Vital Signs
Your patient has loose stools and recovering from an ear infection. Which type of thermometer will you use to measure the temperature?
A. Oral thermometers
B. Rectal thermometers
C. Tympanic thermometers
D. Temporal thermometers
The temporal artery route, while not as accurate as the rectal route for obtaining a precise body temperature, is noninvasive and can be used to obtain a temperature in a patient who might have an ear infection and who is having diarrhea.
The nurse should place the probe behind the ear if the client is diaphoretic but should avoid placing it over an area covered with hair.
Healthcare agencies need to reduce the incidence of healthcare-associated infections (HAIs). Which nursing action directly meets this goal?
a. Report all workplace injuries.
b. Attend educational sessions on infection prevention.
c. Perform hand hygiene as appropriate.
d. Wash scrub uniforms as soon as possible once home.
Hand hygiene is the first defense in infection prevention.
The nurse should report all injuries, attend educational offerings, and wash uniforms, but these do not directly prevent HAIs like handwashing does.
While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Center for Disease Control and Prevention recommends washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids.
What factors impact the nurse’s ability to recognize and cluster clinical cues? Select all that apply.
a. Ability to identify a single, significant cue and follow up
b. Knowledge of normal human anatomy
c. Experience in the clinical setting
d. Placing higher value on subjective data.
e. Understanding of pathological changes within the body
a,b,c,e
The ability of the nurse to quickly and accurately cluster cues is based on the knowledge of what is normal and not normal within the body from anatomy and physiology (normal) and pathophysiology (abnormal) courses. The presence of a single abnormal finding triggers the examiner to search for related cues that are often present at the same time. Over time and with experience, the examiner begins seeing the data clusters as a group, rather than as individual cues.
What is the normal oral temperature?
a. 98.6 F
b.102.2 F
c. 98.6 F
d. 104
Oral 98.6-100.4 F
Mild fever 102.2 F
Average rectal 98.6
hypothermia 82.4-95 F
Heatstroke 104-113F
A client recovering from hip replacement asks what they should eat to help heal faster. How should the nurse reply?
a. “To boost healing, you need to decrease your water intake.”
b. “You should make sure you increase your protein intake.”
c. “Make sure you increase vegetables but not fruits.”
d. “You should decrease your carbohydrates because this increases inflammation.”
Vitamins and minerals support the immune system while protein supports healing. Nutrition, such as eating vegetables and fruits, plays a role in maintaining the “good” bacteria in the body.
During a follow-up assessment of an individual recently discharged from the hospital, which cues, when clustered, indicate the client is at risk for ineffective health maintenance? Select all that apply.
a. The person is unable to recall the reason they are taking two of their prescribed medications.
b. When asked how long they have had high blood pressure, the individual says they don’t have that.
c. The individual request information about their illness.
d. A person with diabetes shares that they are following a plant-based diet to help with glucose control.
e. The person accurately lists the symptoms of asthma that indicate use of the rescue inhaler is needed.
a,b
Being unable to recall the reason for taking prescribed medications and denying a valid medical diagnosis indicate the client is at risk of not following the treatment plan to maintain their health.
Health maintenance refers to a person’s ability to take care of themselves and requires knowledge of their health status and current conditions, an understanding of why they are taking medications and what to expect as a result, and lifestyle choices that can improve their health. A person who knows what they don’t know and asks questions is not at risk for ineffective health maintenance.
Which of the following is true regarding the nursing assessment of a pulse? Select all that apply.
a. Carotid pulses should never be palpated simultaneously
b. The peripheral pulses will weaken as cardiac output decreases
c. The radial and brachial arteries are the most easily palpated peripheral pulse sites
d. Any artery or vein can be assessed for pulse rate
e. Pulses are relatively superficial and should not require deep palpation
f. When a patient's condition suddenly deteriorates, the radial site is the best for finding a pulse quickly
a,b,e
Any artery can be assessed for pulse rate. The radial and carotid arteries are the most easily palpated peripheral pulse sites. Pulses are relatively superficial and should not require deep palpation. When a patient's condition suddenly deteriorates, the carotid site is the best for finding a pulse quickly. The heart continues delivering blood through the carotid artery to the brain as long as possible. The peripheral pulses will weaken as cardiac output decreases. Carotid pulses should never be palpated simultaneously as this will occlude blood flow to the brain.
The nurse is taking care of four clients on a surgical floor. Which client is most at risk of developing a healthcare-associated infection?
a. A 50-year-old client who smokes a pack of cigarettes daily
b. A 60-year-old client who is a vegetarian
c. A 35-year-old client who has an indwelling urinary catheter
d. An 80-year-old client who has impaired mobility
One of the causes of healthcare-associated infection (HAI) is indwelling urinary catheters. The nurse should provide proper catheter care and monitor the client.
True or False.
Clinical judgment is defined as the observed outcome of critical thinking and decision-making.
True
“Clinical judgment is defined as the observed outcome of critical thinking and decision-making. It is an iterative process that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care”
A nurse is assessing the vital signs of a postoperative adult client. The client’s respiratory rate is 22 breaths/minute. What is the next step for the nurse to take?
a. Ask the client if they are short of breath.
b. Assess other vital signs.
c. Assess the depth and rhythm of the respirations.
d. Alert the anesthesiologist.
A respiratory assessment to determine if the client’s airway, breathing, and circulation (ABCs) are stable is the priority action.
The other actions, including alerting the anesthesiologist, assessing other vital signs, and asking the client if they are short of breath, may be indicated and may influence respirations, but they are not the first step.
What is an example of direct contact?
a. C. difficile
b. Tuberculosis
c. E. coli
d. Varicella
After assessing your patient, you noted that your patient has a fever, swollen red throat, difficulty swallowing, abdominal pain, and lethargy.
Which finding is most likely responsible for the fever?
What are your nursing interventions?
Red and swollen throat may indicate an infection, which would cause a fever. The fact that it hurts to swallow is an additional cue that supports the assumption that the fever is a result of either tonsillitis or strep throat.
A nurse is caring for a postoperative client and assessing their vital signs. What factors associated with the client's postoperative status will likely impact their blood pressure (BP)? Select all that apply.
a. Air temperature in the surgical suite
b. Prolonged supine position.
c. Use of oxygen therapy intraoperatively
d. Amount of intravenous (IV) fluid infused during the procedure
e. Postoperative pain.
f. Intraoperative hemorrhage.
g. Postoperative administration of intravenous (IV) antibiotic
b,d,e,f
The amount of IV fluid infused during the procedure and intraoperative hemorrhage will impact blood volume and cardiac output. The presence of postoperative pain would also likely have an impact on BP. Also, BP naturally decreases when going from a lying position to a sitting position or from a sitting to a standing position. Some medications, dehydration, anemia, recent blood loss, or prolonged bed rest may cause orthostatic hypotension.
The use of oxygen therapy intraoperatively, the air temperature in the surgical suite, and postoperative administration of antibiotics would not likely impact BP in this circumstance.
What type of room should a patient with Tuberculosis be assigned to prevent transmission to other patients?
Negative Pressure Room Also known as isolation.
A negative pressure room is an isolated room. Air flows into the room but does not flow out. Negative pressure rooms are used in facilities that require infection control, such as in hospitals in inpatient rooms.
What is the priority nursing care need?
a. Maintain safety during activities of daily living (ADLs).
b. Increase strength and stamina
c. Lower serum cholesterol and triglycerides
d. Arrange permanent placement in an assisted living facility
Primary care needs are to assure patient safety as the patient increases strength and stamina.
What are safety interventions?
The nurse is now going to assess Mr. Jones’ blood pressure (BP) and obtains an adult BP cuff and the automatic BP device on the unit. The BP reading is 140/90 mmHg. The nurse suspects that this measurement is inaccurate based on knowledge of Mr. Jones. What are appropriate actions for the nurse to take? Select all that apply.
a. Verify the results of the device’s reading by auscultating a manual BP.
b. Ask Mr. Jones to lower his arm so that it is perpendicular to his body and retake the BP
c. Ask another nurse to verify the BP results
d. Ensure that the BP cuff size is correct for the size of Mr. Jones’ arm.
a, d
Ensure that the BP cuff is the correct size for the client’s arm. Verify the BP using a manual BP.
Mr. Jones’ arm should remain at heart level. There is no need to ask someone else to verify the result at this point.
A client is recovering from an infection in a wound and has no dietary restrictions. Which choice should the nurse encourage the client to eat in order to promote healing?
a. salad
b. Meat, egg, vegetables, fruit
c. fried chicken, mixed vegetables
d. pasta and sauce
b.
Vitamins, minerals, and proteins promote immune health and healing. Clients should be encouraged to eat a well-rounded diet and avoid large quantities of carbohydrates and fried foods.
Your patient had a fall while ambulating to the bathroom. You return the patient safely to bed. The doctor and family are notified.
What type of documentation should be completed?
Complete an incident report. Healthcare providers benefit from having complete data available.
What is the normal range for SpO2?
90%-100%
95%-100%
98%-100%
93%-100%
Peripheral arterial hemoglobin saturation is measured as SpO2. The normal range for SpO2 is 93%–100%.
A SpO2 less than 90% is considered a clinical emergency and will likely be accompanied by respiratory rate, depth, and rhythm changes.
If the nurse has sterile gloves and gown on and is touching a non-sterile pen and clipboard, this violates which client care aspect of asepsis?
a. barriers
b. client and equipment preparation
c. contact guidelines
d. environmental controls
c.
Type
Aspects
Type
Keeping all instruments in sterilized packaging before use is part of client and equipment preparation.
Environmental controls are used to keep pathogens off surfaces and out of the air. Contact guidelines are followed to keep sterile and non-sterile items from being touched. Barriers, such as a skin drape, are used to prevent sterile items, such as hands or equipment, from touching non-sterile items, such as the client’s skin.
What type of nursing note is this considered?
Narrative documentation in nursing involves documenting the patient's symptoms, treatment, and response to treatment1. A narrative nursing note should include the following elements:
Here is the 14:15 nursing progress note written using the SOAP format.