Question 1

The nurse explains that one method of environmental heat loss is convection, which is exemplified by body heat being reduced by:

Accepted Answer

A)  being transferred to ice packs. 
B)  production of sweat. 
C)  being removed by fast air currents from a fan. 
D)  exposure to a cool environment. 
A)  being transferred to ice packs. 
B)  production of sweat. 
C)  being removed by fast air currents from a fan. 
D)  exposure to a cool environment.

Question 2

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

Accepted Answer

A)  notify the charge nurse of the hypotension. 
B)  notify the doctor of the bradycardia. 
C)  check medications that might be the cause of the irregularity. 
D)  check the patient's record to determine his baseline blood pressure. 
A)  notify the charge nurse of the hypotension. 
B)  notify the doctor of the bradycardia. 
C)  check medications that might be the cause of the irregularity. 
D)  check the patient's record to determine his baseline blood pressure.

Question 3

The nurse clarifies the average cardiac output in the adult is about _____ L/minute.

Accepted Answer

5
five
The average c

Question 4

The accuracy in measuring the apical pulse is enhanced when the nurse:

Accepted Answer

A)  counts the radial pulse at the same time. 
B)  counts the beats for one minute. 
C)  keeps the patient warm. 
D)  uses the bell of the stethoscope. 
A)  counts the radial pulse at the same time. 
B)  counts the beats for one minute. 
C)  keeps the patient warm. 
D)  uses the bell of the stethoscope.

Question 5

The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

Accepted Answer

A)  dizziness upon rising to a standing position. 
B)  a drop of 15 to 20 mm Hg from baseline when changing position. 
C)  nausea. 
D)  syncope. 
E)  blurred vision. 
A)  dizziness upon rising to a standing position. 
B)  a drop of 15 to 20 mm Hg from baseline when changing position. 
C)  nausea. 
D)  syncope. 
E)  blurred vision.

Question 6

The nurse anticipates that if the stroke volume of a patient is reduced, the pulse will be:

Accepted Answer

A)  stronger. 
B)  weaker. 
C)  bradycardic. 
D)  irregular. 
A)  stronger. 
B)  weaker. 
C)  bradycardic. 
D)  irregular.

Question 7

Because the elderly have non-elastic blood vessels, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:

Accepted Answer

A)  keep the patient in bed in a high Fowler's position. 
B)  allow the patient to sit on the side of the bed for a minute before standing. 
C)  instruct the patient to use the wheelchair for all mobility activity. 
D)  help the patient to rise quickly and support the patient for a minute. 
A)  keep the patient in bed in a high Fowler's position. 
B)  allow the patient to sit on the side of the bed for a minute before standing. 
C)  instruct the patient to use the wheelchair for all mobility activity. 
D)  help the patient to rise quickly and support the patient for a minute.

Question 8

An elderly patient has a tympanic temperature of 96.2° F (35.7° C). What nursing intervention would best meet this patient's need?

Accepted Answer

A)  Take the patient's vital signs every 4 hours, including temperature. 
B)  Provide fluids to increase circulation. 
C)  Increase room temperature to 72° F (22.2° 
C)  and add blankets to the bed. 
D)  Check the temperature orally to confirm the accuracy of the reading. 
A)  Take the patient's vital signs every 4 hours, including temperature. 
B)  Provide fluids to increase circulation. 
C)  Increase room temperature to 72° F (22.2° 
C)  and add blankets to the bed. 
D)  Check the temperature orally to confirm the accuracy of the reading.

Question 9

Elderly patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:

Accepted Answer

A)  continue to listen until the cuff is deflated. 
B)  pump up the cuff until no sound is heard and then let the air out. 
C)  make sure the bell of the stethoscope is placed firmly over the artery. 
D)  stop midway and begin to inflate again. 
A)  continue to listen until the cuff is deflated. 
B)  pump up the cuff until no sound is heard and then let the air out. 
C)  make sure the bell of the stethoscope is placed firmly over the artery. 
D)  stop midway and begin to inflate again.

Question 10

The nurse is aware that the use of an oral glass thermometer would be contraindicated in a:

Accepted Answer

A)  5-year-old with a facial laceration. 
B)  12-year-old patient with a recent seizure. 
C)  15-year-old with an abscessed tooth. 
D)  20-year-old with severe dehydration. 
A)  5-year-old with a facial laceration. 
B)  12-year-old patient with a recent seizure. 
C)  15-year-old with an abscessed tooth. 
D)  20-year-old with severe dehydration.

Question 11

The nurse would record a pulse as bradycardic if the rate were _____ beats/min.

Accepted Answer

A)  64 
B)  62 
C)  60 
D)  59 
A)  64 
B)  62 
C)  60 
D)  59

Question 12

The nurse explains to a patient that the pulse oximeter can measure the arterial oxygen by:

Accepted Answer

A)  assessing the amount of blood passing through the sensor. 
B)  assessing the relative warmth of the skin on the monitored part. 
C)  measuring the oxygenated hemoglobin through a capillary bed. 
D)  measuring the respirations to the blood pressure via infrared rays. 
A)  assessing the amount of blood passing through the sensor. 
B)  assessing the relative warmth of the skin on the monitored part. 
C)  measuring the oxygenated hemoglobin through a capillary bed. 
D)  measuring the respirations to the blood pressure via infrared rays.

Exam 21: Measuring Vital Signs

The nurse explains that one method of environmental heat loss is convection, which is exemplified by body heat being reduced by:

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

The nurse clarifies the average cardiac output in the adult is about _____ L/minute.

The accuracy in measuring the apical pulse is enhanced when the nurse:

The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

The nurse anticipates that if the stroke volume of a patient is reduced, the pulse will be:

Because the elderly have non-elastic blood vessels, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:

An elderly patient has a tympanic temperature of 96.2° F (35.7° C). What nursing intervention would best meet this patient's need?

Elderly patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:

The nurse is aware that the use of an oral glass thermometer would be contraindicated in a:

The nurse would record a pulse as bradycardic if the rate were _____ beats/min.

The nurse explains to a patient that the pulse oximeter can measure the arterial oxygen by:

Nursing and the Health Care System

Concepts of Health, Illness, Stress, and Health Promotion

Legal and Ethical Aspects of Nursing

Nursing Process and Critical Thinking

Assessment, Nursing Diagnosis, and Planning

Implementation and Evaluation

Documentation of Nursing Care

Communication and the Nurse-Patient Relationship

Patient Teaching for Health Promotion

Delegation, Leadership, and Management

Growth and Development: Infancy Through Adolescence

Adulthood and the Family

Promoting Healthy Adaptation to Aging

Cultural and Spiritual Aspects of Patient Care

Loss, Grief, the Dying Patient, and Palliative Care

Infection Prevention and Control: Protective Mechanisms and Asepsis

Infection Prevention and Control in the Hospital and Home

Lifting, Moving, and Positioning Patients

Assisting with Hygiene, Personal Care, Skin Care, and the Prevention of Pressure Ulcers

Patient Environment and Safety

Assessing Health Status

Admitting, Transferring, and Discharging Patients

Diagnostic Tests and Specimen Collection

Fluid, Electrolyte, and Acid–Base Balance

Concepts of Basic Nutrition and Cultural Considerations

Diet Therapy and Assisted Feeding

Assisting with Respiration and Oxygen Delivery

Promoting Urinary Elimination

Promoting Bowel Elimination

Pain, Comfort, and Sleep

Complementary and Alternative Therapies

Pharmacology and Preparation for Drug Administration

Administering Oral, Topical, and Inhalant Medications

Administering Intradermal, Subcutaneous, and Intramuscular Injections

Administering Intravenous Solutions and Medications

Care of the Surgical Patient

Providing Wound Care and Treating Pressure Ulcers

Promoting Musculoskeletal Function

Common Physical Care Problems of the Elderly

Common Psychosocial Care Problems of the Elderly

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