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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.
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The nurse is caring for an infant and is obtaining the patient's vital signs. Which artery will the nurse use to best obtain the infant's pulse?
- A. Radial
- B. Brachial
- C. Femoral
- D. Popliteal
Correct Answer: B
Rationale: In infants, the brachial artery (B) is preferred for pulse due to accessibility and strength; radial (A) is weak and hard to palpate. Femoral (C) and popliteal (D) are less practical. Choice B is correct, per pediatric norms, ensuring accurate infant pulse assessment.
When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this?
- A. 138/70
- B. 138/62
- C. 70/62
- D. 138/70/62
Correct Answer: B
Rationale: BP is recorded as systolic (onset, 138) over diastolic (disappearance, 62), so 138/62 (B). Muffling (70) is phase IV, not standard for adults. 138/70 (A) uses muffling incorrectly. 70/62 (C) is invalid. 138/70/62 (D) isn't standard. Choice B is correct, per AHA guidelines.
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.
After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action?
- A. Temperatures vary depending on the route used.
- B. Temperatures are readings of core measurements.
- C. Rectal temperatures are cooler than when taken orally.
- D. Axillary temperatures are higher than oral temperatures.
Correct Answer: A
Rationale: Temperature varies by route (A) e.g., rectal is 1?°F higher, axillary 1?°F lower than oral requiring documentation for accuracy. Not all are core (B). Rectal is warmer (C incorrect). Axillary is lower (D incorrect). Choice A is correct, per nursing documentation standards.
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.