Vitals Signs (a)
Rectal Temperature (Procedure)
When taking a rectal temperature, the client should be positioned in:
A. Supine position
B. Prone position
C. Sims’ position
D. High Fowler’s position
C. Sims’ position
Which of the following actions promotes vein dilation before inserting a peripheral IV catheter?
Elevate the arm above the heart
Apply a cool compress
Apply a warm compress
Ask the client to keep the arm still
C. Apply a warm compress
The nurse should insert the rectal thermometer approximately:
A. 0.5 cm
B. 1 cm
C. 2.5 cm (1 inch)
D. 5 cm (2 inches)
C. 2.5 cm (1 inch)
Before IV insertion, the nurse should:
A. Massage the vein vigorously
B. Apply a warm compress for 5-10 minutes
C. Apply ice to the vein
D. Ask the client to lower their arm
B. Apply a warm compress for 5-10 minutes
Palpating systolic blood pressure involves:
A. Listening for Korotkoff sounds
B. Noting the point where the pulse returns
C. Measuring diastolic pressure only
D. Using a Doppler device
B. Noting the point where the pulse returns
3) When selecting a site for peripheral IV insertion in an adult, the nurse should choose:
A. The dominant hand first
B. The most proximal site first
C. A distal site on the nondominant hand
D. The lower extremity
C. A distal site on the nondominant hand
When taking a manual blood pressure, the nurse should:
A. Keep the client’s arm above heart level
B. Use a cuff with a width equal to half the arm circumference
C. Ensure the cuff is snug with the lower edge 2.5 cm above the antecubital fossa
D. Inflate the cuff to 100 mmHg regardless of baseline
C. Ensure the cuff is snug with the lower edge 2.5 cm above the antecubital fossa
Which vein is most appropriate for routine peripheral IV insertion?
A. Femoral vein
B. Dorsal metacarpal vein
C. External jugular vein
D. Saphenous vein
B. Dorsal metacarpal vein
Why is palpating systolic blood pressure performed before auscultating?
A. To identify diastolic pressure
B. To prevent a falsely low systolic reading
C. To identify irregular rhythms
D. To save time during assessment
B. To prevent a falsely low systolic reading
5) After administering a subcutaneous injection, the nurse should:
A. Massage the site vigorously
B. Apply gentle pressure to the site
C. Immediately apply ice
D. Cover with a warm compress
B. Apply gentle pressure to the site
A client has a BP of 168/94 mmHg. The nurse’s first action should be:
A. Administer antihypertensive medication immediately
B. Recheck the blood pressure after a few minutes
C. Document and continue assessment
D. Notify the provider immediately
B. Recheck the blood pressure after a few minutes
The nurse has just administered an IM injection; what should be documented?
A. Type of syringe only
B. Only the time of administration
C. Medication, dose, site, and patient response
D. Lot number only
C. Medication, dose, site, and patient response
If a client’s blood pressure is elevated during initial assessment, the nurse should:
A. Reassess after ensuring the client is rested
B. Ask the client to walk before retaking BP
C. Use a smaller cuff to retake BP
D. Place the client in a supine position and recheck
A. Reassess after ensuring the client is rested
7) If the nurse realizes the wrong IV fluid is infusing, the first action should be:
A. Notify the provider immediately
B. Stop the infusion
C. Document the incident
D. Continue the infusion while calling pharmacy
B. Stop the infusion
9) Which of the following actions helps reduce fever in a client?
A. Applying warm blankets
B. Providing warm fluids
C. Increasing the room temperature
D. Providing cool fluids and tepid sponge bath
D. Providing cool fluids and tepid sponge bath
During IV medication administration, if the nurse notes infiltration, the priority action is to:
A. Slow the rate of infusion
B. Stop the infusion and remove the IV
C. Elevate the extremity and continue infusion
D. Flush the IV with saline
B. Stop the infusion and remove the IV
A client with a fever of 39.5°C (103.1°F) should be assessed for:
A. Chills and diaphoresis
B. Bradycardia
C. Hypotension
D. Decreased oxygen demand
A. Chills and diaphoresis
9) A client with an IV site reports burning and the site appears red and warm. This indicates:
A. Infiltration
B. Phlebitis
C. Fluid overload
D. Air embolism
B. Phlebitis
A nurse is assessing the vital signs of a 72-year-old client who is alert and resting in bed. Which of the following findings should the nurse report to the provider immediately?
A. Respiratory rate: 18 breaths/min
B. Blood pressure: 182/96 mmHg
C. Heart rate: 88 bpm
D. Temperature: 37.4°C (99.3°F)
B. Blood pressure: 182/96 mmHg
The nurse observes swelling and coolness at the IV site. This is likely:
A. Phlebitis
B. Infiltration
C. Infection
D. Hematoma
B. Infiltration