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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.
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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.
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.
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 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.
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.