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A patient was diagnosed with a urinary tract infection. The patient has been drinking fruit juice
and has increased his intake of fluids but has failed to take his antibiotic as prescribed because it
caused gastric upset. Three days later, the patient presents to the clinic with fever, malaise,
nausea, and vomiting. What might you suspect?
The patient probably has the flu.
The patient may now have a systemic infection.
The patient is displaying signs of a localized infection.
The patient is experiencing an allergic response to his medication. - Answer>>> The patient may
now have a systemic infection.
A newborn patient's temperature has been rising rapidly and the baby has been crying. Which of
the following thermometers would be the best to use in measuring this patient's temperature?
A. Rectal electronic
B. Chemical dot
D. Tympanic
E. Temporal artery - Answer>>> E. Temporal artery
,A patient will be moved up in bed with the use of a friction-reducing device. How will the nurse
place this device under the patient?
Roll the patient from side to side, and place the device under the draw sheet.
Sit the patient up in the bed, and place the device behind the shoulders.
Remove the draw sheet, and replace it with the device.
Lift the patient to place the device directly under him or her. - Answer>>> Roll the patient from
side to side, and place the device under the draw sheet.
Which of the following situations may affect a patient's vital signs? (Select all that apply.)
A. Isolation precautions.
B. Moving from lying to standing position.
C. Occupation.
D. Pain rated as a 7 on 0-10 pain scale.
E. Time of day. - Answer>>> B. Moving from lying to standing position.
D. Pain rated as a 7 on 0-10 pain scale.
E. Time of day.
,It is 7 a.m. and the nurse takes the vital signs of a postoperative patient and finds his blood
pressure is elevated. Which of the following could explain the cause for this alteration in BP?
A. The patient has a temperature of 99.0°F when assessed rectally.
B. The patient has been NPO since midnight before the surgery.
C. The patient complains of pain at a 9 on a 0-10 pain scale.
D. The body is compensating for the cool environment of the surgical suite. - Answer>>> C. The
patient complains of pain at a 9 on a 0-10 pain scale.
The nurse will take the patient's vital signs preoperatively and record them as part of the patient's
preparation for surgery. Why is it necessary to take vital signs preoperatively? (Select all that
apply.)
A. To verify the patient is not experiencing any complications that may contraindicate surgery or
require intervention.
B. To provide a set of vital signs to use for comparison during and after surgery.
C. To ensure the equipment is appropriately calibrated and functional.
D. To provide the patient with reassurance that he or she is being cared for by a competent staff.
, E. To determine whether the patient is "feeling funny" or "different" - Answer>>> A. To verify
the patient is not experiencing any complications that may contraindicate surgery or require
intervention.
B. To provide a set of vital signs to use for comparison during and after surgery.
The nurse is preparing to set up a sterile field for a patient who is going to have a sterile dressing
change. Which of the following assessment measures would be unnecessary at this time?
The nurse reviews documentation to see what supplies will be needed.
The nurse asks the patient to rate his pain on a pain scale.
The nurse asks the patient if he needs to use the bathroom.
The nurse asks the patient if he has ambulated in the hall today. - Answer>>> The nurse asks the
patient if he has ambulated in the hall today.
One evaluation measure of creating and maintaining a sterile field involves monitoring the
patient for developing signs and symptoms of localized or systemic infection. Which of the
following is cause for concern?
Temperature of 102.5° F (39.2° C).
Incisional area light pink in color.
White blood cell count at 6500 per mm3.
Absence of purulent drainage. - Answer>>> Temperature of 102.5° F (39.2° C).
A nurse is preparing a medication for subcutaneous administration. As the nurse recaps the
needle using the scoop method, the nurse accidentally touches the table with the uncovered
needle. What is the nurse's best action?