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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.
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A nurse is caring for a group of patients on a medical-surgical unit. Which patient will the nurse assess first?
- A. A 17-year-old male who has just returned from outside 'for a smoke' who needs a temperature taken.
- B. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60.
- C. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74.
- D. An 87-year-old male suspected of hypothermia whose temperature is below normal.
Correct Answer: B
Rationale: A postoperative BP drop from 128/70 to 100/60 (B) indicates potential shock or bleeding, a priority. Smoking (A) or pain with stable BP (C) is less urgent. Hypothermia (D) needs attention but lacks acuity data. Choice B is correct, per triage urgency in surgical care.
The nurse is working the night shift on a surgical unit and notices that the patient's temperature is 96.8?°F (36?°C), whereas at 4:00 PM the preceding day, it was 98.6?°F (37?°C). What should the nurse do?
- A. Call the health care provider immediately to report a possible infection.
- B. Administer medication to lower the temperature further.
- C. Provide another blanket to conserve body temperature.
- D. Wait 30 minutes and recheck the patient's temperature.
Correct Answer: D
Rationale: A temperature of 96.8?°F (36?°C) is slightly low but within normal diurnal variation (lowest at night). Waiting 30 minutes to recheck (D) confirms if it's a trend or artifact, avoiding overreaction. Calling the provider (A) is premature for a non-critical value without symptoms. Lowering it further (B) is illogical for hypothermia. Adding a blanket (C) assumes hypothermia without confirmation. Choice D is correct, reflecting nursing judgment to monitor trends, aligning with circadian temperature dips and post-surgical assessment protocols.
The patient's blood pressure is 140/60. Which value will the nurse record for the pulse pressure?
- A. 60
- B. 80
- C. 140
- D. 200
Correct Answer: B
Rationale: Pulse pressure is systolic minus diastolic: 140 - 60 = 80 (B). 60 (A) is diastolic. 140 (C) is systolic. 200 (D) is unrelated. Choice B is correct, reflecting arterial pressure dynamics, a key nursing calculation.
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.
The nurse needs to obtain an accurate respiratory rate from a patient who is talking with visitors. What will the nurse do?
- A. Tell the patient to continue talking.
- B. Count respirations while the patient is talking.
- C. Obtain without the patient knowing.
- D. Wait until the patient finishes talking.
Correct Answer: C
Rationale: Talking alters respiratory rate, so counting discreetly (C) during conversation ensures an undisturbed baseline. Continuing talking (A) or counting during it (B) skews results. Waiting (D) delays assessment. Choice C is correct, a nursing tactic to capture natural breathing patterns accurately.