Thermoregulation
Which newborn should the nursery nurse identify as being at significant risk for hypo alteration in thermoregulation?
What is low birth rate
The nurse is making rounds on the hospital unit and observes a patient sleeping. The patient's pulse and respirations are slower than baseline. The nurse realizes the patient has most likely just entered which stage of non-rapid eye movement sleep?
What is stage 2
The patient requires temperatures to be taken every 2 hours. Which task will be the responsibility of RN
What is assessing changes in body temperature.
The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take?
What is determine whether the toddler has a latex allergy
The patient's blood pressure is 140/60. Which value will the nurse record for the pulse pressure?
What is 80
1Shopping at an indoor mall
2Using a fan at low speed
3Walking slowly in the park
What is shopping at an indoor mall
A patient tells the nurse that he experiences daytime fatigue even after 7-8 hours of sleep each night. What is the best assessment question for the nurse to ask?
What is Do you also have any recent lifestyle or behavior changes?
The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures, which route will the nurse use to obtain this patient's temperature?
What is tympanic
The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use?
A nurse is caring for a group of patients, which patient will the nurse see first?
postoperative patient whose BP went from 128/70 to 100/60
patient with pain BP went from 124/70 to 130/74
Who is postoperative patient whose BP went from 128/70 to 100/70
During orientation in an Emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation?
1. Physical agility 2 Impaired cognition 3. Occupational exposure 4 Temperature extremes
What is physical agility
The nurse enters a patient's room. The patient startles easily and appears to jerk his arms and legs before awakening. Which stage of non-rapid eye movement sleep did the patient most likely awaken from?
What is Stage 1
The assistant personnel is taking vital signs and reports that a patient's blood pressure is abnormally low. What should the nurse do next.
What is retake the blood pressure personally and assess the patient's condition
A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for nurse to understand before assessing the patient's blood pressure
What is smoking results in vasoconstriction, falsely increasing blood pressure for up to 15 minutes.
The nurse is completing an assessment on an older-adult patient who is having difficulty falling asleep. Which condition will the nurse further assess for in this patient?
1. Depression, 2.mild fatigue, 3.HTN, 4.Hypothyroidism
What is depression?
What is the most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation?
What is rectal thermometer
The nurse is caring for a child with tonsillar enlargement. What is the nurse's priority concern?
What is low oxygen saturation
The nurse is caring for a patient who has a temperature reading of 100.4 F(38C) The patient's last two temperatures readings were 98.6 (37C) and 96.8(36C) What action will the nurse take?
What is wait 30 minutes and recheck the patient's temperature.
When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding?
What is 138/62
A patient complains of not being able to fall asleep at night and asks the nurse if there is a safe, non-prescription medication he can try. After consulting the HCP, the nurse should recommend which naturally occurring hormone?
What is melatonin
Which similar exemplar should the nurse consider when planning care for a patient with hypothermia?
1.Infection 2. Prematurity 3. Heat Stroke 4. Heat exhaustion
What is Prematurity
A mother tells the nurse she is concerned because her 8 month old infant sleeps all day and night and is only awake about 2-3 hours per day. What is the nurse's best response?
What is recommending that she notify the child's pediatrician.
The nurse is caring for an infant and is obtaining the patient's vital signs. Which artery will the nurse use to best obtain the infant's pulse?
What is the brachial
The nurse reviews the lab results for a patient and determines the viscosity of the blood is thick. Which lab result did the nurse check?
What is hematocrit
The nurse must awaken a patient from Stage 4 non-rapid eye movement sleep in order to prepare the patient for a procedure. The patient is disoriented - What is the nurses best action?
What is reassess the patient's orientation