Nokea
The disadvantages of the oral and skin temperatures assessment routes for an adult patient include which of the following?
- A. Risk of body fluid exposure
- B. Affected by severe environmental temperatures
- C. Not affected by smoking
- D. Not for confused or unconscious patients
Correct Answer: A,B,D
Rationale: Oral and skin routes risk fluid exposure, are affected by environmental temperatures, and are unsuitable for confused or unconscious patients.
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You must assess the temperature of an 89-year-old female who is confused, hostile, and combative. Which route would be most appropriate to use?
- A. Rectal
- B. Oral
- C. Temporal
- D. Axillary
Correct Answer: C
Rationale: Temporal route is non-invasive, safe, and accurate for confused or combative patients.
The nurse would refrain from taking a BP on which of the following areas?
- A. Amputation of the arm
- B. Mastectomy on the affected side
- C. IV infusion on the selected sites
- D. Presence of a shunt
Correct Answer: A,B,C,D
Rationale: BP measurement is contraindicated in areas with amputation, mastectomy, IV infusion, or shunts to avoid injury or inaccurate readings.
Upon assessing the vital signs of a 56-year-old male, you find that he has an apical pulse of 71 bpm and a radial pulse of 62 bpm. Which of the following numbers would be correct to document as the pulse deficit?
- B. 3
- C. 7
- D. 9
- E. 133
Correct Answer: D
Rationale: Pulse deficit is the difference between apical (71) and radial (62) pulses, which is 9.
Which of the following objective vital signs, all taken on adults, have one or more components that fall outside of typical normal ranges?
- A. BP - 118/66 mm Hg, T - 99.2°F, P - 74 regular and strong, R - 17, O2 sats - 99%
- B. BP - 98/62 mm Hg, T - 98.2°F, P - 98 regular and strong, R - 20, O2 sats - 97%
- C. BP - 142/92 mm Hg, T - 98.4°F, P - 62 regular and bounding, R - 14, O2 sats - 96%
- D. BP - 120/74 mm Hg, T - 100.6°F, P - 86 regular and strong, R - 24, O2 sats - 98%
Correct Answer: B,C,D
Rationale: Normal ranges: BP 100-130/60-80, T 97.8-99°F, P 60-100, R 12-20. Options B (low BP), C (high BP), and D (high T, R) are abnormal.
Uncontrolled hypertension can result in permanent damage of which organs?
- A. Heart and eyes
- B. Pancreas and spleen
- C. Large intestine and skeletal structures
- D. Brain and kidneys
- E. Urinary bladder
Correct Answer: A,D
Rationale: Hypertension damages the heart, eyes, brain, and kidneys due to increased vascular pressure.