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The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address?
- A. Non-Hispanic Caucasians
- B. European Americans
- C. African Americans
- D. Asian Americans
Correct Answer: C
Rationale: African Americans (C) have higher hypertension prevalence (e.g., AHA data), making them a priority for BP clinics. Other groups (A, B, D) have lower rates. Choice C is correct, reflecting public health focus on at-risk populations for cardiovascular screening.
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The nurse needs to increase heat conservation in a newborn. Which action will the nurse take?
- A. Apply just a diaper.
- B. Double the clothing.
- C. Place a cap on their heads.
- D. Increase room temperature to 90 degrees.
Correct Answer: C
Rationale: Newborns lose heat rapidly, especially from the head, due to a large surface area and limited thermoregulation. Placing a cap (C) conserves heat by covering this key area, a standard neonatal practice. A diaper alone (A) offers minimal coverage, increasing heat loss. Doubling clothing (B) helps but is less effective than a cap for head protection. Raising the room to 90?°F (D) risks overheating. Choice C is correct, supported by pediatric guidelines (e.g., AAP) emphasizing head coverage to maintain newborn temperature stability.
The nursing assistive personnel (NAP) is taking vital signs and reports that a patient's blood pressure is abnormally low. What should the nurse do next?
- A. Ask the NAP to retake the blood pressure.
- B. Instruct the NAP to assess the patient's other vital signs.
- C. Disregard the report and have it rechecked at the next scheduled time.
- D. Retake the blood pressure personally and assess the patient's condition
Correct Answer: D
Rationale: Abnormally low BP requires verification and assessment. The nurse retaking it (D) ensures accuracy and allows immediate patient evaluation, overriding NAP data. Retaking by NAP (A) or adding vitals (B) delays RN judgment. Ignoring it (C) risks harm. Choice D is correct, per RN accountability standards.
The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do?
- A. Allow the patient to breathe into a paper bag.
- B. Use oxygen cautiously in this patient.
- C. Administer high levels of oxygen.
- D. Give CO2 via mask.
Correct Answer: B
Rationale: Chronic lung disease (e.g., COPD) with smoking risks CO2 retention; cautious oxygen use (B) prevents suppressing hypoxic drive while addressing shortness of breath. Paper bag (A) is for hyperventilation. High oxygen (C) risks respiratory depression. CO2 (D) worsens hypoxia. Choice B is correct, per respiratory nursing guidelines.
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.
Which statement correctly defines hyperthermia?
- A. Hyperthermia is a downward shift in the set point.
- B. Hyperthermia is an upward shift in the set point.
- C. Hyperthermia occurs when the body cannot reduce heat production.
- D. Hyperthermia results from a reduction in thermoregulatory mechanisms.
Correct Answer: C
Rationale: Hyperthermia is an uncontrolled rise in body temperature when heat production exceeds dissipation (C), often from external factors or exertion, not set-point shifts. A downward set-point shift (A) isn't hyperthermia. An upward shift (B) defines fever, not hyperthermia. Reduced mechanisms (D) may contribute but isn't the definition. Choice C is correct, distinguishing hyperthermia from fever per nursing pathophysiology, critical for appropriate interventions.