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When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding?
- A. This is normal for an infant.
- B. This is too fast for an infant.
- C. This is too slow for an infant.
- D. This is not a rate for an infant but for a toddler
Correct Answer: A
Rationale: Infant pulse ranges from 120-160 beats/min; 145 (A) is normal with regular rhythm. Too fast (B) or slow (C) misaligns with norms. Toddler rates (D) are lower (80-130). Choice A is correct, per pediatric vital sign standards.
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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.
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.
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.
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.
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.