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A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How would the nurse evaluate his blood pressure?
- A. Blood pressure and pulse should be recorded in the supine, sitting, and standing positions.
- B. The patient should be directed to walk around the room and his blood pressure assessed after this activity.
- C. Blood pressure and pulse are assessed at the beginning and at the end of the examination.
- D. Blood pressure is taken on the right arm and then 5 minutes later on the left arm.
Correct Answer: A
Rationale: Orthostatic vital signs should be taken when the person is hypertensive or is taking antihypertensive medications, when the person reports fainting or syncope, or when volume depletion is suspected.
The blood pressure and pulse readings are recorded in the supine, sitting, and standing positions.
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The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How would the nurse assess this child's respirations?
- A. Respirations should be counted for 1 full minute.
- B. Child's pulse and respirations should be simultaneously checked for 30 seconds and then multiplied by 2.
- C. Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern.
- D. Patient's respirations should be counted for 15 seconds and then multiplied by 4.
Correct Answer: A
Rationale: To accurately assess a child's respiratory pattern, the nurse should count respirations for a full minute. This duration provides a comprehensive view of the child's breathing pattern, ensuring abnormalities are not missed. Counting for only 30 seconds may not capture irregularities effectively. Checking respirations for 5 minutes is excessive and unnecessary for a routine assessment. Counting for 15 seconds and multiplying by 4 is not as precise as a full-minute count. Pulse and respirations should not be checked simultaneously; instead, the nurse should count respirations unobtrusively while appearing to take the child's pulse. Therefore, the correct approach is to count the child's respirations for 1 full minute to obtain an accurate assessment.
As a charge nurse, what is your primary responsibility for a 50-year-old blind and deaf patient admitted to your floor?
- A. Inform others about the patient's deficits.
- B. Communicate patient safety concerns to your supervisor.
- C. Provide continuous updates to the patient about the social environment.
- D. Provide a secure environment for the patient.
Correct Answer: D
Rationale: The primary responsibility of the charge nurse for a blind and deaf patient is to provide a secure environment. Ensuring patient safety is crucial to prevent medical errors and adverse outcomes. By creating a safe environment, the nurse can protect the patient from harm and promote well-being. Option A is incorrect as the focus should be on ensuring patient safety rather than highlighting deficits. Option B is not the primary responsibility in this scenario, as the immediate concern is the patient's safety. Option C is irrelevant and does not address the patient's primary needs, which are safety and security.
What technique would the nurse use to accurately assess a rectal temperature in an adult?
- A. Use a lubricated blunt tip thermometer.
- B. Insert the thermometer 2 to 3 inches into the rectum.
- C. Leave the thermometer in place for up to 8 minutes if the patient is febrile.
- D. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.
Correct Answer: A
Rationale: To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes. Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate. Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort. Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.
In which of these patients would rectal temperatures be measured?
- A. Older adult
- B. Critically ill patient
- C. School-age child
- D. Patient receiving oxygen via nasal cannula
Correct Answer: B
Rationale: Rectal temperature measurement is preferred in situations where other routes are impractical or when the most accurate measure is necessary, such as in critically ill patients. The rectal route may be chosen due to its reliability in such cases. For older adults, school-age children, and patients receiving oxygen via nasal cannula, rectal temperature measurement is not typically indicated. Other routes like oral, tympanic, or axillary measurements are more commonly used in these populations due to comfort, convenience, and non-invasive nature.
A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?
- A. These readings are a normal response and attributable to changes in the patient's position.
- B. The change in blood pressure readings is called orthostatic hypotension.
- C. The blood pressure reading in the lying position is within normal limits.
- D. The change in blood pressure readings is considered within normal limits for the patient's age.
Correct Answer: B
Rationale: The correct answer is, 'The change in blood pressure readings is called orthostatic hypotension.' Orthostatic hypotension is defined as a drop in systolic pressure of ³20 mm Hg or ³10 mm Hg drop in diastolic pressure that occurs with a quick change to a standing position. This condition is common in individuals on prolonged bed rest, older adults, those with hypovolemia, or taking specific medications. The blood pressure readings provided in the question (150/90 mm Hg lying, 130/80 mm Hg sitting, and 100/60 mm Hg standing) demonstrate a significant change in blood pressure with position changes, which is indicative of orthostatic hypotension. Choices A, C, and D are incorrect because the readings do not indicate a normal response or blood pressure within normal limits for the patient's age; rather, they suggest the presence of orthostatic hypotension.