N310 - Quiz 1 Review

A nurse receives information during shift report that a patient is afebrile. What action will the nurse take in response?

• Checking the MAR for prescribed antipyretic medication

• Reporting the finding to the primary care provider

• No action is necessary; this is a normal reading

• Taking the patient’s temperature using a different method

A nurse is caring for a newborn with hypothermia. What action does the nurse take to prevent heat loss from convection?

• Wrapping the newborn in a blanket

• Placing the newborn on a warmed surface

• Reducing the temperature in the room

• Increasing the temperature in the room

Answer explanation

During assessment of vital signs, a patient reports severe abdominal pain. Which pain-related changes in vital signs may be present? Select all that apply.

• Respiratory rate of 24

• Increased respiratory depth

• Blood pressure 154/86

• Body temperature 98.8°F

• Pulse rate of 102

A nurse enters a room and finds a patient who is unable to catch their breath, has a respiratory rate of 28, and is using accessory muscles to breathe. What intervention will the nurse use to relieve dyspnea?

• Remove pillows from under the head

• Raise the head of the bed

• Elevate the foot of the bed

• Reassess the respiratory rate

A nurse has assessed an older adult for orthostatic hypotension as shown in the electronic health record (EHR). What action will the nurse take?

Electronic health record (EHR): 0800

BP lying 124/76

BP sitting 118/74

BP standing 98/58

• Administer medication to increase blood pressure

• Return the patient to bed and place them in Fowler position

• Suggest that in the future the patient “dangle” for a few minutes before standing

• Encourage the patient to rise from a sitting position quickly to improve blood flow

A nurse is caring for a postoperative patient who experienced hypovolemic shock necessitating transfer to the ICU. The nurse manager reviews the medical record and suspects which situation contributed to the emergency?

Electronic health record (EHR)

2:00 PM T 99.2, P 88, RR 16, BP 106/54

2:15 PM T 99.6, P 94, RR 16, BP 100/52

2:30 PM T 99.4, P 110, RR 18, BP 96/50

2:45 PM T 99.2, P 120, RR 20, BP 84/48

 

• Using an inappropriate format to document the vital signs

• Failing to report tachycardia and hypotension to the provider

• Not following the postoperative vital sign protocol

• Failing to reflect a pain assessment in the documentation

A patient has a blood pressure reading of 130/90 mm Hg during a clinic visit. What recommendation for follow-up will the nurse make?

• Follow-up measurements of blood pressure

• Change in dietary intake

• No action, because the nurse considers this reading is due to anxiety

• Immediate treatment by a health care provider

The nurse must assess a patient’s blood pressure using a thigh cuff, due to presence of a right antecubital IV and a left arm dialysis access. Which of these arteries will the nurse use for auscultation?

• Brachial

• Carotid

• Popliteal

• Radial

During which stage of infection is the patient most contagious?

• Incubation Stage

• Full (Acute) Stage

• Convalescent Stage

• Prodromal Stage

When should only standard precautions be used?

• Caring for a patient with C. Diff

• Caring for a patient with VRE

• Caring for a patient vomiting blood

• Caring for a noninfectious patient