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A nurse is caring for a group of patients on a medical-surgical unit. Which patient will the nurse assess first?
- A. A 17-year-old male who has just returned from outside 'for a smoke' who needs a temperature taken.
- B. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60.
- C. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74.
- D. An 87-year-old male suspected of hypothermia whose temperature is below normal.
Correct Answer: B
Rationale: A postoperative BP drop from 128/70 to 100/60 (B) indicates potential shock or bleeding, a priority. Smoking (A) or pain with stable BP (C) is less urgent. Hypothermia (D) needs attention but lacks acuity data. Choice B is correct, per triage urgency in surgical care.
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After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action?
- A. Temperatures vary depending on the route used.
- B. Temperatures are readings of core measurements.
- C. Rectal temperatures are cooler than when taken orally.
- D. Axillary temperatures are higher than oral temperatures.
Correct Answer: A
Rationale: Temperature varies by route (A) e.g., rectal is 1?°F higher, axillary 1?°F lower than oral requiring documentation for accuracy. Not all are core (B). Rectal is warmer (C incorrect). Axillary is lower (D incorrect). Choice A is correct, per nursing documentation standards.
The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient's symptoms?
- A. Red blood cell count of 5.0 million/mm3
- B. Hemoglobin level of 8.0 g/100 mL
- C. Hematocrit level of 45%
- D. Pulse oximetry of 95%
Correct Answer: B
Rationale: Shortness of breath and chest discomfort suggest reduced oxygen delivery. Hemoglobin of 8.0 g/dL (B) indicates anemia (normal 12-16 g/dL), impairing oxygen transport. RBC 5.0 million/mm3 (A) and hematocrit 45% (C) are normal. Oximetry 95% (D) is adequate. Choice B is correct, linking anemia to symptoms per nursing pathophysiology.
A patient is experiencing pyrexia. Which piece of equipment will the nurse obtain to monitor this condition?
- A. Stethoscope
- B. Thermometer
- C. Blood pressure cuff
- D. Sphygmomanometer
Correct Answer: B
Rationale: Pyrexia (fever) requires temperature monitoring, making a thermometer (B) essential. A stethoscope (A) assesses heart/lung sounds, not temperature. A blood pressure cuff (C) or sphygmomanometer (D) measures pressure, not fever. Choice B is correct as thermometers directly track temperature changes, a fundamental tool in nursing to manage and document febrile states accurately.
When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this?
- A. 138/70
- B. 138/62
- C. 70/62
- D. 138/70/62
Correct Answer: B
Rationale: BP is recorded as systolic (onset, 138) over diastolic (disappearance, 62), so 138/62 (B). Muffling (70) is phase IV, not standard for adults. 138/70 (A) uses muffling incorrectly. 70/62 (C) is invalid. 138/70/62 (D) isn't standard. Choice B is correct, per AHA guidelines.
The nurse is preparing to assess the blood pressure of a 3 year old. How should the nurse proceed?
- A. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds.
- B. Obtain the reading before the child has a chance to 'settle down.'
- C. Choose the cuff that says 'Child' instead of 'Infant.'
- D. Explain the procedure to the child.
Correct Answer: D
Rationale: For a 3-year-old, explaining the procedure (D) reduces anxiety, improving cooperation. Diaphragm (A) is less effective than the bell for Korotkoff sounds. Pre-settling (B) risks agitation. Child cuff (C) is correct but secondary. Choice D is correct, per pediatric nursing communication strategies.