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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.
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The patient wants to monitor blood pressure at home and asks the nurse's advice about how to purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient?
- A. You can apply the cuff in any manner.
- B. You will need to recalibrate the machine.
- C. You can move your arm during the reading.
- D. You will need to use a stethoscope properly.
Correct Answer: B
Rationale: Portable BP devices require recalibration (B) for accuracy, a key teaching point. Random cuff placement (A) or arm movement (C) skews readings. Stethoscopes (D) aren't needed for electronic devices. Choice B is correct, ensuring reliable home monitoring per nursing education.
The nurse is caring for an older-adult patient and notes that the temperature is 96.8?°F (36?°C). How will the nurse interpret this?
- A. This is normal for an older adult.
- B. This is too high for an older adult.
- C. This is indicative of infection.
- D. This requires immediate intervention.
Correct Answer: A
Rationale: Older adults often have lower baseline temperatures (e.g., 96.8?°F) due to slower metabolism; (A) is normal. Too high (B) or infection (C) doesn't fit without symptoms. Intervention (D) is unnecessary. Choice A is correct, per geriatric nursing norms.
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.
The patient with heart failure is restless with a temperature of 102.2?°F (39?°C). Which action will the nurse take?
- A. Place the patient on oxygen.
- B. Encourage the patient to cough.
- C. Restrict the patient's fluid intake.
- D. Increase the patient's metabolic rate.
Correct Answer: A
Rationale: Heart failure with fever (102.2?°F) and restlessness suggests increased oxygen demand. Applying oxygen (A) addresses potential hypoxemia, a priority in heart failure exacerbation. Coughing (B) is irrelevant without respiratory symptoms. Restricting fluids (C) may worsen dehydration in fever. Increasing metabolic rate (D) exacerbates stress. Choice A is correct, aligning with nursing priorities to support oxygenation in cardiac patients with fever-induced strain.
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.