Nokea
Uncontrolled hypertension can result in permanent damage of which organs?
- A. Heart and eyes
- B. Pancreas and spleen
- C. Large intestine and skeletal structures
- D. Brain and kidneys
- E. Urinary bladder
Correct Answer: A,D
Rationale: Hypertension damages the heart, eyes, brain, and kidneys due to increased vascular pressure.
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The nurse would refrain from taking a BP on which of the following areas?
- A. Amputation of the arm
- B. Mastectomy on the affected side
- C. IV infusion on the selected sites
- D. Presence of a shunt
Correct Answer: A,B,C,D
Rationale: BP measurement is contraindicated in areas with amputation, mastectomy, IV infusion, or shunts to avoid injury or inaccurate readings.
In which situations would it be inappropriate to delegate the vital sign assessment?
- A. Routine vital signs on a patient with pneumonia
- B. A patient whose level of consciousness has gone from alert to responding only to pain stimuli
- C. A teenager admitted with influenza A whose temperature 2 hours ago was 100.6°F orally
- D. A confused and lethargic patient brought to the emergency room after being involved in an automobile accident
- E. An adult patient who becomes diaphoretic and pale and complains of sudden onset of severe left chest pain while ambulating in the hallway
Correct Answer: B,D,E
Rationale: Vital signs require nursing assessment in unstable conditions like altered consciousness, confusion, or acute chest pain.
Which of the following objective vital signs, all taken on adults, have one or more components that fall outside of typical normal ranges?
- A. BP - 118/66 mm Hg, T - 99.2°F, P - 74 regular and strong, R - 17, O2 sats - 99%
- B. BP - 98/62 mm Hg, T - 98.2°F, P - 98 regular and strong, R - 20, O2 sats - 97%
- C. BP - 142/92 mm Hg, T - 98.4°F, P - 62 regular and bounding, R - 14, O2 sats - 96%
- D. BP - 120/74 mm Hg, T - 100.6°F, P - 86 regular and strong, R - 24, O2 sats - 98%
Correct Answer: B,C,D
Rationale: Normal ranges: BP 100-130/60-80, T 97.8-99°F, P 60-100, R 12-20. Options B (low BP), C (high BP), and D (high T, R) are abnormal.
You must assess the temperature of an 89-year-old female who is confused, hostile, and combative. Which route would be most appropriate to use?
- A. Rectal
- B. Oral
- C. Temporal
- D. Axillary
Correct Answer: C
Rationale: Temporal route is non-invasive, safe, and accurate for confused or combative patients.
Upon assessing the vital signs of a 56-year-old male, you find that he has an apical pulse of 71 bpm and a radial pulse of 62 bpm. Which of the following numbers would be correct to document as the pulse deficit?
- B. 3
- C. 7
- D. 9
- E. 133
Correct Answer: D
Rationale: Pulse deficit is the difference between apical (71) and radial (62) pulses, which is 9.