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Questions and Answers
The nurse is assessing the rectal temperature of a patient with an electronic thermometer. Which patient position would promote comfort?
The nurse is assessing the rectal temperature of a patient with an electronic thermometer. Which patient position would promote comfort?
Which vital sign can be altered because of a decrease in sweat gland reactivity in older adults?
Which vital sign can be altered because of a decrease in sweat gland reactivity in older adults?
Which range is acceptable for the diastolic blood pressure in a healthy adult?
Which range is acceptable for the diastolic blood pressure in a healthy adult?
Which body temperature would indicate a fever in the older- adult patient?
Which body temperature would indicate a fever in the older- adult patient?
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After measuring the temperature of the temporal artery, the nurse cleans the sensor with the alcohol swab. Which rationale would direct the nurse's action?
After measuring the temperature of the temporal artery, the nurse cleans the sensor with the alcohol swab. Which rationale would direct the nurse's action?
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At what age in years does the respiratory system begin to decline in healthy people?
At what age in years does the respiratory system begin to decline in healthy people?
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Which tympanic body temperature is normal for adults?
Which tympanic body temperature is normal for adults?
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When assessing the patient's respiration, for which reason would the nurse elevate the bed to 60 degrees in a sitting position?
When assessing the patient's respiration, for which reason would the nurse elevate the bed to 60 degrees in a sitting position?
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While assessing the oral temperature of a patient using an electronic thermometer, for which reason would the nurse ask the patient to close the lips?
While assessing the oral temperature of a patient using an electronic thermometer, for which reason would the nurse ask the patient to close the lips?
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The nurse locates different anatomical landmarks to identify the point of the apical impulse. Which rationale would direct this nursing action?
The nurse locates different anatomical landmarks to identify the point of the apical impulse. Which rationale would direct this nursing action?
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While assessing the apical pulse in a patient, the nurse places the diaphragm of the stethoscope in her palm for 10 seconds. Which rationale would direct this action?
While assessing the apical pulse in a patient, the nurse places the diaphragm of the stethoscope in her palm for 10 seconds. Which rationale would direct this action?
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The nurse is measuring the rectal temperature of an adult patient. The nurse inserts the thermometer probe into the anus of the patient up to 3 cm in the direction of the umbilicus. Which rationale would direct this nursing intervention?
The nurse is measuring the rectal temperature of an adult patient. The nurse inserts the thermometer probe into the anus of the patient up to 3 cm in the direction of the umbilicus. Which rationale would direct this nursing intervention?
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How would the nurse determine the ventilatory rhythm in a patient?
How would the nurse determine the ventilatory rhythm in a patient?
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The nurse is delegating a task of measuring a patient's oxygen saturation (SpO ). Which instruction would be provided to the assistive personnel (AP)?
The nurse is delegating a task of measuring a patient's oxygen saturation (SpO ). Which instruction would be provided to the assistive personnel (AP)?
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When measuring the blood pressure of a patient, the nurse palpates the artery distal to the cuff and inflates the cuff rapidly to a pressure 30 mm Hg above the point at which the pulse disappears. Which rationale would direct this action?
When measuring the blood pressure of a patient, the nurse palpates the artery distal to the cuff and inflates the cuff rapidly to a pressure 30 mm Hg above the point at which the pulse disappears. Which rationale would direct this action?
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For which patients would the nurse pull the ear pinna backward, up, and out during temperature assessment at the tympanic membrane site?
For which patients would the nurse pull the ear pinna backward, up, and out during temperature assessment at the tympanic membrane site?
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Which finding would the nurse report immediately to the health care provider?
Which finding would the nurse report immediately to the health care provider?
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Which vital sign finding in an adult patient would the nurse report to the health care provider immediately?
Which vital sign finding in an adult patient would the nurse report to the health care provider immediately?
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Which action related to measuring body temperature correlates to the assessment step in the nursing pocess? Select all that apply.
Which action related to measuring body temperature correlates to the assessment step in the nursing pocess? Select all that apply.
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Which sequence is the correct order of steps for measuring temperature using temporal artery thermometer?
Which sequence is the correct order of steps for measuring temperature using temporal artery thermometer?
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The registered nurse is teaching a nursing student about respiratory assessment. Which statement by the nursing student indicates the need for further learning?
The registered nurse is teaching a nursing student about respiratory assessment. Which statement by the nursing student indicates the need for further learning?
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Place in order the steps the nurse would follow when measuring vital signs:
Place in order the steps the nurse would follow when measuring vital signs:
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Which admitting vital sign measurement is outside of the normal range for an adult patient?
Which admitting vital sign measurement is outside of the normal range for an adult patient?
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A patient has been transferred to the unit from the respiratory ICU, where he has been for the past two weeks recovering from pneumonia. Which information would be most helpful in prioritizing nursing interventions?
A patient has been transferred to the unit from the respiratory ICU, where he has been for the past two weeks recovering from pneumonia. Which information would be most helpful in prioritizing nursing interventions?
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Which intervention would the nurse perform after determining that the patients BP is inadequate for perfusion?
Which intervention would the nurse perform after determining that the patients BP is inadequate for perfusion?
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Which statement is true regarding the factors affecting the vital signs of older adults? Select all that apply.
Which statement is true regarding the factors affecting the vital signs of older adults? Select all that apply.
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The nurse is assessing a patient's radial and apical pulses. Which anatomical landmark is located by the nurse in the given figure?
The nurse is assessing a patient's radial and apical pulses. Which anatomical landmark is located by the nurse in the given figure?
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Which patient report indicates abnormal vital signs?
Which patient report indicates abnormal vital signs?
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Which parameter would be considered abnormal in an 80 year old patient? Assessment Parameter
- Heart sounds
- BP
- Body temp
- HR at rest
Observation Made
- Muffled heart sounds
- Decreased systolic pressure
- slightly less than normal range
- decreased heart rate
Which parameter would be considered abnormal in an 80 year old patient? Assessment Parameter
- Heart sounds
- BP
- Body temp
- HR at rest Observation Made
- Muffled heart sounds
- Decreased systolic pressure
- slightly less than normal range
- decreased heart rate
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When measuring the axillary temperature of a patient, how can the nurse ensure proper positioning of the probe against the blood vessels in the axilla?
When measuring the axillary temperature of a patient, how can the nurse ensure proper positioning of the probe against the blood vessels in the axilla?
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Arrange the steps involved in measuring blood pressure
Arrange the steps involved in measuring blood pressure
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Which of the vital signs is abnormal for an adult? select all that apply
Which of the vital signs is abnormal for an adult? select all that apply
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The nurse observes significant differences in a patient's vital signs compared to the values recorded before surgery. Which action would the nurse take first?
The nurse observes significant differences in a patient's vital signs compared to the values recorded before surgery. Which action would the nurse take first?
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The registered nurse is teaching a nursing student about the guidelines for measuring vital signs. Which statements by the nursing student indicate the need for further teaching? Select all that apply.
The registered nurse is teaching a nursing student about the guidelines for measuring vital signs. Which statements by the nursing student indicate the need for further teaching? Select all that apply.
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The nurse measures the vital signs of four different adults. Which patient has abnormal findings?
Vital Signs------pt 1--------pt 2--------pt 3--------pt 4
Pulse
pressure-----28mmHg--34mmHg--48mmHg--40mmHg
Respir.-----------8-----------16----------12----------18
Pulse------------48---------80----------68---------75
Capnography---30---------36---------40----------44
(EtCO2)
The nurse measures the vital signs of four different adults. Which patient has abnormal findings?
Vital Signs------pt 1--------pt 2--------pt 3--------pt 4 Pulse pressure-----28mmHg--34mmHg--48mmHg--40mmHg Respir.-----------8-----------16----------12----------18 Pulse------------48---------80----------68---------75 Capnography---30---------36---------40----------44 (EtCO2)
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The registered nurse teaches the student nurse about the correct times to measure vital signs. Which statement by the student nurse shows ineffective learning?
The registered nurse teaches the student nurse about the correct times to measure vital signs. Which statement by the student nurse shows ineffective learning?
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In which situation would the nurse measure the vital signs? Selecta all that apply
In which situation would the nurse measure the vital signs? Selecta all that apply
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The nurse is working in a surgical unit. When should the nurse measure vital signs? Select all that apply.
The nurse is working in a surgical unit. When should the nurse measure vital signs? Select all that apply.
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Sequence the order of the steps for axillary temperature measurement with an electronic thermometer
Sequence the order of the steps for axillary temperature measurement with an electronic thermometer
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Which order os steps is correct for measuring blood pressure using the 1-step method?
Which order os steps is correct for measuring blood pressure using the 1-step method?
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The licensed practical nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first?
The licensed practical nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first?
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The registered nurse teaches a nursing student about the assessment of vital signs in a patient with orthostatic hypotension. Which statement made by the nursing student indicates a need for further learning?
The registered nurse teaches a nursing student about the assessment of vital signs in a patient with orthostatic hypotension. Which statement made by the nursing student indicates a need for further learning?
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The registered nurse is teaching a nursing student about the assessment of vital signs in older adults. Which statement by the nursing student indicates the need for further teaching?
The registered nurse is teaching a nursing student about the assessment of vital signs in older adults. Which statement by the nursing student indicates the need for further teaching?
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The nurse is unable to hear the blood pressure reading of patient using a stethoscope and sphygmomanometer. Which action would the nurse take next? select all that apply
The nurse is unable to hear the blood pressure reading of patient using a stethoscope and sphygmomanometer. Which action would the nurse take next? select all that apply
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Which statement by the nursing student about when to measure vital signs indicates the need for further learning? Select all that apply.
Which statement by the nursing student about when to measure vital signs indicates the need for further learning? Select all that apply.
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Which tasks can be delegated to the assistive personnel?
Which tasks can be delegated to the assistive personnel?
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A 60-year-old male patient complains of severe breathlessness, sweating, pain in the chest, and cough. What guidelines should the nurse follow when measuring the vital signs? Select all that apply
A 60-year-old male patient complains of severe breathlessness, sweating, pain in the chest, and cough. What guidelines should the nurse follow when measuring the vital signs? Select all that apply
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The registered nurse is teaching a nursing student about measuring vital signs. Which statements by the nursing student indicate a need for further learning? Select all that apply
The registered nurse is teaching a nursing student about measuring vital signs. Which statements by the nursing student indicate a need for further learning? Select all that apply
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Which tasks can the nurse delegate to assistive personnel? select all that apply
Which tasks can the nurse delegate to assistive personnel? select all that apply
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The RN is teaching a nursing student about actions to be taken while measuring blood pressure. Which statement made by nursing student indicates a need for further learning? Select all that apply
The RN is teaching a nursing student about actions to be taken while measuring blood pressure. Which statement made by nursing student indicates a need for further learning? Select all that apply
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The registered nurse is teaching a nursing student about the guidelines for measuring vital signs. Which statement by the nursing student indicates the need for further learning? Select all that apply
The registered nurse is teaching a nursing student about the guidelines for measuring vital signs. Which statement by the nursing student indicates the need for further learning? Select all that apply
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The nurse is caring for a patient who underwent surgery. In which situation would the nurse measure the vital signs? Select all that apply
The nurse is caring for a patient who underwent surgery. In which situation would the nurse measure the vital signs? Select all that apply
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The registered nurse is teaching a nursing student about the vital parameters for older adults. Which statements by the nursing student indicate a need for further teaching? Select all that apply.
The registered nurse is teaching a nursing student about the vital parameters for older adults. Which statements by the nursing student indicate a need for further teaching? Select all that apply.
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Sequence the order of steps for assessing the radial pulse
Sequence the order of steps for assessing the radial pulse
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Order the steps for measuring rectal temperature
Order the steps for measuring rectal temperature
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The nurse decides not to measure the temperature of an older adult using the oral site. Which patient factor is is the likely reason for this decision. Select all that apply
The nurse decides not to measure the temperature of an older adult using the oral site. Which patient factor is is the likely reason for this decision. Select all that apply
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The assistive personnel report to the nurse about abnormal vital sign values in a patient who underwent abdominal surgery. Which action would the nurse take first?
The assistive personnel report to the nurse about abnormal vital sign values in a patient who underwent abdominal surgery. Which action would the nurse take first?
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Study Notes
Patient Position and Comfort
- Positioning patients for rectal temperature assessment should prioritize comfort, typically using the left lateral position.
Vital Signs in Older Adults
- Sweat gland reactivity decreases in older adults, leading to altered body temperature regulation and potential hyperthermia.
Blood Pressure Norms
- Acceptable diastolic blood pressure range for healthy adults is generally between 60-80 mmHg.
Body Temperature and Fever
- A body temperature of 100.4°F (38°C) or higher indicates a fever in older adult patients.
Cleaning Thermometers
- Using an alcohol swab to clean the temporal artery thermometer sensor prevents cross-contamination and ensures hygiene.
Respiratory System Decline
- The respiratory system begins to decline in healthy individuals around the age of 40.
Tympanic Temperature Norms
- Normal tympanic body temperature for adults is around 98.6°F (37°C).
Assessing Respirations
- Elevating the bed to 60 degrees during respiratory assessment improves lung expansion and patient comfort.
Oral Temperature Measurement
- Asking patients to close their lips while measuring oral temperature helps ensure an accurate reading.
Apical Pulse Assessment
- Identifying landmarks such as the 5th intercostal space at the midclavicular line is crucial for accurate apical pulse assessment.
Stethoscope Placement
- Placing the diaphragm of the stethoscope in the nurse's palm before assessing the apical pulse ensures a secure grip and clear sound transmission.
Rectal Temperature Procedure
- Inserting the thermometer probe about 3 cm into the anus toward the umbilicus is to facilitate accurate temperature measurement without injury.
Determining Ventilatory Rhythm
- The nurse assesses ventilatory rhythm by observing the depth and pattern of the patient’s breathing.
Delegating Oxygen Saturation Measurement
- The nurse instructs assistive personnel to ensure the oximeter is placed correctly on the patient’s finger for accurate readings.
Blood Pressure Measurement Technique
- Rapid cuff inflation to 30 mmHg above the pulse disappearance point assists in determining systolic pressure accurately.
Tympanic Membrane Assessment
- Pulling the ear pinna backward, up, and out during temperature assessment allows for better visualization and access to the tympanic membrane.
Critical Findings to Report
- Any abnormal vital sign finding, particularly changes from baseline post-surgery, should be reported to the healthcare provider immediately.
Abnormal Vital Signs in Adult Patients
- A pulse pressure significantly less than normal may indicate potential cardiovascular issues and warrants further evaluation.
Temperature Measurement in Axillary Site
- Proper placement of the thermometer probe against blood vessels in the axilla ensures accurate axillary temperature measurement.
Vital Signs After Surgery
- Significant deviations from pre-surgery vital signs demand immediate nurse assessment to address potential complications.
Teaching and Learning in Vital Sign Measurements
- Nursing students should understand guidelines for measuring vital signs, recognizing when to seek clarification or further education from instructors.
Identifying Delegable Tasks
- Tasks such as measuring vital signs can be delegated to assistive personnel, but critical assessments require the nurse's expertise.
Situations for Vital Sign Measurement
- Vital signs should be measured when there are changes in patient condition, prior to treatments, and as part of routine assessments post-surgery.
Blood Pressure Measurement Steps
- Steps for measuring blood pressure using different techniques must be performed in a systematic order to ensure accuracy.
Factors Influencing Vital Signs in Older Adults
- Awareness of physiological changes that affect vital signs in older adults allows for better assessment and individualized care strategies.
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Description
This quiz focuses on assessing the best patient position to promote comfort while measuring rectal temperature with an electronic thermometer. Understanding these positions is essential for healthcare professionals to ensure patient comfort during the procedure.
