Nursing Practice Test #3

Vital Signs and Temperature Assessment

• Fever can result from tissue injury, including cardiac events, pulmonary issues, cancer, trauma, and surgical procedures.
• A temperature of 38.5°C (101.3°F) is classified as a fever.
• The oral route for temperature assessment is appropriate for a healthy 15-year-old but not suitable for infants, oxygen-dependent patients, or unconscious individuals.
• Care is needed with rectal temperature assessment to avoid bradycardia (decrease in heart rate).
• A pulse rate of 140 beats/min should be reported immediately if found during assessment.
• Increased pulse rate can be expected with acute abdominal pain.
• To assess an apical pulse, use a stethoscope.
• A difference of 8 beats per minute between apical and radial pulse rates is documented as a pulse deficit.

Respiratory and Blood Pressure Assessment

• Normal respiratory rate for adults is 12 to 20 breaths/min.
• For a patient experiencing dyspnea, the initial action is to elevate the head of the bed.
• Blood pressure measures the force of blood against arterial walls; it tends to be higher in older adults due to decreased arterial elasticity.
• A reading of 130/90 mm Hg should lead to recommendations for follow-up measurements.
• Systolic pressure is represented by the first number in blood pressure readings.
• Accurate blood pressure measurement requires the correct cuff size to avoid erroneous readings.
• If a patient has IV fluids in one arm, blood pressure should be taken in the opposite arm.

Sleep and Pain Management

• Body temperature can vary based on the time of day, with a late afternoon reading of 37.2ºC (99ºF) typically indicating a normal circadian rhythm.
• The electromyograph (EMG) records muscle tone.
• Sleep disturbances can lead to involuntary muscle jerking, particularly during Stage I NREM sleep.
• A typical night of sleep includes about 4 to 5 cycles.
• REM sleep is characterized by active dreaming; prolonged REM deprivation may lead to symptoms of psychosis.
• Chronic insomnia is the most common complaint among patients in sleep disorder clinics.
• Caffeine intake should be avoided 4 to 5 hours before bedtime to promote better sleep quality.
• A sleep diary tracks daily physical activity and sleep habits; it assists in diagnosing sleep issues.

Pain Characteristics and Management

• Visceral pain is difficult to localize, while referred pain occurs in a different site than its origin.
• Behavioral responses to pain can include protective actions like cradling the injured area.
• Imagery techniques can help distract from pain by focusing on pleasant thoughts or settings.
• Pain that cannot be effectively managed is termed intractable pain; it is often resistant to treatment.
• Pupil dilation is a physiological response expected with moderate pain.
• Breakthrough pain in cancer patients can be effectively managed with supplemental short-acting opioids.
• Chronic pain management is most effective with around-the-clock (ATC) analgesics.

Urinary Function Assessment and Care

• Urine output can decrease and become highly concentrated during fever or diaphoresis.
• Indwelling catheters pose a risk for urinary tract infections, particularly in patients with compromised immunity.
• Urinary retention is characterized by the inability to void, despite urine production.
• Kegel exercises can aid older patients in managing urinary incontinence.
• Behavioral techniques are prioritized in treating urinary issues in elderly patients.
• Urine may turn orange-red due to the intake of phenazopyridine (Pyridium).

Monitoring and Complications

• Vigilant monitoring is vital for patients receiving epidural analgesia to prevent respiratory depression.
• A sedation level of 4 in patients on continuous opioid infusion warrants immediate physician notification.
• Results from routine urinalysis may be affected if urine is not processed quickly, highlighting the importance of prompt handling.
• Encouraging adequate fluid intake is essential for patients with indwelling catheters unless contraindicated.
• Ignoring the urge to void can exacerbate difficulty in urination.### Nursing Care Priorities
• Providing privacy for patients during voiding is essential for dignity and comfort.
• Regularly scheduled urinal offers help manage urinary needs effectively.
• For male patients using condom catheters, preventing tubing from kinking ensures free drainage.

Nursing Diagnoses and Patient Conditions

• Impaired urinary elimination in a child is defined as involuntary urination beyond the age of 4.
• For older adults with urinary incontinence, critical evaluation data includes incontinence patterns, physical mobility, and medications, but age is less relevant.

Dietary Considerations

• Alcohol should be avoided when instructed to steer clear of laxative-effect foods.
• Excessive flatulence may be linked to regular consumption of cauliflower.

Enemas and Bowel Management

• An oil-retention enema requires the patient to retain the solution for at least 30 minutes.
• Fecal drainage from an ileostomy consists of liquid, and irrigation is not needed for regulation.
• A hypertonic solution in enemas utilizes osmosis to help soften fecal contents.

Documentation and Health Information Privacy

• The nursing plan should include accurate and timely documentation, avoiding vague terms.
• Patients have rights under HIPAA, including access and the ability to request changes to their health records.
• Disclosures of patient information, especially for public figures, require special authorization.

Verbal Orders and Charting Procedures

• Verbal orders are only acceptable in emergencies and must be documented appropriately afterward.
• Focus charting uses the DAR (data, action, response) method to streamline nursing documentation.

General Nursing Actions

• Assisting patients in a normal position is crucial to promote regular bowel habits.
• Regularly assessing and managing bowel habits includes allowing sufficient time for evacuation.

Medical Test Explanations

• A colonoscopy provides a visual examination of the large intestine, while a barium enema is conducted prior to upper GI studies to prevent clouding the colon.

Risk Management

• Avoiding habitual laxative use is critical as it can lead to chronic constipation, demonstrating the need for proper patient education.

Patient Advocacy

• Nurses must maintain patient confidentiality, refusing requests for information from friends or family without patient consent.

Special Notes on Patient Experience

• Bradycardia may occur during fecal impaction removal due to vagal stimulation, highlighting the need for careful monitoring in such procedures.

This information encapsulates various nursing responsibilities, patient care protocols, and the significance of documentation while ensuring patient privacy and rights are upheld.