Nokea
When measuring the vital signs of a 6-month-old infant, which action by the nurse is correct?
- A. Respirations are measured first, followed by pulse and temperature.
- B. Vital signs should be measured as frequently as in an adult.
- C. Procedures are explained to the parent, and the infant is encouraged to handle the equipment.
- D. The nurse should first measure the infant's vital signs before performing a physical examination.
Correct Answer: A
Rationale: When assessing vital signs in a 6-month-old infant, the correct order is to measure respirations first, followed by pulse and temperature. This sequence is important to avoid potential alterations in respiratory and pulse rates caused by factors like crying or discomfort. Measuring the temperature first, especially rectally, may lead to an increase in respiratory and pulse rates, which can skew the results. It is crucial to follow this specific order to obtain accurate baseline values. Therefore, option A is the correct choice. Option B is incorrect as the frequency of measuring vital signs in infants differs based on individual needs rather than being consistently more frequent than in adults. Option C is not directly related to the correct sequence for measuring vital signs in infants. Option D is incorrect because the physical examination typically follows the assessment of vital signs in clinical practice.
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What is the correct action regarding thigh pressure when comparing it to arm pressure in an adolescent with high blood pressure?
- A. The popliteal artery should be auscultated to obtain thigh pressure.
- B. The best position to measure thigh pressure is the prone position.
- C. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure.
- D. Thigh pressure is generally higher than arm pressure due to the proximity to the heart and the size of the popliteal vessels.
Correct Answer: C
Rationale: When blood pressure measured in the arm is significantly elevated, especially in adolescents and young adults, it is crucial to compare it with thigh pressure to assess for coarctation of the aorta. The popliteal artery, not the femoral artery, should be auscultated for the thigh pressure reading as the femoral artery is closer to the placement of the blood pressure cuff. Generally, thigh pressure is higher than arm pressure; however, if there is coarctation of the artery, arm pressures can be higher than thigh pressures. The preferred position for measuring thigh pressure is the prone position, not supine, with the knee slightly bent to facilitate accurate readings.
When auscultating the blood pressure of a 25-year-old patient, the nurse notices that the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?
- A. 200/92
- B. 200/100
- C. 100/200/92
- D. 200/100/92
Correct Answer: A
Rationale: When auscultating blood pressure, it is crucial to note the points at which Korotkoff sounds change. In adults, the last audible sound indicates the diastolic pressure. In this case, the Korotkoff sounds muffle at 100 mm Hg and disappear at 92 mm Hg. Therefore, the blood pressure should be recorded as systolic/diastolic, which is 200/92. Choices B, C, and D are incorrect because they do not reflect the correct points where the Korotkoff sounds change during blood pressure measurement.
The nurse is teaching a student nurse about the different types of thermometers. When teaching the student about the advantages of the tympanic membrane thermometer (TMT), which statement would the nurse include?
- A. "Measuring temperature using the TMT is cost-effective."?
- B. "The rapid measurement of the TMT is beneficial for uncooperative younger children."?
- C. "TMT is not recommended for measuring core body temperature in newborn infants."?
- D. "TMT is not the preferred method for measuring body temperature in patients with otitis media."?
Correct Answer: B
Rationale: The correct answer is "The rapid measurement of the TMT is beneficial for uncooperative younger children." TMT is ideal for young children who may not cooperate for oral temperatures or fear rectal temperatures. However, using TMT for newborn infants is not recommended due to inconsistencies in results. Measuring temperature with TMT is not necessarily cost-effective. The most accurate method for measuring core temperature is through rectal temperatures. TMT may not be the preferred method for patients with otitis media due to potential inaccuracies caused by fluid behind the tympanic membrane.
A 4-month-old child is at the clinic for a well-baby checkup and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs?
- A. The infant's radial pulse should be palpated, and the nurse should notice any
fluctuations resulting from activity or exercise. - B. The nurse should auscultate an apical rate for 1 minute and then assess for any
normal irregularities, such as sinus dysrhythmia. - C. The infant's blood pressure should be assessed by using a stethoscope with a large
diaphragm piece to hear the soft muffled Korotkoff sounds. - D. The infant's chest should be observed and the respiratory rate counted for 1
minute; the respiratory pattern may vary significantly.
Correct Answer: B
Rationale: The nurse auscultates an apical rate, not a radial pulse, with infants and toddlers. The pulse should be counted by listening to the heart for 1 full minute to account for normal irregularities, such as sinus dysrhythmia. Children younger than 3 years of age have such small arm vessels; consequently, hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic lood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds.
An infant's respiratory rate should be assessed by observing the infant's abdomen, not chest, because an infant's respirations are normally more diaphragmatic than thoracic. The nurse should auscultate an apical heart rate, not palpate a radial pulse, with infants and toddlers.
How many cc are there in 25 ounces?
- A. 250
- B. 500
- C. 750
- D. 1000
Correct Answer: C
Rationale: To convert ounces to cc, we know that there are 30 cc in 1 ounce. Therefore, to find out how many cc are in 25 ounces, we multiply 30 cc/ounce by 25 ounces which equals 750 cc. This makes choice C, 750, the correct answer. Choices A, B, and D are incorrect as they do not correctly convert ounces to cc.