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1. You have delegated vital signs to assistive personnel. The assistant
informs you that the patient has just finished a bowl of hot soup. The
nurse's most appropriate advice would be to: A. take a rectal temperature.
B. take the oral temperature as planned.
C. advise the patient to drink a glass of cold water.
D. wait 30 minutes and take an oral temperature.: D. wait 30 minutes and take
an oral temperature.
2. You notice that a teenager has an irregular pulse. The best action you
should take includes:
A. reading the history and physical.
B. assessing the apical pulse rate for 1 full minute.
C. auscultating for strength and depth of pulse.
,D. asking whether the patient feels any palpitations or faintness of breath.: B.
assessing the apical pulse rate for 1 full minute.
3. A postoperative patient is breathing rapidly. You should immediately: A.
call the physician.
B. count the respirations.
C. assess the oxygen saturation.
D. ask the patient if he feels uncomfortable.: C. assess the oxygen saturation.
4. When assessing the blood pressure of a school-age child, using an adult
cuff of normal size will affect the reading and produce a value that is: A.
accurate.
B. indistinct.
C. falsely low.
D. falsely high.: C. falsely low.
5. CASE STUDY
Mr. Charles Lamont is a 45-year-old patient who is visiting his primary care
physician for his an annual checkup. His wife is waiting for him in the lobby;
,she is hoping that Mr. Lamont will tell the physician about his recent bout of
coughing and shortness of breath. Mr. Lamont works for a construction
company as a heavy machine operator. He smokes 1½ packs of cigarettes per
day. His wife has been encouraging Mr. Lamont to stop, but he has not
showed any interest in quitting. Laura, the registered nurse, takes Mr. Lamont
to an examination room. Laura asks him about his overall health and he tells
her about a nagging cough and how he sometimes feels short of breath. He
then denies any other health problems. Laura takes Mr. Lamont's vital signs
and gets the following results: blood pressure, 156/94 mm Hg; temperature,
99.8° F orally; apical pulse, 104 beats/min; respirations, 25 breaths/min and
regular; and pulse oximetry, 95%.
1. Mr. Lamont asks Laura if everything is normal. Before she answers, she
reviews the results and determines which of the results are abnormal? What
are Laura's findings? What would be normal for any of these that are not
normal?
, 2. The primary care physician examines Mr. Lamont and tells him he
should quit smoking. He gives him an antihypertensive medication to help
lower his blood pressure. Mr. Lamont asks Laura if she can teach his wife
how to take his blood pressure. Laura agrees and brings Mrs. Lamont in to
explain the process. Laura decides that she will use demonstration to teach
Mrs. Lamont the procedure, but she also wants to explain some important
concepts. What should she include? (Select all that apply.) A. Choose a cuff
that is the right size.
B. Ensure that the patient is sitting or lying.
C. Support the extremity.
D. Ensure proper cuff application.
3. Mr. Lamont tells Laura that he doesn't understand how smoking could
influence his blood pressure. How should Laura respond?
4. Mr. Lamont tells his wife that the physician told him his respiratory rate
was increased. Mrs. Lamont asks Laura what could cause him to breathe