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The nurse is caring for a patient whose condition is deteriorating and needs a pulse assessment. Which site should the nurse use?
- A. Radial
- B. Brachial
- C. Carotid
- D. Popliteal
Correct Answer: C
Rationale: In deteriorating patients, carotid (C) provides a strong, accessible pulse, reliable even in low perfusion, unlike radial (A) or brachial (B). Popliteal (D) is impractical. Choice C is correct, per emergency nursing standards (e.g., AHA), for critical pulse checks.
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The patient is lying in bed under a ceiling fan. Which technique is the nurse using when the fan produces heat loss?
- A. Radiation
- B. Conduction
- C. Convection
- D. Evaporation
Correct Answer: C
Rationale: A ceiling fan moves air over the patient, causing heat loss via convection (C), where warm air around the body is replaced by cooler moving air. Radiation (A) involves heat emission without contact, not fan-driven. Conduction (B) requires direct contact (e.g., cold pack), not air movement. Evaporation (D) involves moisture loss, not primarily fan-related here. Choice C is correct because convection matches the mechanism of air circulation enhancing heat dissipation, a principle nurses apply in thermoregulation strategies to cool patients effectively in clinical settings.
The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient's temperature?
- A. Oral
- B. Rectal
- C. Axillary
- D. Tympanic
Correct Answer: D
Rationale: For a confused, agitated patient with seizures, tympanic (D) is safest and fastest, avoiding oral risks (biting) or rectal invasiveness (agitation, seizure risk). Oral (A) is unreliable with agitation. Rectal (B) risks injury or vagal stimulation. Axillary (C) is slow and less accurate. Choice D is correct, per nursing safety protocols, balancing accuracy and patient stability.
The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn?
- A. 30 to 60
- B. 22 to 28
- C. 16 to 20
- D. 10 to 15
Correct Answer: A
Rationale: Newborn respiratory rate is 30-60 breaths/min; rapid breathing within this (A) is normal if pink, warm, dry. Lower ranges (B, C, D) apply to older ages. Choice A is correct, per neonatal norms, guiding care planning.
The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient's low heart rate?
- A. The patient has a fever.
- B. The patient has possible hemorrhage or bleeding.
- C. The patient has chronic obstructive pulmonary disease (COPD).
- D. The patient has calcium channel blockers or digitalis medication prescriptions.
Correct Answer: D
Rationale: A pulse of 48 (bradycardia) with normal BP suggests a cause like medications. Calcium channel blockers or digitalis (D) slow heart rate, a common side effect. Fever (A) increases pulse. Hemorrhage (B) lowers BP, not seen here. COPD (C) doesn't typically cause bradycardia. Choice D is correct, per pharmacology and nursing assessment principles.
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.