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The nurse is caring for a patient who reports feeling light-headed and 'woozy.' The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do?
- A. Apply more pressure to the radial artery to feel pulse.
- B. Notify the health care provider of the findings.
- C. Tell the patient to expect these symptoms occasionally.
- D. Recheck the vital signs in an hour.
Correct Answer: B
Rationale: Light-headedness, irregular pulse, and a BP drop (100/72 from 113/80) suggest instability (e.g., arrhythmia). Notifying the provider (B) ensures prompt evaluation. More pressure (A) won't clarify irregularity. Dismissing symptoms (C) or delaying (D) risks deterioration. Choice B is correct, per nursing escalation protocols.
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A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely?
- A. Pulse
- B. Temperature
- C. Respirations
- D. Blood pressure
Correct Answer: B
Rationale: The hypothalamus regulates body temperature, so damage from a head injury disrupts thermoregulation, potentially causing hypo- or hyperthermia. Monitoring temperature (B) is critical to detect these shifts, which can indicate injury severity or complications like fever from inflammation. Pulse (A) reflects cardiac response but isn't directly hypothalamic. Respirations (C) may change secondary to brain injury but aren't primarily hypothalamic. Blood pressure (D) can fluctuate with intracranial pressure, yet temperature is the most directly affected vital sign here. Choice B is correct as it aligns with the hypothalamus's role in maintaining thermal homeostasis, a priority in neuro nursing to prevent further brain damage or systemic issues.
What is the primary purpose of pulse assessment?
- A. Assessing changes in blood pressure
- B. Assessing changes in body temperature
- C. Assessing changes in cardiac status
- D. Assessing changes in respiratory status
Correct Answer: C
Rationale: Pulse assessment primarily evaluates cardiac status (C), reflecting heart rate and rhythm, key indicators of cardiovascular function. Blood pressure (A) relates but requires a cuff. Temperature (B) isn't pulse-related. Respiratory status (D) is secondary. Choice C is correct, per nursing fundamentals, as pulse directly monitors heart performance, guiding cardiac care.
When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse's action?
- A. It is not affected by skin moisture.
- B. It has no risk of injury to patient or nurse.
- C. It reflects rapid changes in radiant temperature.
- D. It is accurate even when the forehead is covered with hair
Correct Answer: B
Rationale: Temporal artery thermometers are non-invasive, posing no injury risk (B), ideal for newborns and children. Moisture (A) can affect accuracy. Radiant changes (C) are less relevant. Hair (D) interferes. Choice B is correct, per pediatric safety 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 nurse is caring for a group of patients. Which patient will the nurse see first?
- A. A crying infant with P-165 and R-54
- B. A sleeping toddler with P-88 and R-23
- C. A calm adolescent with P-95 and R-26
- D. An exercising adult with P-108 and R-24
Correct Answer: A
Rationale: An infant with pulse 165 and respirations 54 (A) is borderline high (normal 120-160, 30-60), plus crying suggests distress, warranting priority. Toddler (B), adolescent (C), and adult (D) values are normal for context. Choice A is correct, per triage prioritizing potential instability.