blood pressure& The nurse e<plains that the neonateFs diastolic blood pressure is normally HHHHHHH mm=g

lower than the normal adultFs&

)tandard Tet:

Corre!t "ns#er: 5":%%

Rationa$e # The normal neonatal blood pressure is 5":%%8 the normal adult blood pressure is !/:/&





%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question -2

Type: MCMA

A client returns to the nursing unit after laparoscopic surgery& The nurse prepares to ta.e the clientFs vital signs atseveral intervals$ including#


1. +very % minutes for first hour&

2. +very "/ minutes for second and third hours&

3. +very hour for fourth through seventh hours&

. +very "/ minutes for three hours&

-. +very four hours from return from surgery&

Corre!t "ns#er: $!$"

Rationa$e 1# The nurse ta.es vital signs every % minutes for hour after surgery$ if vital signs remain stable&



Rationa$e # The nurse ta.es vital signs every % minutes for hour after surgery$ if vital signs remain stable&

Rationa$e -# The nurse ta.es vital signs every % minutes for hour after surgery$ if vital signs remain stable&

%$o&a$ Rationa$e:


C$ient Need )u&:


(earning ut!ome:

Question -3

Type: MCSA





The nurse modifies her schedule to be certain to ta.e a clientFs vital signs before and after routine administrationof which of the following types of medications?

1. Antipyretics

2. Antibiotics

3. Anticoagulants

. Antihelmintics

Corre!t "ns#er:

Rationa$e 1# The nurse measures vital signs before and after administration of a medication that can impact vitalsigns8 an antipyretic is meant to reduce temperature&


signs8 an antipyretic is meant to reduce temperature&

Rationa$e 3# The nurse measures vital signs before and after administration of a medication that can impact vitalsigns8 an antipyretic is meant to reduce temperature&

Rationa$e # The nurse measures vital signs before and after administration of a medication that can impact vital

signs8 an antipyretic is meant to reduce temperature&

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question -

Type: S+I

There are several sites for assessing a clientFs temperature& The nurse understands that each method has benefits$

and that the accuracy of each method is different& *an. the methods of temperature measurement from most to

least accurate#


Choi!e 1. *ectal

Choi!e 2. Tympanic

Choi!e 3. ral





Choi!e . A<illary



core temperature&

Rationa$e 2# The most accurate means of measuring temperature is rectally because this is a measurement of thecore temperature&

Rationa$e 3# The most accurate means of measuring temperature is rectally because this is a measurement of thecore temperature&

Rationa$e # The most accurate means of measuring temperature is rectally because this is a measurement of the

core temperature&

%$o&a$ Rationa$e:


C$ient Need )u&:


(earning ut!ome:

Question --

Type: MCMA

The nurse is caring for a client with hyperthyroidism who has been e<periencing fevers& The nurse understands

that a number of factors affect the bodyFs heat production$ including#


1. -asal metabolic rate&

2. Thyro<ine output&

3. Sympathetic stimulation&

. Jender&

-. Jenetics&



activities such as breathing&





Rationa$e 2# The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essentialactivities such as breathing&



Rationa$e # The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essential


Rationa$e -# The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essential


%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question -

Type: MCMA

0hen ma.ing initial rounds$ the nurse notes a clientFs shivering& 0hich of the following processes are stimulated

by the hypothalamus to increase the body temperature?


1. Shivering

2. Sweating

3. 1asoconstriction

. 1asodilation

-. (ncreased respiratory rate

Corre!t "ns#er: $"

Rationa$e 1# The hypothalamus stimulates shivering to increase heat production&



Rationa$e # The hypothalamus stimulates shivering to increase heat production&





Rationa$e -# The hypothalamus stimulates shivering to increase heat production&

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question -/

Type: MCSA

0hen planning to assess a clientFs temperature$ the nurse reali@es that the safest$ least invasive method oftemperature measurement is#

1. *ectal&

2. ral&

3. A<illary&

. 1ia the tympanic membrane&

Corre!t "ns#er: "


inEury to the rectum&

Rationa$e 2# 0hile rectal temperature measurement is the most reliable$ it is the most invasive$ and can causeinEury to the rectum&


inEury to the rectum&

Rationa$e # 0hile rectal temperature measurement is the most reliable$ it is the most invasive$ and can causeinEury to the rectum&

%$o&a$ Rationa$e:


C$ient Need )u&:


(earning ut!ome:

Question -0

Type: MCMA





'rior to delegating temperature measurement to assistive personnel$ the nurse determines the appropriate methodof measuring the clientFs temperature& Safety considerations include#


1. Gorcing the thermometer into place to ma.e sure it is accurate&

2. Ma.ing sure the client .nows not to roll over when a rectal thermometer is in place&

3. ,sing the blue3tipped thermometer for an oral temperature&

. ,sing a site other than oral if the client is .nown to have frequent sei@ures&

-. ,sing probe covers$ e<cept for a<illary temperatures&

Corre!t "ns#er: "$4

Rationa$e 1# Thermometers should never be forced into place8 if one does not enter easily$ reassess the site$ and

consider a different location&





Rationa$e # Thermometers should never be forced into place8 if one does not enter easily$ reassess the site$ and


Rationa$e -# Thermometers should never be forced into place8 if one does not enter easily$ reassess the site$ andconsider a different location&

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question -

Type: MCMA

0hen ta.ing a %!3year3oldFs pulse rate$ the nurse considers which of the following factors that might increase theclientFs pulse?






1. Age

2. Stress

3. Gever

. Morning vital signs

-. =emorrhage


Rationa$e 1# As age increases$ the pulse rate gradually decreases&

Rationa$e 2# (n response to stress$ sympathetic nervous stimulation increases the rate as well as the force of theheartbeat&

Rationa$e 3# The pulse rate increases in response to the lowered blood pressure that results from peripheral

vasodilation associated with elevated body temperature$ and because of the increased metabolic rate&

Rationa$e # 'ulse rate is lower in the morning and rises later in the day&

Rationa$e -# Boss of blood from the vascular system normally increases pulse rate&

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question

Type: MCMA

The nurse measures a !/3year3oldFs pulse at %6 beats:minute at 5 p&m& 0hich of the following factors might be

responsible for a lower pulse rate?


1. Age

2. +<ercise

3. Time of day

. +pinephrine





Rationa$e 3# Carotid pulse is used for infants if brachial pulse is not accessible&

Rationa$e # -rachial pulse is used during cardiac arrest for infants&

Rationa$e -# 'edal pulses are assessed to determine circulation to the foot&

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 2

Type: G(-

The nurse .nows that the pulse is commonly ta.en in any of HHHH sites&

)tandard Tet:

Corre!t "ns#er: 9

Rationa$e # The pulse is commonly measured from one of the following 9 sites# temporal$ carotid$ apical$

brachial$ radial$ femoral$ popliteal$ posterior tibial$ or pedal&

%$o&a$ Rationa$e:

Cogniti'e (e'e$: nowledge



(earning ut!ome:

Question 3

Type: MCMA

The nurse is preparing to measure a clientFs pulse& 0hich of the following are appropriate to use?


1. Thumb and inde< finger

2. Stethoscope

3. Three middle fingers

. ;oppler ultrasound stethoscope





-. Two last fingers


Rationa$e 1#

Rationa$e 2#

Rationa$e 3#

Rationa$e #

Rationa$e -#

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question

Type: MCSA

The nurse is caring for a client with C';& As they tal.$ the client as.s what the difference is between ventilation

and respiration& The nurse responds#

1. K*espiration is the inta.e of air into the lungs&L

2. K*espiration refers to the e<change of carbon dio<ide and o<ygen at the cellular level&L

3. K1entilation refers to the movement of air in and out of the lungs&L

. K1entilation refers to very shallow respirations&L

Corre!t "ns#er: "

Rationa$e 1# *espiration is the act of breathing&

Rationa$e 2# (nternal respiration refers to the e<change of carbon dio<ide and o<ygen at the cellular level betweenthe circulating blood and the cells of the body tissues&

Rationa$e 3# 1entilation refers to the movement of air in and out of the lungs&

Rationa$e # =ypoventilation refers to very shallow inadequate respirations&

%$o&a$ Rationa$e:







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Question -

Type: MCMA

The nurse is assessing a clientFs respirations& Characteristics of costal breathing include#


1. ,se of e<ternal intercostal muscles&

2. Contraction of the diaphragm&

3. ,se of accessory muscles&

. Movement of the abdomen&

-. Movement of the chest upward and outward&

Corre!t "ns#er: $"$%

Rationa$e 1# Thoracic >costal breathing involves the use of e<ternal intercostal muscles&

Rationa$e 2# Abdominal breathing involves the contraction and rela<ation of the diaphragm&

Rationa$e 3# Thoracic >costal breathing involves the use of accessory muscles&

Rationa$e # ;iaphragmatic breathing involves contraction and rela<ation of the diaphragm&

Rationa$e -# Costal breathing can be observed by the movement of the chest upward and outward&

%$o&a$ Rationa$e:




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Question

Type: MCMA

The nurse is assessing a clientFs respiratory status& (ndicators of normal respiratory status include#






1. +upnea&

2. ,se of e<ternal intercostal muscles&

3. Suprasternal retraction&

. rthopnea&

-. Apnea&

Corre!t "ns#er: $!

Rationa$e 1# +upnea describes normal adult respirations$ !N!4 rpm depending on baseline&

Rationa$e 2# The use of e<ternal intercostal muscles is a characteristic of normal thoracic respirations&

Rationa$e 3# Suprasternal retraction$ the indrawing above the clavicles and sternum$ is not characteristic ofnormal respirations&

Rationa$e # rthopnea$ the ability to breathe only in an upright sitting or standing position$ is not characteristic

of normal respirations&

Rationa$e -# Apnea$ the cessation of breathing$ is not characteristic of normal respirations&

%$o&a$ Rationa$e:



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Question /

Type: MCMA

The nurse measures a clientFs respiratory rate at "4 rpm& The nurse reviews the clientFs chart and discovers the

following factors that might be causing the increase in respirations#


1. The client is febrile&

2. The client was Eust told about a poor prognosis&

3. The client has been diagnosed with increased intracranial pressure&





. The client was Eust medicated for pain&

-. The clientFs body temperature is 967G&

Corre!t "ns#er: $!

Rationa$e 1# The client who is febrile will often have an increased respiratory rate&

Rationa$e 2# The client who is undergoing stress might have an increased respiratory rate as the body readies for

Kfight or flight&L

Rationa$e 3# The client with increased intracranial pressure will show a decrease in respiratory rate&

Rationa$e # Certain medications$ such as narcotics and analgesics$ will decrease the respiratory rate&

Rationa$e -# The client with a decreased body temperature will show a decreased respiratory rate&

%$o&a$ Rationa$e:



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Question 0

Type: MCMA

0hile assessing a clientFs respirations as abnormal$ the nurse notes the following#


1. The rate of respirations

2. The depth of respirations

3. The clientFs normal breathing patterns

. The relationship of respirations to cardiovascular function

-. Bac. of sound when breathing


Rationa$e 1# The nurse notes the rate of respirations$ by number$ as well as terms such as tachypnic and bradypnic&

Rationa$e 2# The nurse notes the depth of the clientFs respirations by watching the movement of the chest&





Rationa$e 3# A change in the clientFs normal breathing pattern should be noted&

Rationa$e # A client with compromised cardiovascular status is li.ely to have alterations in her respiratory

pattern$ with increased or decreased breath sounds$ respiratory rate$ or depth&

Rationa$e -# )ormal breathing is silent&

%$o&a$ Rationa$e:



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Question

Type: MCMA

The nurse is e<plaining the basic physiology and significance of blood pressure to a client who has beenhospitali@ed for hypertension& (nformation that is important to discuss includes#


1. 1enous blood pressure is a measure of the force e<erted by the blood as it flows through the arteries&

2. The systolic pressure is the pressure of the blood as a result of contraction of the ventricles&

3. The diastolic blood pressure is the lower pressure that is present at all times within the arteries&

. -lood pressure is static&

-. -lood pressure is recorded as a fraction&


Rationa$e 1# Arterial blood pressure is a measure of the force e<erted by the blood as it flows through the arteries

Rationa$e 2# The systolic pressure is the result of contraction of the ventriclesthe pressure at the height of the

blood wave&

Rationa$e 3# The diastolic pressure is the pressure when ventricles are at rest&

Rationa$e # -lood pressure is not static$ and normally changes from minute to minute&

Rationa$e -# -lood pressure is measured in millimeters of mercury$ recorded as a fraction$ with the systolic

pressure written above the diastolic pressure&

%$o&a$ Rationa$e:







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Question /

Type: MCMA

As the nurse assesses a clientFs blood pressure$ he understands that blood pressure is a result of#


1. The volume of blood pumped into the arteries by the heart&

2. The volume of blood pumped into the veins by the heart&

3. The compliance of the veins&

. The si@e of the arterioles&

-. The thic.ness of the blood&

Corre!t "ns#er: $4$%

Rationa$e 1#

Rationa$e 2#

Rationa$e 3#

Rationa$e #

Rationa$e -#

%$o&a$ Rationa$e:




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Question /1

Type: MCMA

As the nurse teaches a group of high school students about factors affecting blood pressure$ the following non3modifiable factors are discussed#






1. Age

2. besity

3. ;iurnal variations

. +<ercise

-. Medications

Corre!t "ns#er: $"

Rationa$e 1# Age is a non3modifiable factor8 blood pressure increases with age from the newborn to the pea. atthe onset of puberty& (n older people$ the elasticity of the arteries is decreased$ which yields elevated systolic and

diastolic pressures&

Rationa$e 2# -lood pressure is generally higher in overweight and obese people8 weight can be lost through dietand e<ercise modification&

Rationa$e 3# -lood pressure is usually lowest early in the morning$ when the metabolic rate is lowest&

Rationa$e # 'hysical activity increases the cardiac output and the blood pressure&

Rationa$e -# Many medications can increase of decrease the blood pressure$ and medications should be reviewed

if abnormal measurements are determined&

%$o&a$ Rationa$e:



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Question /2

Type: MCSA

The community health nurse is holding a blood pressure chec. at a community center& 0hich of the following

measurements indicates stage hypertension?

1. %:56

2. "6:

3. %4:9/





. 6!:9/

Corre!t "ns#er: "

Rationa$e 1# This blood pressure is within normal limits$ and should be rechec.ed in year&

Rationa$e 2# This blood pressure indicates prehypertension$ and should be rechec.ed within 6N! months&

Rationa$e 3# This blood pressure indicates stage hypertension$ and should be rechec.ed within month&

Rationa$e # This blood pressure indicates a split category$ between stage and !$ and should be evaluated or

referred to a source of care within wee.&

%$o&a$ Rationa$e:



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Question /3

Type: MCSA

The nurse is caring for a client who has been on bedrest for several wee.s& The nurse ta.es precaution when

assisting the client to the chair due to the ris. of#

1. =ypotension&

2. =ypertension&

3. rthostatic hypertension&

. rthostatic hypotension&

Corre!t "ns#er: 4

Rationa$e 1# =ypotension is a condition where blood pressure that is below normal is combined with the presenc


Rationa$e 2# =ypotension is a condition where blood pressure that is below normal is combined with the presencof symptoms8 the information given does not support this answer

Rationa$e 3# =ypotension is a condition where blood pressure that is below normal is combined with the presenc


Rationa$e # =ypotension is a condition where blood pressure that is below normal is combined with the presencof symptoms8 the information given does not support this answerCognitive Bevel# Applying





%$o&a$ Rationa$e:

Cogniti'e (e'e$: =ypotension is a condition where blood pressure that is below normal is combined with the presence of symptoms8 the information given does not support this answerCognitive Bevel# Applying


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Question /

Type: S+I

orot.offFs sounds can be differentiated into five phases& Correlate the phase from to % with the appropriate

choice&


Choi!e 1. Systolic blood pressure

Choi!e 2. Sounds have a muffled$ whooshing$ swishing quality&

Choi!e 3. Sounds become crisper$ more intense&

Choi!e . Sounds become muffled$ with a soft blowing quality&

Choi!e -. ;iastolic blood pressure

Corre!t "ns#er: $!$"$4$%

Rationa$e 1# 'hase is the pressure level at which the first faint$ clear tapping or thumping sounds are heart8 thefirst tapping sound heard during deflation of the cuff is the systolic blood pressure&

Rationa$e 2# 'hase ! is the period during deflation when the sounds have a muffled$ whooshing$ or swishing

quality&

Rationa$e 3# 'hase " is the period during which the blood flows freely through an increasingly open artery andthe sounds become crisper and more intense and again assume a thumping quality$ but softer than in phase &

Rationa$e # 'hase 4 is the time when the sounds become muffled and have a soft$ blowing quality&

Rationa$e -# 'hase % is the level when the last sound is heard8 the pressure at which the last sound is heard is thediastolic blood pressure in adults&

%$o&a$ Rationa$e:



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Question /-

Type: MCMA

The nurse identifies factors that can cause errors in blood pressure measurement that yield higher results$ such as


1. ,se of an electronic blood pressure device&

2. ,se of an aneroid sphygmomanometer&

3. ,se of a ;oppler ultrasound stethoscope&

. A blood pressure cuff that is too small for the diameter of the clientFs arm&

-. A blood pressure cuff that is too long&

Corre!t "ns#er: $4

Rationa$e 1# *esearch indicates that automated electronic devices produce higher values than do manual

readings&

Rationa$e 2# The manual sphygmomanometer will yield the most accurate measurement&

Rationa$e 3# The use of a ;S is indicated when orot.offFs sounds are difficult to hear&

Rationa$e # (f the bladder of the blood pressure cuff is too narrow for the clientFs arm$ the blood pressure readin

will be erroneously elevated&

Rationa$e -# (f the blood pressure cuff is too long for the client$ the blood pressure reading will be erroneously

low&

%$o&a$ Rationa$e:

Cogniti'e (e'e$: Analysis


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Question /

Type: MCMA

The nurse is choosing the appropriate blood pressure cuff for a client& The following considerations affect thedecision#





-. Arteriovenous fistula&


Rationa$e 1# The client with a unilateral mastectomy should have the blood pressure measured on the unaffected

arm&

Rationa$e 2# The client with (1s in both arms should have the blood pressure measured on the thigh&

Rationa$e 3# The client with burns or trauma affecting the upper body$ including the shoulders or hands

>bilaterally$ should have the blood pressure measured on the thigh&

Rationa$e # The client with bilateral mastectomies should have the blood pressure measured on the thigh&

Rationa$e -# The client with an arteriovenous fistula should have the blood pressure measured on the unaffected

arm&

%$o&a$ Rationa$e:

Cogniti'e (e'e$: Analysis


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Question /0

Type: S+I

The nurse uses the two3step palpatory blood pressure measurement to ensure accurate results& 'lace the steps in

the appropriate order#


Choi!e 1. The blood pressure cuff is inflated until the brachial or radial pulse is occluded&

Choi!e 2. The nurse notes the reading$ and deflates the cuff&

Choi!e 3. The nurse waits "/N6/ seconds&

Choi!e . The cuff is inflated !/N"/ mm=g higher than number noted&


Rationa$e 1# The blood pressure cuff is inflated while palpating the radial or brachial pulse$ until the artery is

occluded and the pulse cannot be palpated&

Rationa$e 2# The nurse notes the reading and deflates the cuff&





Rationa$e 3# The nurse waits "/N6/ seconds prior to reinflating cuff$ to allow blood flow to normali@e&

Rationa$e # The cuff is inflated !/N"/ mm=g higher than the number noted on palpation$ and the rest of the

procedure is the same as with the auscultatory method&

%$o&a$ Rationa$e:

Cogniti'e (e'e$: AnalysisC$ient Need: 'hysiological (ntegrity

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Ramont2e Rev TIF Ch21

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Transcript of Ramont2e Rev TIF Ch21