Question 1

The nurse is taking a rectal temperature on an adult patient.She expects to insert the thermometer __________ inches.

Accepted Answer

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.

Question 2

An irregular heartbeat, often found in children, that speeds up with inspiration and slows down with expiration is known as a sinus ___________.

Accepted Answer

dysrhythmia
Children often have a sinus dysrhythmia, which is an irregular heartbeat that speeds up with inspiration and slows down with expiration.

Question 3

A person's core temperature is considered the most accurate since it is:

Accepted Answer

A) reflective of the surrounding environment. 
B) the same for everyone. 
C) controlled by the hypothalamus. 
D) independent of external influences. 
A) reflective of the surrounding environment. 
B) the same for everyone. 
C) controlled by the hypothalamus. 
D) independent of external influences. C

Question 4

What is a disadvantage of using the disposable sensor pad for pulse oximetry?

Accepted Answer

A) It is less restrictive. 
B) It contains latex. 
C) It is less expensive to use. 
D) It is available in different sizes. 
A) It is less restrictive. 
B) It contains latex. 
C) It is less expensive to use. 
D) It is available in different sizes.

Question 5

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 2 days.When the nurse takes his vital signs, however, the patient's apical pulse is 152 and regular.The nurse suspects that the:

Accepted Answer

A) patient is having a reaction to his narcotic medication. 
B) patient may be suffering from hypothermia. 
C) patient's fever may have returned. 
D) patient may be an athlete. 
A) patient is having a reaction to his narcotic medication. 
B) patient may be suffering from hypothermia. 
C) patient's fever may have returned. 
D) patient may be an athlete.

Question 6

An appropriate procedure for measurement of an adult's temperature with a tympanic membrane sensor is:

Accepted Answer

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. 
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.

Question 7

What steps should the nurse take to conduct an assessment of a possible pulse deficit?

Accepted Answer

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. 
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.

Question 8

The percent to which hemoglobin is filled with oxygen is known as _________________.

Accepted Answer

arterial blood oxygen saturati

Question 9

The nurse is about to take vital signs on a newborn patient in the nursery.She should:

Accepted Answer

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. 
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.

Question 10

_________ is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction.

Accepted Answer

S2
S2 is the sound of the pulm

Question 11

An appropriate method of assessing a patient's respirations is for the nurse to:

Accepted Answer

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. 
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.

Question 12

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:

Accepted Answer

A) hypotension 
B) prehypertension 
C) hypertension 
D) orthostatic hypotension 
A) hypotension 
B) prehypertension 
C) hypertension 
D) orthostatic hypotension

Question 13

The patient has an order to be off the floor for 15 minutes every 2 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:

Accepted Answer

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. 
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.

Question 14

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:

Accepted Answer

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. 
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.

Question 15

When heat loss mechanisms are unable to keep pace with heat production, ____________ is the result.

Accepted Answer

fever
Fever occurs when heat l

Question 16

_____________ occurs when the systolic blood pressure falls to 90 mm Hg or below.

Accepted Answer

Hypotension
Hypotension occurs when the

Question 17

An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a ____________.

Accepted Answer

pulse deficit
An inefficient contraction

Question 18

When evaluating the patient's temperature levels, the nurse expects the patient's temperature to be lower:

Accepted Answer

A) in the morning. 
B) after exercising. 
C) during periods of stress. 
D) during the postoperative period. 
A) in the morning. 
B) after exercising. 
C) during periods of stress. 
D) during the postoperative period.

Question 19

The nurse should report an assessment of _____ respirations per minutes for a(n) _____.

Accepted Answer

A) 14; adult patient 
B) 16; 8-year-old patient 
C) 25; toddler 
D) 38; newborn 
A) 14; adult patient 
B) 16; 8-year-old patient 
C) 25; toddler 
D) 38; newborn

Question 20

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:

Accepted Answer

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. 
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.

Exam 5: Vital Signs

The nurse is taking a rectal temperature on an adult patient.She expects to insert the thermometer __________ inches.

An irregular heartbeat, often found in children, that speeds up with inspiration and slows down with expiration is known as a sinus ___________.

A person's core temperature is considered the most accurate since it is:

What is a disadvantage of using the disposable sensor pad for pulse oximetry?

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 2 days.When the nurse takes his vital signs, however, the patient's apical pulse is 152 and regular.The nurse suspects that the:

An appropriate procedure for measurement of an adult's temperature with a tympanic membrane sensor is:

What steps should the nurse take to conduct an assessment of a possible pulse deficit?

The percent to which hemoglobin is filled with oxygen is known as _________________.

The nurse is about to take vital signs on a newborn patient in the nursery.She should:

_________ is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction.

An appropriate method of assessing a patient's respirations is for the nurse to:

The patient has an order to be off the floor for 15 minutes every 2 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:

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:

When heat loss mechanisms are unable to keep pace with heat production, ____________ is the result.

_____________ occurs when the systolic blood pressure falls to 90 mm Hg or below.

An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a ____________.

When evaluating the patient's temperature levels, the nurse expects the patient's temperature to be lower:

The nurse should report an assessment of _____ respirations per minutes for a(n) _____.

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:

Using Evidence in Nursing Practice

Admitting, Transfer, and Discharge

Communication

Documentation and Informatics

Health Assessment

Medical Asepsis

Sterile Technique

Safe Patient Handling, Transfer, and Positioning

Exercise and Ambulation

Orthopedic Measures

Support Surfaces and Special Beds

Safety and Quality Improvement

Disaster Preparedness

Pain Assessment and Basic Comfort Measures

Palliative Care

Personal Hygiene and Bed Making

Pressure Ulcer Care

Care of the Eye and Ear

Safe Medication Preparation

Oral and Topical Medications

Parenteral Medications

Oxygen Therapy

Performing Chest Physiotherapy

Airway Management

Closed Chest Drainage Systems

Emergency Measures for Life Support

Intravenous and Vascular Access Therapy

Blood Transfusions

Oral Nutrition

Enteral Nutrition

Parenteral Nutrition

Urinary Elimination

Bowel Elimination and Gastric Intubation

Ostomy Care

Preoperative and Postoperative Care

Intraoperative Care

Wound Care and Irrigations

Dressings, Bandages, and Binders

Therapeutic Use of Heat and Cold

Home Care Safety

Home Care Teaching

Specimen Collection

Diagnostic Procedures

Filters

The nurse should report an assessment of _ respirations per minutes for a(n) _.