a. The nurse needs to insist that the patient stop smoking for a at least 3 assessment .
b. Caffeine and smoking can cause false blood pressure elevation.
C Neither caffeine nor smoking affects blood pressure.
d. The nurse should have the patient perform mild exercises.
26. If a blood pressure cuffed used on a client is too narrow, the numerical reading will be:
a. False high
b. Correct
C False low
d. False low or high
27. A patient has had a cerebral vascular accident (CVA). The doctor suspects that the injury has affected the brain stem. Which of the following problems would the nurse expect to observe?
a. A decreased respiratory sensitivity to external stimuli
b. An increased respiratory rate, with an irregular rhythm
c. A decrease in the level of arterial carbon dioxide
D A decrease in the rate and depth of respiration
28. When auscultating a patient’s breath sounds, the nurse hears a sound that is unfamiliar. The nurse’s next step is to:
a. Notify the health care provider.
B Ask another Nurse to validate the finding.
c. Document the findings exactly as heard.
d. Assess the sound 20 mins later.
29. The nurse is evaluating a new graduate’s understanding of the implementation phase of the nursing process by engaging in which activity?
a. Asking about history of allergies
b. Obtaining a list of the patient’s current medication taken at home
C Administering an antipyretic medication for an elevated temperature as prescribed by the health care provider.
d. Taking a patient’s blood pressure immediately after administering an anti-hypertensive medication.
30. Which of the following statements represents subjective data obtained from the patient regarding the skin?
a. Reddened area noted on the lateral aspect of right leg
b. No obvious lesions on upper extremities
C Denies color change on any area of the body
d. Facial skin appears dry and flaky
31. Which of the following breath sounds auscultated over the base of the lungs during inspiration would direct the nurse to perform a focused physical assessment on the patient?
A Bronchovesicular breath sounds
B Vesicular breath sounds
c. Bronchial breath sounds
d. Adventitious breath sounds
32. The nurse is preparing to assess a newly admitted hospitalized patient who is experiencing significant respiratory distress. How should the nurse proceed with this assessment?
a. Perform a head to toe nursing assessment immediately
b. Obtain a complete nursing history and physical assessment from data obtained from the patient’s family member
C Assess body systems appropriate to the problem and then complete the nursing assessment after the problem has resolved.
d. Place the patient in supine position to obtain accurate cardiac, respiratory, and abdominal assessments.
33. The nurse is called to the gymnasium regarding an injured student. The student is crying in severe pain with a malformed fractured right lower leg. The correct sequence for the nurse’s initial assessment is:
A Inspection, light palpation
b. Inspection, deep palpation, light palpation
c. Auscultation, light palpation, inspection
d. Light palpation, deep palpation, inspection
Step 1/9
25. A nurse is performing vital sign on a patient admitted to a medical-surgical unit. The patient smokes cigarettes and deinks caffeine. Which point is important for the nurse to understand before assessing the patient’s blood pressure?
a. The nurse needs to insist that the patient stop smoking for a at least 3 assessment .
b. Caffeine and smoking can cause false blood pressure elevation.
C Neither caffeine nor smoking affects blood pressure.
d. The nurse should have the patient perform mild exercises.
The answer is b. Caffeine and smoking can cause false blood pressure elevation
It's important for the nurse to understand that both smoking and caffeine can temporarily raise blood pressure levels, which can result in inaccurate readings. To get the most accurate measurement, it's recommended to have the patient avoid caffeine and smoking for a short period of time before the assessment.
Step 2/9
26. If a blood pressure cuffed used on a client is too narrow, the numerical reading will be:
a. False high
b. Correct
C False low
d. False low or high
The answer is a. False high
If a blood pressure cuff used on a client is too narrow, it can lead to an overestimation of the blood pressure reading, which is known as a false high reading. This is because a too-narrow cuff cannot accommodate the volume of blood in the underlying artery, leading to an artificially high pressure reading. To avoid this, it is important to use the appropriate size cuff based on the patient's arm circumference.
Step 3/9
27. A patient has had a cerebral vascular accident (CVA). The doctor suspects that the injury has affected the brain stem. Which of the following problems would the nurse expect to observe?
a. A decreased respiratory sensitivity to external stimuli
b. An increased respiratory rate, with an irregular rhythm
c. A decrease in the level of arterial carbon dioxide
d. A decrease in the rate and depth of respiration
The answer is d. A decrease in the rate and depth of respiration
If the injury from the cerebral vascular accident (CVA) has affected the brain stem, the nurse may expect to observe a decrease in the rate and depth of respiration. This is because the brain stem is responsible for controlling many of the body's autonomic functions, including breathing. A decrease in respiration can lead to a buildup of carbon dioxide in the bloodstream, which can be dangerous and potentially life-threatening. The nurse would closely monitor the patient's respiratory status and report any changes to the doctor.Role of a Nurse in Assessing and Monitoring Vital Signs of Patient Care Essay Paper
Step 4/9
28. When auscultating a patient’s breath sounds, the nurse hears a sound that is unfamiliar. The nurse’s next step is to:
a. Notify the health care provider.
B Ask another Nurse to validate the finding.
c. Document the findings exactly as heard.
d. Assess the sound 20 mins later.
The answer is a. Notify the health care provider.
If the nurse hears an unfamiliar breath sound when auscultating a patient's breath, it is important to immediately notify the healthcare provider. This could indicate a potential problem with the patient's respiratory function and requires further assessment and intervention. The nurse should also document the finding accurately and clearly describe the sound to the healthcare provider. Having another nurse validate the finding may also be useful, but the priority should be to inform the healthcare provider. Delaying assessment or intervention could potentially worsen the patient's condition.
Step 5/9
29. The nurse is evaluating a new graduate’s understanding of the implementation phase of the nursing process by engaging in which activity?
a. Asking about history of allergies
b. Obtaining a list of the patient’s current medication taken at home
c. Administering an antipyretic medication for an elevated temperature as prescribed by the health care provider.
d. Taking a patient’s blood pressure immediately after administering an anti-hypertensive medication.
The answer is c. Administering an antipyretic medication for an elevated temperature as prescribed by the health care provider.
The implementation phase of the nursing process involves carrying out the plan of care, which includes administering medications and treatments as prescribed by the healthcare provider. In this scenario, the nurse is evaluating the new graduate's understanding of the implementation phase by having them administer an antipyretic medication for an elevated temperature. This activity will help the nurse assess the new graduate's knowledge of medication administration, as well as their ability to follow the plan of care and adhere to the healthcare provider's orders.
Step 6/9
30. Which of the following statements represents subjective data obtained from the patient regarding the skin?
a. Reddened area noted on the lateral aspect of right leg
b. No obvious lesions on upper extremities
C Denies color change on any area of the body
d. Facial skin appears dry and flaky
The answer is C Denies color change on any area of the body
Subjective data is information obtained from the patient's own perspective, as opposed to objective data, which is obtained through physical examination or testing. In this case, "Denies color change on any area of the body" is a statement made by the patient and represents subjective data. This information provides insight into the patient's perception of their skin condition and can be important in understanding their overall health and well-being.
Step 7/9
31. Which of the following breath sounds auscultated over the base of the lungs during inspiration would direct the nurse to perform a focused physical assessment on the patient?
A Broncho vesicular breath sounds
B Vesicular breath sounds
c. Bronchial breath sounds
d. Adventitious breath sounds
The answer is c. Bronchial breath sounds
Bronchial breath sounds are a type of adventitious breath sound that can indicate a potential problem with the respiratory system. They are characterized by a loud, harsh quality and are typically auscultated over the trachea or near the base of the lungs. When these sounds are heard, it is important for the nurse to perform a focused physical assessment to determine the underlying cause and any potential implications for the patient's respiratory function. This may include further assessment of the patient's breathing patterns, oxygen saturation levels, and any signs of distress. The nurse may also need to report the findings to the healthcare provider for further evaluation and intervention. Role of a Nurse in Assessing and Monitoring Vital Signs of Patient Care Essay Paper
Step 8/9
32. The nurse is preparing to assess a newly admitted hospitalized patient who is experiencing significant respiratory distress. How should the nurse proceed with this assessment?
a. Perform a head to toe nursing assessment immediately
b. Obtain a complete nursing history and physical assessment from data obtained from the patient’s family member
C Assess body systems appropriate to the problem and then complete the nursing assessment after the problem has resolved.
d. Place the patient in supine position to obtain accurate cardiac, respiratory, and abdominal assessments.
The answer is C Assess body systems appropriate to the problem and then complete the nursing assessment after the problem has resolved.
When a patient is experiencing significant respiratory distress, it is important for the nurse to prioritize and focus on the body systems most relevant to the problem. In this case, the respiratory system should be assessed first to determine the severity of the distress and to provide appropriate interventions. The nurse should assess the patient's breathing patterns, oxygen saturation levels, and any other relevant respiratory assessments. Once the patient's respiratory distress has been stabilized, the nurse can then proceed with a complete nursing assessment, including obtaining a complete nursing history and physical assessment. The patient's position may also need to be adjusted during the assessment to ensure accuracy and comfort. However, placing the patient in a supine position is not always necessary and should be based on the patient's overall condition and needs.
Step 9/9
33. The nurse is called to the gymnasium regarding an injured student. The student is crying in severe pain with a malformed fractured right lower leg. The correct sequence for the nurse’s initial assessment is:
A Inspection, light palpation
b. Inspection, deep palpation, light palpation
c. Auscultation, light palpation, inspection
d. Light palpation, deep palpation, inspection
The answer is d. Light palpation, deep palpation, inspection
In a situation like this, it is important for the nurse to follow a systematic approach to the physical assessment in order to minimize further injury and provide appropriate care. The initial assessment should begin with a light palpation to assess for any deformities or obvious fractures, followed by a deep palpation to assess for any underlying soft tissue injuries. Finally, an inspection should be performed to assess the overall appearance of the affected area and to identify any other potential injuries. Auscultation may not be necessary in this case, as it is primarily used to assess the sounds within the body and is not typically used to assess fractures or soft tissue injuries. The nurse should also obtain a complete history and any relevant information about the injury to assist in providing appropriate care and to determine the need for further evaluation or referral to a healthcare provider.
Final answer
The role of a nurse in assessing and monitoring vital signs is critical in the provision of patient care. Role of a Nurse in Assessing and Monitoring Vital Signs of Patient Care Essay Paper
