Processes
When admitting a patient to the hospital, the nurse observes that the patient is distracted and tense. What does this behavior suggest as a common reaction to hospitalization?
Fear of the unknown
The method that most accurately assesses true core temperature is:
Rectal
When assessing vital signs on a 40-year-old male, the nurse identifies a pulse rate of 120. What is this pulse interpreted as by the nurse?
Tachycardic
The best and most appropriate pulse to be used when performing CPR is the:
Carotid
How should the nurse position the ear pinna when using the tympanic thermometer on a child?
Downward and back
What essential part of the admission procedure is performed by the RN?
Obtaining a health history
The nurse is placing an identification band on a patient who was admitted through the emergency department. What is best to say as the band is applied?
“The primary purpose of the band is to maintain safety.”
What type of body temperature remains relatively constant and is the temperature of the deep tissues?
Core
The difference between the systolic and diastolic blood pressure is known as the:
Pulse pressure
A rational patient wished to leave the hospital against medical advice (AMA), despite the nurse’s best attempt at therapeutic communication. What is the nurse’s first responsibility?
Notify the provider
A nurse is admitting a patient to an acute care facility. During the admission procedure, what nursing intervention would best help reduce patient anxiety?
Greet the patient by name
How should the nurse position the earpieces on a stethoscope to ensure optimum reception?
Toward the face
The nurse must be sensitive to an older adult patient experiencing separation anxiety when admitted to the hospital. When a child experiences separation anxiety, they will usually cry. What will an older adult often demonstrate when experiencing separation anxiety?
Depression
A nurse assesses a patient’s dorsalis pedis pulse. The pulse feels full and springlike even under moderate pressure. How should the nurse document this finding?
Bounding pulse
If a patient has an order for an interagency transfer, where does the nurse explain that the patient will be moved?
One facility to another
What is the term for the exchange of carbon dioxide and oxygen that takes place at the alveolar level?
Internal respiration
The patient’s pulse oximetry reading appears to be lower than expected. The patient is breathing easily, the lungs are clear, the oxygen is delivered as ordered, and the patient reports, "feeling fine.” What would the nurse do first?
Check the position of the pulse oximeter
What part of the body maintains a balance between heat production and heat loss, regulating body temperature?
Hypothalamus
The patient is being discharged from the hospital to home and will be assisted with abdominal bandage changes by his wife. Which nursing action is most important?
After teaching, ask the patient and his wife to perform the bandage change and observe their technique
The pressure against the walls of the arteries when the heart is contracting is the:
Systolic pressure
What is the third assessment technique in a standard physical examination, defined as the process of listening to sounds produced by the body?
Auscultation
The physician orders daily weights on a patient residing in a long-term care setting. What actions should the nurse implement to assess weight accurately?
Weigh patient at the same time each day
Encourage patient to void before being weighed
Ensure same amount of clothing is worn by patient
Calibrate by setting scale at zero before each weight
What does the nurse use the diaphragm of the stethoscope to best assess?
Lung sounds
A patient is suspected of having a cardiac arrhythmia. The nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80. What is the term for the difference between these two rates?
Pulse deficit
The nurse is alarmed when a patient with a severe head injury of the occipital lobe has a respiratory rate of 10 breaths per minute. Where might this finding indicate that there is an injury?
Medulla oblongata