Nightingale BSN 205, Week 3 ISB, Vital Signs
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| 1. Which of the following patients would require follow-up? | show 🗑
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| Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? | show 🗑
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| The nurse had delegated the task of temperature assessment to the NAP. Which information should be provided to the NAP? (SELECT ALL THAT APPLY) | show 🗑
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| show | Paton rated as a 7 on a 0-10 pain scale. Moving from lying to standing position. Time of day.
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| The nurse will take the patient's vital signs preoperatively and record them as part of the patient's preparation for surgery. Why is it necessary to take vital signs preoperatively? (Select all that apply.) | show 🗑
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| show | Assess the patient’s blood pressure.
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| Which patient would it be appropriate for the nurse to delegate vital signs? | show 🗑
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| 2. Which person would be expected to have the lowest body temperature? | show 🗑
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| show | ‘ Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature."
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| For which patient would a tympanic thermometer be the preferred thermometer to use? | show 🗑
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| show | An adult female in the recovery room following a hysterectomy. A young adult with a white blood count of 15,000/mm3. A patient receiving a blood transfusion for chronic anemia.
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| The NAP reports that the patient's temperature is 39° C (102.2 °F). | show 🗑
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| show | The NAP inserts the red-tipped electronic thermometer probe into the patient’s mouth after applying a probe cover. The NAP wipes the single-use chemical stuff thermometer and places it back int he patient’s drawer for future use.
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| Identify the factors that may have an effect on an elderly patient's temperature: (Select all that apply.) | show 🗑
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| If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? | show 🗑
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| show | Temporal artery.
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| 3. The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select all that apply.) | show 🗑
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| show | A patient with peripheral vascular disease. The patient who was just informed of a diagnosis of cancer. A patient who is receiving bonus IV fluids.
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| show | Auscultate the apical pulse for quality and rate.
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| What is the normal pulse range for an adult? | show 🗑
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| show | False.
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| In which of the following patients would the nurse expect to find a decrease in pulse rate? (Select all that apply.) | show 🗑
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| show | The NAP is assessing for a pulse on the ulnar side of the wrist. The NAP is pressing down too hard on the patient’s radial site.
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| show | Count the respiratory rate again for a full 60 seconds (1 minute). Assess physiologi factors that may be causing the patient to breathe so fast.
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| show | Having an addiction problem with amphetamines/cocaine. Feeling anxious when taking a test. Walking 1 mile briskly.
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| When assessing the respiratory rate, the nurse has difficulty seeing the patient's chest rise and fall with inspiration and expiration. What is the nurse’s best action? | show 🗑
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| show | Continue to act as though taking the patient’s pulse while discretely observing the rise and fall of the patient’s chest.
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| The nurse is validating the NAP’s skill with respiratory rate assessment. Which of the following actions, if made by the NAP, indicates that further instruction is needed? | show 🗑
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| 5. The nurse assesses the BP in both arms of a newly admitted patient. Why would the nurse do this? | show 🗑
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| Which of the following patients would be considered hypertensive after having two or more consistent readings of these values? | show 🗑
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| For which patient should you avoid using a leg pressure cuff (thigh cuff) to assess BP? | show 🗑
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| The student nurse is unsure of the BP measurement. What should the student nurse do first? | show 🗑
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| show | Image A = 120/80, Image B = 128/76, Image C = 140/90, Image D = 138/84
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| show | The patient complains of pain at a 9 on a 0-10 pain scale.
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| show | In the right arm.
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| show | Take the patient's BP manually using a sphygmomanometer.
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| 6. The NAP reports to the nurse the patient's respirations are 32 and the patient is complaining of shortness of breath. What is the best action by the nurse at this time? | show 🗑
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| show | A patient with a continuous pulse oximetry reading of 84%.
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| show | I will turn the continuous pulse oximetry alarms off at night so you can sleep."
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| show | Reassess the patient’s pulse oximetry. Place the patient in the high-Fowler’s position. Assess the patient’s respiratory and cardiac status.
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| show | Have the NAP use a different site, such as the ear lobe, to obtain the SpO2 reading.
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