Ch 19

18問 • 3年前

問題一覧

1. A nurse notes a patient has abnormal vital signs. What action by the nurse is best?

c. Compare with prior readings.

2. A patient returned from a procedure and has vital sign measurements ordered every hour. The patient’s blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg. What priority action by the nurse is most appropriate?

d. Plan to take the vital signs more often.

3. A nurse is told in the hand-off report that a patient is afebrile. What assessment finding correlates with this statement?

b. Oral temperature 98.4 F (36.8 C)

4. A nurse is caring for a patient who has an elevated temperature. The nurse plans to help the patient regain a normal temperature through conduction. What technique does the nurse use?

b. Putting ice packs in the patient’s axillae

5. A nurse is going to take an oral temperature on a patient who has just consumed a cup of coffee. What action by the nurse is best?

b. Return in 30 minutes to take the patient’s temperature.

6. A nurse observes a student taking an adult patient’s tympanic temperature. What action by the student requires the nurse to intervene?

b. Student pulls the pinna of the patient’s ear down and back.

7. A nurse assesses a patient’s radial pulse rate to be 110 beats/min and regular. What action by the nurse is best?

a. Assess the patient for causes of tachycardia.

8. The student nurse is assessing a patient’s pulses. What action by the student requires the nurse to intervene?

b. Assessing the dorsalis pedis pulse by palpating behind the patient’s knee

9. The nurse assesses a patient’s pulse and finds it hard to obliterate with palpation. What action by the nurse is the most appropriate?

a. Assess the patient for fluid volume overload.

10. The nursing faculty member is observing a student taking a patient’s carotid pulse. What action by the student requires intervention by the faculty member?

c. Compares pulses in both carotid arteries at the same time.

11. A nurse is caring for a patient who has orthopnea. What action by the nurse is most appropriate?

c. Keep the head of the bed elevated.

12. The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The pulse oximeter does not provide a good reading. What action by the nurse is best?

b. Assess the fingers for good circulation.

13. A patient’s blood pressure is 142/76 mm Hg. What does the nurse chart as the pulse pressure?

d. 66

14. A nurse performs orthostatic blood pressure readings on a patient with the following results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best?

a. Instruct the patient not to get up without help.

15. The nurse is caring for a woman who had a right-sided mastectomy 2 years ago. What action by the nurse is most appropriate?

a. Place a sign above the bed: “No blood pressures on the right arm.”

16. Which patient assessment result would require the nurse to assess that patient further?

b. A 65-year-old man with a respiratory rate of 10.

17. The nurse receives a hand-off report on four patients. Which patient finding should the nurse assess first?

c. Pulse 42 beats/min

18. A nursing student is caring for a patient with metabolic acidosis. The student asks the registered nurse why he is experiencing tachypnea. What response by the nurse is best?

b. “The lungs are trying to rid the body of extra carbon dioxide.”

NUR 170 exam 4

V Farris · 50問 · 2年前

NUR 170 exam 4