Temperature Trouble
A nurse obtains an oral temperature immediately after a patient finishes drinking ice water. Before documenting the temperature as accurate, the nurse should have taken this action.
What is wait 15–30 minutes?
A patient's radial pulse is 108 beats/min. The medical term used to document this rate is this.
What is tachycardia?
A patient says, “Something feels wrong.” The vital signs were normal 30 minutes ago. What should the nurse do first?
What is reassess the patient and obtain current vital signs?
During manual blood-pressure measurement, the first Korotkoff sound represents this pressure.
What is systolic pressure?
A patient has fatigue, malaise, and a low-grade fever but has not yet developed disease-specific manifestations. This stage of infection is also described in the lecture as the period when the patient may be most contagious.
What is the prodromal period?
A patient becomes overheated and begins to perspire. As the moisture changes from liquid on the skin to vapor, body heat is lost by this mechanism.
What is evaporation?
The nurse documents a peripheral pulse as 0+. This description best communicates the pulse's characteristics.
What is absent?
A patient is found lying on the floor beside the bed. What is the nurse's first action?
What is assess the patient for injury?
A patient's blood pressure is 118/76 mm Hg. This patient's pulse pressure is this.
What is 42 mm Hg?
A urinary catheter allows microorganisms to bypass normal defenses and enter the urinary tract. Within the chain of infection, the catheter is this link.
What is the portal of entry?
Which patient would be the best candidate for a rectal temperature?
A. A patient with diarrhea
B. A patient who just had rectal surgery
C. An unconscious patient who cannot safely use an oral thermometer
D. A patient with severe neutropenia
Who is C, the unconscious patient who cannot safely use an oral thermometer?
Two nurses simultaneously obtain an apical pulse of 96 beats/min and a radial pulse of 96 beats/min. The pulse deficit is this.
What is 0 beats/min?
A patient refuses a recommended treatment because of a cultural belief. What should the nurse do first?
What is ask the patient about their beliefs and concerns?
A patient's blood pressure is unexpectedly 86/52 mm Hg, but the patient is alert and asymptomatic. What should the nurse do first?
What is reassess the patient and recheck the blood pressure?
A nurse enters the room of a patient requiring Airborne Precautions. In addition to Standard Precautions, these two protective requirements distinguish airborne isolation.
What are an N95 respirator and a negative-pressure isolation room?
An older adult's baseline temperature is 97.0°F. Today it is 99.2°F with new confusion. How should the nurse interpret this finding?
What is a possible fever/change from baseline requiring further assessment?
While assessing a radial pulse, the nurse notes that the beats are not evenly spaced. Instead of counting for 30 seconds and multiplying by two, the nurse should take this action.
What is count the pulse for one full minute at the apical pulse?
A confused patient repeatedly tries to get out of bed. What should the nurse try before applying a restraint?
What are less-restrictive safety interventions?
A patient has an IV infusing in the right arm and a history of left-sided mastectomy. Before automatically selecting either arm for a blood pressure, the nurse could use this alternate method.
What is using a thigh cuff?
DOUBLE JEOPARDY!
A patient has erythema, warmth, edema, and pain surrounding an injured ankle. A student immediately concludes that the patient has an infection. This is the more accurate interpretation.
What is the findings demonstrate an inflammatory response but do not, by themselves, establish infection?
A patient with pyrexia develops tachycardia and tachypnea. This physiological change explains why both the heart rate and respiratory rate increase.
What is increased metabolic activity causing increased oxygen demand?
A patient has an apical pulse of 110 and radial pulse of 94. In your best explanation, what is the physiological reason for why the values differ.
What is not every cardiac contraction is producing a pressure wave strong enough to be palpated peripherally?
A patient's SpO₂ suddenly reads 76%, but the patient is talking normally with no respiratory distress. What should the nurse do first?
What is check the pulse oximeter/equipment and reassess the reading?
When taking a manual blood pressure, how far above the point where the pulse disappears should the nurse inflate the sphygmomanometer?
What is 30 mm Hg above the point where the pulse disappears?
A patient on Droplet Precautions must leave the room for a test. What should the patient wear during transport?
What is a surgical mask?