B
besides high blood pressure values, what other signs and symptoms may the nurse observe if hypertension is present?
A) Unexplained pain and hyperactivity
B) Headache, flushing of the face, and nosebleed
C) Dizziness, mental confusion, and mottled extremit
D
Which of the following vlues for vital signs would the nurse address first?
A) Heart rate = 72 beats per minute
B) Respiration rate = 28 breaths per minute
C) Blood pressure = 160/86
D) Oxygen saturation by pulse oximetry = 89%
E) Temperature = 37.2� C (9
D
An 82-year-old widower brought via ambulance is admitted to the emergency department with complaints of shortness of
breath, anorexia, and malaise. He recently visited his health care provider and was put on an antibiotic for pneumonia. The client indicat
C
The client, who has been on bed rest for 2 days, asks to get out of bed to go to the bathroom. He has new orders for "up ad lib." What action should the nurse take?
A) Give him some slippers and tell him where the bathroom is located.
B) Ask the nursing a
A
Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 36.1� C (97� F). The client's remaining vital signs are in the normally acceptable range. What should the nurse do next?
A) Check
B
The nurse decides to take an apical pulse instead of a radial pulse. Which of the following client conditions influenced the nurse's decision?
A) The client is in shock.
B) The client has an arrhythmia.
C) The client underwent surgery 18 hours earlier.
D)
D
The nurse is to measure vital signs as part of the preparation for a test. The client is talking with a visiting pastor. How should the nurse handle measuring the rate of respiration?
A) Count respirations during the time the client is not talking to the
D
Delegation of some tasks may become one of the decisions the nurse will make while on duty. For which of the following clients would it be most appropriate for unlicensed assistive personnel to measure the client's vital signs?
A) A client who recently st
D
The client has an oral temperature of 39.2� C (102.6� F). What are the most appropriate nursing interventions?
A) Provide an alcohol sponge bath and monitor laboratory results.
B) Remove excess clothing, provide a tepid sponge bath, and administer an anal
D
The hypothalamus controls body temperature. The anterior hypothalamus controls heat loss, and the posterior hypothalamus controls heat production. What heat conservation mechanisms will the posterior hypothalamus initiate when it senses that the client's
C
The nurse's documentation indicates that a client has a pulse deficit of 14 beats. The pulse deficit is measured by:
A) Subtracting 60 (bradycardia) from the client's pulse rate and reporting the difference
B) Subtracting the client's pulse rate from 100
D
The nurse observes that a client's breathing pattern represents Cheyne-Stokes respiration. Which statement best describes the Cheyne-Stokes pattern?
A) Respirations cease for several seconds.
B) Respirations are abnormally shallow for two to three breaths
D
The nurse finds that the systolic blood pressure of an adult client is 88 mm Hg. What are the appropriate nursing interventions?
A) Check other vital signs.
B) Recheck the blood pressure and give the client orange juice.
C) Recheck the blood pressure afte
C
52 year old woman admitted with dyspnea and discomfort in her left chest with deep breaths. SHe smoked for 35 years and recently lost over 10 pounds. What vital sign should not be delegated to a nursing assistant:
a) temperature
b) radial pulse
c) respira
1, 5, 2, 4, 3
Place the vital signs in order of priority for your nursing interventions:
1) SpO2= 89%
2) BP= 160/86 mmHG
3) Temperature= 37.3 (99.4)
4) HR= 72 BPM
5) RR= 28 BrPM
1, 2, 4, 7
82 yr old admitted via ambulance to ER with shortness of breath, anorexia, and malaise. He recently visited the health care center and is on antibiotic for pneumonia. He is also on a diuretic, beta-adrergic blocker, which helps his "high blood".
He has a