Nokea
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.
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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.
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.
A 68-year-old African American female is admitted for hypertension. She is at risk for hypertension based on which of the following?
- A. Smoking
- B. Obesity
- C. Lower cholesterol level in the blood
- D. Moderate to heavy alcohol consumption
- E. Low stress level
Correct Answer: A,B,D
Rationale: Smoking, obesity, and alcohol consumption are modifiable risk factors for hypertension.
The disadvantages of the oral and skin temperatures assessment routes for an adult patient include which of the following?
- A. Risk of body fluid exposure
- B. Affected by severe environmental temperatures
- C. Not affected by smoking
- D. Not for confused or unconscious patients
Correct Answer: A,B,D
Rationale: Oral and skin routes risk fluid exposure, are affected by environmental temperatures, and are unsuitable for confused or unconscious patients.