Download test bank for nursing interventions and clinical skills 5th edition by perry

This is especially important when assessing temperature and blood pressure since a variety of devices are available for measuring these vital signs.. Documentation is an important part o

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Test Bank for Nursing Interventions and Clinical Skills

5th Edition by Perry

Perry: Nursing Interventions & Clinical Skills, 5 th Edition

Chapter 06: Vital Signs

MULTIPLE CHOICE

1 The patient’s oral temperature is 39° C Which conclusion can the nurse

make about the patient on the basis of this information?

A The patient is febrile

B The patient is afebrile

C An infection is present

D Inflammation is present

A temperature of 39° C is above normal, and the patient with an

aboveaverage temperature is febrile Afebrile indicates a lack of fever but does not necessarily imply a subnormal temperature An infection often causes a fever in the patient, but a physical examination and laboratory work or culture are necessary before concluding that the patient has an infection A patient with an inflammation can have a fever, but the

patient can have an inflammation without being febrile

PTS: 1 DIF: 2 REF: Page 84, 95-96

TOP: Cognitive Level: Comprehension MSC: Nursing Process:

Diagnosis

2 The nurse is preparing to obtain a set of vital signs Which is the most

important factor for the nurse to consider when measuring patient vital

signs?

A Documentation of vital signs requires timely and accurate recording

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B Normal limits are very narrow and are generally the same for all patients

C Measuring equipment must suit the patient’s condition and

characteristics

D Environmental factors play a minor role on patient vital signs

Suitable measuring equipment for patient condition and characteristics is important because improper equipment distorts the results increasing the risk

of patient injury If data are obtained with improper equipment and patient treatment is based on the faulty data, the people who use the improper

equipment and the faulty data are liable for the results This is especially important when assessing temperature and blood pressure since a variety of devices are available for measuring these vital signs Documentation is an important part of taking vital signs; however, if the nurse uses improper equipment or technique to obtain vital signs, accurate and prompt recording

is to no avail Depending on the parameter, the normal limits are not

relatively narrow The benefit of a wider normal range is that the body is able to respond to stress and recover while remaining within normal limits Environmental factors play a significant role on vital signs (e.g., an overly warm room affects patient temperature)

PTS: 1 DIF: 1 REF: Page 84-86

Assessment

3 The patient was hospitalized after a severe closed head injury and has erratic tympanic temperatures Which action should the nurse take when the next temperature is due?

A Obtain both the tympanic temperature and the temperature from another site to validate the reading

B Watch for increased patient heat loss from vasodilation

C Evaluate the vital signs at 4-hour intervals around the clock

D Watch for increased intracranial pressure on the hypothalamus

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Obtain the temperature from another site to validate the reading The most likely causes of the erratic temperatures are variations in the technique,

resulting in a high percentage of abnormal results Because of the brain

involvement, it is essential that the temperature be watched Vasodilation is not a common result of a closed head injury Taking temperature every 4 hours is normal procedure in hospitals If increased intracranial pressure were the cause of the temperature fluctuations, it is much more likely that the temperature would be at a sustained, abnormal point or trending up or down

PTS: 1 Analysis DIF: 3 REF: Page 84-86 TOP: Cognitive Level: MSC: Nursing Process: Planning

4 A patient has a severe upper respiratory and ear infection and has been

experiencing diarrhea Assessment of the temperature would be most accurate

if the nurse checked the temperature using which site?

A The rectum

B The axilla

C Under the tongue

D The tympanic membrane

The axilla is the only area listed where there is no infection or health issue and where there is no interference to its accuracy The rectum is an

inappropriate site because of the diarrhea The oral route, under the tongue,

is an inappropriate site because of the severe upper respiratory infection If the patient cannot breathe through the nose, mouth breathing occurs, and the mouth cannot be closed to create a seal for an accurate temperature

measurement The tympanic membrane is an inappropriate site because of the ear infection

PTS: 1 DIF: 3 REF: Page 84-86 TOP: Cognitive Level: Analysis

MSC: Nursing Process: Assessment

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5 The nurse is validating the measurement of an infant’s pulse by a nursing

student Which method should the nurse use to obtain the most accurate

count?

A Compress the bell of the stethoscope over the apex of the heart

B Locate the pulsations in the antecubital space

C Palpate the superficial artery on the medial side of wrist

D Place the thumb and forefinger along the ridge on the outer side of the wrist

Counting the pulsations in the antecubital fossa from the brachial artery

would give the most accurate count Compressing the bell of the stethoscope turns it into a diaphragm; the bell is never compressed during use Placing the thumb and forefinger along the ridge on the outer side of the wrist

locates the radial artery, the preferred site for measuring an adult’s pulse

PTS: 1 DIF: 1 REF: Page 86-87, 98

TOP: Cognitive Level: Knowledge MSC: Nursing Process:

Implementation

6 A patient born without arms needs to have a blood pressure assessment

Which artery should the nurse use to most accurately obtain this

measurement? A Femoral

B Carotid

C Brachial

D Popliteal

The nurse can use the popliteal artery to measure blood pressure by applying

a properly sized cuff to the patient’s thigh The femoral artery does not

provide an area for assessment of the blood pressure The brachial arteries are in the arm The carotid artery, which is in the neck, is impossible to use for blood pressure measurement because applying cuff pressure to

temporarily occlude both carotid arteries would stop blood flow to the brain and risk cerebral hypoxia

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Implementation

7 The nurse is running a blood pressure screening clinic at the community

health center Which action should the nurse implement to obtain an accurate measurement of a patient’s blood pressure on an upper extremity?

A Use a cuff with a cuff width that is 40% wider than the circumference of the arm

B Limit the cuff deflation rate to 10 mm Hg per second or heartbeat

C Record the second Korotkoff sound as the systolic pressure

D Apply the diaphragm of the stethoscope lightly over the brachial artery

For accurate results, a properly sized blood pressure cuff is at least 40% wider than the circumference of the patient’s arm on which the blood

pressure is measured Deflating the cuff at 10 mm Hg is excessively fast The systolic blood pressure is the first Korotkoff sound The diaphragm is placed firmly over the brachial artery to prevent environmental sound from interfering with blood pressure auscultation

Implementation

8 The patient is unstable; so the nurse is using an electronic blood pressure

device to measure blood pressures every 15 minutes What should the nurse

do to verify the accuracy of the electronic blood pressure measurements?

A Check when the device was last calibrated

B Know that the device adheres to current medical industry standards

C Take a manual blood pressure within several minutes of the electronic reading

D Verify that the systolic pressure is within 20% of patient baseline

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If the blood pressure readings from the electronic blood pressure

measurement device are close to the patient’s blood pressure on auscultation using a sphygmomanometer, the nurse assumes that the electronic device is accurate Knowing when the device was calibrated does not guarantee its current accuracy Medical industry standards do not exist for electronic

blood pressure devices A systolic measurement accurate within 20% of the patient’s baseline is grossly inaccurate, and using such a measurement can potentially lead to catastrophic results

PTS: 1 DIF: 2 REF: Page 109

TOP: Cognitive Level: Application MSC: Nursing Process:

Evaluation

9 A patient has an electronic blood pressure cuff that inflates every 15 minutes for a reading Which activity by the nursing student would require the nurse

to intervene?

A The cuff is positioned carefully on the gown sleeve for comfort

B The cuff is removed every 2 hours for a skin assessment

C The alarm limits on the electronic device are checked frequently

D The cuff is rotated to the other extremity every few hours as possible

The cuff should be directly on the patient’s skin, not over the gown, for an accurate reading All other actions are appropriate

PTS: 1 DIF: 2 REF: Page 108 TOP: Cognitive Level: Knowledge

MSC: Nursing Process: Planning

10 The nurse delegates temperature measurement to nursing assistive personnel (NAP) For which patient should the nurse instruct the NAP to use the

tympanic thermometer?

A 10-year-old patient with a left leg fracture

B 12-hour-old infant in the newborn nursery

C 5-year-old patient with bilateral otitis media

D 15-year-old patient with postbilateral tympanoplasties

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The 10-year-old patient is a suitable candidate for use of the tympanic

thermometer if the NAP uses proper technique for positioning the sensor because of the age and condition of the child The anatomy of the ear canal makes it difficult to position the probe accurately in neonates Whenever ear infections are present, a tympanic thermometer can cause injury and record

an inaccurate reading because of fluid, wax, or infectious material in the ear Tympanic temperatures are prohibited when ear surgery has just been

performed because they increase the risk for injury and infection

Planning

11 The nurse needs to measure the adult patient’s temperature, but the patient has just finished a cup of coffee Which is the best type of temperature for the nurse to obtain accurate results efficiently?

A Rectal

B Axillary

C Tympanic

D Disposable

The nurse obtains a tympanic temperature because the hot coffee will affect

an oral reading A tympanic temperature is a more reliable indicator of body temperature than the oral reading because a tympanic temperature is a core temperature Rectal temperatures for adult patients are reserved for

occasions when continuous temperature monitoring is required or if no other core temperature site is available; in addition, rectal temperatures are

embarrassing for an alert adult patient Axillary temperatures are not as

reliable as tympanic temperatures and do not reflect core temperature

Disposable thermometers are the least accurate method

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Planning

12 The nurse is preparing to obtain a rectal temperature Nursing care is correct

if the nurse inserts the thermometer how far into the rectum of an adult?

A 1.3 cm (1/2 inch)

B 3.5 cm (1 1/2 inches)

C 5.1 cm (2 inches)

D 6.4 cm (1 1/2 inches)

The nurse inserts the thermometer 2.5 to 3.5 cm (1 to 1 1/2 inches) to obtain

a rectal temperature on an adult The sensor tip will be deep enough into the rectum to eliminate environmental effects but not too deep to risk

penetration or trauma to intestinal tissue 1.3 cm (1/2 inch) is not far enough for an accurate reading 5.1 and 6.4 cm (2 and 2 1/2 inches) are too far to insert the thermometer into an adult

PTS: 1 DIF: 1 REF: Page 92 TOP: Cognitive Level: Knowledge

MSC: Nursing Process: Implementation

13 While inserting a rectal thermometer, the nurse encounters resistance What action should the nurse take?

A Remove the thermometer immediately

B Ask the patient to take a few deep breaths

C Apply mild pressure to advance the thermometer

D Remove the thermometer and reinsert gently

If resistance is felt, the nurse should remove the thermometer probe

Applying pressure to advance the thermometer is contraindicated to prevent complications such as harm to the mucosa If there is an obstruction or a large amount of stool, having the patient take a few deep breaths is useless

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The obstruction or impaction will have to be dealt with first If the nurse removes and then reinserts the thermometer, the stimulation reactivates the sphincter reflex The resistance will more than likely still be present

Planning

14 The nurse notes that the patient’s tympanic temperature is 37.88° C (100.2° F) at 4 PM on the patient’s second postoperative day What should the nurse

do initially?

A Check the leukocyte count

B Collaborate for cultures

C Ask the patient to drink some fluid

D Offer the patient another blanket

The nurse should ask the patient to drink more fluid and cough and deep breathe because low-grade temperatures frequently indicate dehydration and atelectasis in postoperative patients; in addition, patient temperatures

generally peak in late afternoon The nurse evaluates the patient’s

temperature again in 2 hours and expects to obtain a lower temperature If not, the nurse assesses the patient for infection and collaborates with the provider to plan care Until the nurse tries fluid and verifies the temperature, collaborating for specimen cultures is premature; in addition, the provider potentially will not want to culture for a low-grade temperature

PTS: 1 DIF: 2 REF: Page 84, 91, 94

Implementation

15 The nurse is teaching a family member how to check a teenager’s

temperature using a tympanic thermometer Which step is most important for the nurse to include obtaining an accurate reading?

A Pull the pinna down and back

B Move the thermometer in the ear in a figure-eight pattern

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C Place the probe loosely into the ear canal

D Point the probe toward the nose

To obtain a tympanic temperature using proper technique, the nurse inserts the thermometer tip into the ear, making a figure-eight pattern to ensure a snug fit The tip must fit securely in the ear canal to block environmental effects The pinna is pulled back, up, and out for an adult The tip of the thermometer should point toward the patient’s chin for proper positioning

PTS: 1 DIF: 1 REF: Page 94-95 TOP: Cognitive Level: Knowledge

MSC: Nursing Process: Assessment

16 A patient has been experiencing some circulatory issues, and an apical-radial pulse is ordered Nursing care is correct if which procedure is followed?

A One nurse counts the apical pulse at the same time another nurse counts the radial pulse

B The nurse delegates this procedure to an experienced licensed practical nurse/licensed vocational nurse (LPN/LVN) and nursing assistive

personnel (NAP) with 10 years’ experience

C The nurse counts the apical pulse for 60 seconds and then the radial pulse for 60 seconds

D The apical pulse is counted for 30 seconds, the radial pulse for 30

seconds, and the results are doubled

The pulse rate must be counted for 60 seconds at the two sites at the same time by two different people If the patient is unstable or experiencing

problems, this cannot be delegated to NAP The radial and apical pulses are counted at the same time by two different people The apical and radial

pulses are counted for a full minute, not 30 seconds, and the results doubled

PTS: 1 DIF: 2 REF: Page 101

Assessment

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