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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.
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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.
The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient's symptoms?
- A. Red blood cell count of 5.0 million/mm3
- B. Hemoglobin level of 8.0 g/100 mL
- C. Hematocrit level of 45%
- D. Pulse oximetry of 95%
Correct Answer: B
Rationale: Shortness of breath and chest discomfort suggest reduced oxygen delivery. Hemoglobin of 8.0 g/dL (B) indicates anemia (normal 12-16 g/dL), impairing oxygen transport. RBC 5.0 million/mm3 (A) and hematocrit 45% (C) are normal. Oximetry 95% (D) is adequate. Choice B is correct, linking anemia to symptoms per nursing pathophysiology.
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.
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 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.