NP3

Jill, the head nurse of Ward 1, is supervising the new hired nurse as they auscultate a client’s breath sounds. There is a need to intervene when nurse Jill observes the new nurse to?

Utilizing the bell of the stethoscope
Requesting the client to sit upright
Positioning the stethoscope directly on the client’s skin
Advising the client to inhale slowly and deeply through the mouth

Digoxin is used to improve the strength and efficiency of the heart, or to control the rate and rhythm of the heartbeat. This leads to better blood circulation and reduced swelling of the hands and ankles in patients with heart problems. The nurse instructs the parents on how to give digoxin. Which of the mother’s statements implies that more teaching is necessary?

“I’ll combine the medicine with food.”
“Before giving my child the medication, I will check their pulse.”
“I won’t give the medication again if my child throws up after I give it to them.”
“Before giving my husband his medication, I will talk to him about the dosage.”

There is a high risk for the development of heart failure among patients with valvular heart disease. What should the nurse prioritize when monitoring for signs of heart failure?

Pulse rate
Breath sounds
Blood pressure
Ability to tolerate activity

Nurse Karina provides discharge instructions to mother whose child just underwent heart surgery. Which instructions should she give the mother?

The child is allowed to play outside for brief intervals.
After taking a bath, apply powder and lotion to the incision.
After leaving the hospital, the child has one week to go back to school.
In the event that the child has a temperature greater than above 100.5°F, or 38°C, she must notify the physician.

A client with atrial fibrillation is being taught by the nurse the importance of starting long-term anticoagulant medication. Which justification for this therapy works best, according to the nurse?

“This dysrhythmia causes blood to back up in the legs, which increases the risk of blood clots.”
“Blood clots may form in the brain as a result of this dysrhythmia, which lowers the amount of blood pumping from the heart.”
“You need this medication to prevent blood clots, which are a side effect of the antidysrhythmic medications you are taking.”
“Blood travels slowly through the quivering atria, which can cause clots to form along the heart wall. These clots may then release and move to other parts of the body such as the brain or lungs.”

You are making a discharge plan for a patient with leukemia. Instructions should include:

Monitor rectal temperatures every 4 hours.
Check the mouth and anus after every shift for any tissue breakdown.
To preserve the child’s nutritional health, encourage them to eat fresh fruits and vegetables.
Use a toothbrush and mouthwash with alcohol multiple times a day to give your mouth the careful attention it deserves.

A patient asks you what makes the malignant tumors different from benign tumors. What is your response?

“Benign tumors do not cause damage to other tissues.”
“Benign tumors are likely to recur in the same location.”
“Malignant tumors may spread to other tissues or organs.”
“Malignant cells reproduce more rapidly than normal cells.”

You are caring for a patient who smokes two packs/day. What can you do to help lessen the risks of developing cancer?

Teach the patient about the seven warning signs of cancer.
Plan to monitor the patient’s carcinoembryonic antigen (CEA) level.
Teach the patient about annual chest x-rays for lung cancer screening.
Discuss risks associated with cigarette smoking during each patient encounter.

The nurse should suggest which food choice when providing dietary teaching for a patient scheduled to receive external-beam radiation for abdominal cancer?

Fruit salad
Creamy mushroom soup
Roasted chicken
Toasted wheat bread

You are teaching a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Your teaching is effective when the patient states:

“After cancer has not recurred for 5 years, it is considered cured.”
“The cancer will be cured if the entire tumor is surgically removed.”
“I will need follow-up examinations for many years after treatment before I can be considered cured.”
“Cancer is never cured, but the tumor can be controlled with surgery, chemotherapy, and radiation.”

Nurse Kira is handling a lot of patients. By her confusion, Kira administers digoxin 0.25 mg by mouth rather than the prescribed dose of 0.125 mg to the client. After assessing the client and notifying the health care provider, which action should Kira implement first?

Write an incident report.
Administer digoxin immune Fab.
Tell the client about the medication error.
Tell the client about the adverse effects of digoxin.

Kira’s patient is ordered for nitroglycerin transdermal medication patches. What are the lessons included for teaching? Select all that apply.

Apply a new medication patch every 7 days.
Apply a new medication patch in the morning.
Keep a patch in place for 12 to 16 hours or as directed.
Wait 1 day to apply a new medication patch if it becomes dislodged.
Place the medication patch in the area of a skinfold to promote better adherence

Kira is reviewing the electrocardiogram (ECG) rhythm strip of a client with a history of a myocardial infarction (MI) notes that the PR intervals are 0.16 seconds. Kira interprets this as?

A normal finding
An abnormal finding
An impending reinfarction
First-degree atrioventricular (AV) block

A code is called on the unit. Kira is administering emergency care to a patient experiencing ventricular tachycardia is getting ready to perform defibrillation. What nursing action ensures the safest environment during this procedure?

Confirming the absence of any lubricant on the paddles
Applying the charged paddles one by one to the patient’s chest
Stabilizing the patient’s upper torso while defibrillation is carried out
Ensuring that all assisting staff are clear of the patient and the patient’s bed

Her patient is experiencing unstable ventricular tachycardia (VT) loses consciousness and becomes pulseless following an initial intravenous dose of lidocaine. What should be the next equipment she should get?

A pacemaker
A defibrillator
A second dose of lidocaine
An electrocardiogram machine

Nurse Nikki monitors a patient receiving continuous intravenous infusion of heparin sodium therapy. What is the adverse effect she should watch out for?

Tinnitus
Ecchymoses
Increased pulse rate
Decreased blood pressure

She noticed her patient has an activated partial thromboplastin time (aPTT) value of 100 seconds. Before reporting the results to the primary health care provider, she verifies that which medication is available for use if prescribed?

Vitamin K
Vitamin B12
Methylene blue
Protamine sulfate

She is called to the ER for an emergency. A patient arrives at the emergency department with severe, radiating chest pain, exhibiting extreme restlessness, fear, and shortness of breath. Immediate admission orders include administering oxygen via nasal cannula at 4 L per minute, obtaining troponin, creatinine phosphokinase, and isoenzymes blood levels, performing a chest x-ray, and conducting a 12-lead ECG. What should she prioritize?

Conducting the 12-lead ECG.
Collecting blood specimens.
Administering oxygen to the patient.
Scheduling the chest x-ray examination.

A patient experiences an irregular heart rate. Which statement from the patient suggests to the nurse that they are prepared to learn about their condition?

“I feel weak with an irregular pulse.”
“What are the effects of having a pacemaker?”
“Will all my medications be altered?”
“How might this heart rate issue impact me?”

The cardiac-vascular nurse reviews risk factor reduction with a patient who is newly diagnosed with a myocardial infarction. The patient states, “I don’t know why you’re making such a big deal about this stuff. I feel fine, and the doctor said that my heart attack was small.” The nurse’s most effective action is to:

assess the patient’s perception of the event with open-ended questions.
present research to support the need for risk-factor reduction.
reinforce patient education.
review the laboratory values with the patient.

While the cardiac-vascular nurse preceptor is orienting a graduate nurse on the telemetry unit, a patient experiences cardiac arrest. Which action by the preceptor, during the emergency cardiac care procedure, facilitates the graduate nurse’s competence and professional development?

Asking the graduate nurse to review the policy and procedure for cardiac arrest.
Assigning the graduate nurse to comfort the family during the arrest.
Directing the graduate nurse to attempt IV access.
Involving the graduate nurse in the resuscitation by assigning a basic task.

A patient is admitted to the hospital for a carotid angiogram with stent placement. The patient’s spouse states, “I don’t want my spouse to find out there is a risk of a stroke connected with this procedure because they won’t sign the consent form.” The cardiac-vascular nurse’s most appropriate action is to:

Assess the patient’s level of understanding of the risks, benefits, and alternatives.
Assure the patient’s spouse that the risk of stroke is minimal.
Offer the patient emotional support and reinforce the benefits of the procedure.
Perform a neurologic assessment to establish a baseline.

A patient with cardiogenic shock receives a nursing diagnosis of decreased cardiac output. With the appropriate interventions, the anticipated outcome is for the patient to achieve:

Baseline activity level
Baseline cardiac function
Decreased afterload
Reduced anxiety

A patient recently had a cardiac catheterization via right-radial approach and now has a compression device in place. The patient reports numbness and pain in the right hand. The cardiac-vascular nurse notes a diminished pulse, with a cool and cyanotic hand. The nurse:

Calls the physician.
Performs an Allen test.
Reduces the pressure on the puncture site.
Uses the Doppler ultrasound to assess for pulse signals.

In an assessment for intermittent claudication, the cardiac-vascular nurse assesses for leg pain and cramping with exertion, then asks the patient,:

“Does shortness of breath accompany the leg pain?”
“Does this same type of pain occur without activity?”
“Is the leg pain relieved by rest?”
“Is the leg pain relieved with elevation?”

Patients in mechanical ventilation are prone to infection. What measures should the nurse take to avoid ventilator-associated pneumonia (VAP) in intubated clients receiving mechanical ventilation?

Adhere to thorough hand hygiene protocols.
Keep the head of the bed elevated at a 10-degree angle.
Conduct oral cavity secretion suctioning every 4 hours.
Ensure the respiratory therapist replaces the ventilator circuit tubing every 4 hours.

Which ordered intervention should the nurse refrain from performing until a comatose patient is appropriately intubated?

Administering gastric feeding
Inserting a urethral catheter
Conducting a finger stick to assess blood glucose level
Performing venipuncture for a complete blood cell (CBC) count

A patient diagnosed with active tuberculosis (TB) is scheduled for admission to a medical-surgical unit. What action should the nurse prioritize when arranging a bed assignment?

Assigning the patient to a private, well-ventilated room.
Arranging for the patient’s transfer to the intensive care unit.
Allocating the bed farthest from the door in a double room.
Placing the patient in a shared double room with a noninfectious patient.

The nurse has completed suctioning a client’s tracheostomy. What should the nurse monitor to assess the procedure’s effectiveness?

Auscultation of breath sounds
Capillary refill time
Respiratory rate
Oxygen saturation levels

The nurse is ready to initiate emergency care for a patient exhibiting signs of a pulmonary embolism. Which instruction from the primary healthcare provider should the nurse prioritize?

Administer oxygen.
Provide morphine sulfate.
Initiate an intravenous (IV) line.
Perform an electrocardiogram (ECG).

Vanessa, a respiratory nurse, is caring for a patient who will undergo a bronchoscopy. Which actions should she incorporate into the care plan for a patient scheduled for a bronchoscopy? Choose all that apply.

Remove dentures, if present.
Remove contact lenses, if worn.
Limit access to food and drink.
Confirm that informed consent has been obtained.
Ensure the patient empties their bladder before being transported for the procedure.

She is caring for a client with chronic obstructive pulmonary disease (COPD). They are receiving home oxygen therapy at a rate of 2 liters per minute. She notes the client’s respiratory rate as 22 breaths per minute. When the client complains of worsening dyspnea, what should the nurse do first?

Assess whether there is a need to adjust the oxygen flow.
Contact emergency services for assistance at the residence.
Offer reassurance to the client, emphasizing there is no cause for concern.
Gather additional details regarding the client’s respiratory condition.

She is providing discharge instructions to the mother of an 8-year old child who had a tonsillectomy. The mother tells her that the child loves tacos and asks when the child can safely eat one. To prevent complications of the surgical procedure, what should be the appropriate response to the mother?

“In 1 week.”
“In 3 weeks.”
“Six days after surgery.”
“When the primary health care provider says it is okay.”

There is a need for nurse Vanessa to reinforce incentive spirometry teaching if the client states that they should:

Inhales slowly
Breathes through the nose
Removes the mouthpiece to exhale
Forms a tight seal around the mouthpiece with the lips

You are monitoring a client for a hypoglycemic reaction, knowing that NPH insulin peaks in approximately how many hours following administration?

1 hour
2 to 3 hours
4 to 12 hours
16 to 24 hours

A client diagnosed with type 2 diabetes mellitus is being discharged from the hospital after an occurrence of hyperglycemic hyperosmolar state (HHS). You are planning to create a discharge teaching plan for the client and identifies which intervention as a priority?

Exercise routines
Controlling dietary intake
Keeping follow-up appointments
Monitoring for signs/symptoms of dehydration

You create a plan of care for an older client diagnosed with diabetes mellitus. It is important that you plan to complete which action first?

Structure menus for adherence to diet.
Teach with videotapes showing insulin administration to ensure competence.
Encourage dependence on others to prepare the client for the chronicity of the disease.
Assess the client’s ability to read label markings on syringes and blood glucose monitoring equipment.

While observing a patient diagnosed with chronic kidney disease (CKD), which observation warrants reporting to the primary healthcare provider?

Pallor
Fatigue
Lethargy
Petechiae

The nurse is overseeing a client diagnosed with hypercalcemia. What observation suggests a requirement for further evaluation?

Elevated peristalsis
Diminished capillary refill
Heightened deep tendon reflexes
Reduced abdominal circumference

A patient diagnosed with acute kidney injury has elevated blood urea nitrogen (BUN) levels and is struggling with memory retention. What interventions should the nurse employ when communicating with this patient? Select all that apply.

Provide straightforward, understandable instructions.
Involve the family in care-related discussions.
Describe treatments using plain language.
Avoid providing extensive, detailed explanations of procedures.
Utilize various teaching methods to deliver discharge instructions.

The nurse is giving epoetin alfa to a client with chronic kidney disease (CKD). What adverse effect of this treatment should the nurse watch for in the client?

Anemia
Hypertension
Iron overload
Increased bleeding risk

A client diagnosed with chronic kidney disease (CKD) has received dietary advice regarding potassium restriction. The nurse confirms the client has understood the information when they indicate they will take what action when preparing vegetables?

Consume only fresh vegetables.
Boil them and discard the cooking water.
Exclusively use salt substitutes for seasoning.
Opt for frozen vegetables whenever feasible.

Why is diphenhydramine given before a blood transfusion?

To prevent hives
To prevent fever and chills
To improve clotting factors
To increase blood volume

The nurse reviewing a urinalysis report for a client with the diagnosis of acute kidney injury notes that the results are highly positive for proteinuria. The nurse determines that this client has which type of renal failure?

Prerenal failure
Postrenal failure
Intrinsic renal failure
Atypical renal failure

In your nursing care plan you will include which of the following as a nursing diagnosis for this patient?

Risk for infection
Deficient fluid volume
Constipation
Overflow urinary incontinence

You know that you should assess which important parameter on a daily basis?

weight
albumin levels
activity tolerance
blood urea nitrogen (BUN) level

You need to collect urine sample. You know that the urine sample will appear:

Tea-colored
Orange and frothy
Dark and foamy
Straw-colored

Which assessment finding below requires you to notify the physician immediately for a patient with nephrotic syndrome?

Frothy, dark urine
Redden area on the patient’s left leg that is swollen and warm
Elevated lipid level on morning labs
Urine test results that shows proteinuria

It has been identified that Kovu has acute glomerulonephritis. During history-taking the you first asks Kovu’s mother about a recent history of:

Bleeding ulcer
Deep vein thrombosis
Myocardial infarction
Streptococcal infection

The client with acute renal failure has a serum potassium of 6.0 mEq/L. The nurse would plan which of the following as a priority action?

Check the sodium level
Place the client on a cardiac monitor
Encourage increased vegetables in the diet
Allow an extra 500 ml of fluid intake to dilute the electrolyte concentration

While assessing Mr. Johnson, you note that he has increased respiratory rate, shallow breathing, and decreased breath sounds on auscultation. Which of the following conditions should you suspect?

Atelectasis
Pneumothorax
Pulmonary embolism
Acute respiratory distress syndrome (ARDS)

A 40-year-old female patient is admitted to the hospital with a diagnosis of pneumonia. Upon assessment, the nurse notes increased respiratory rate, decreased breath sounds, and dullness to percussion on the right lower lung field. The nurse suspects a complication of pneumonia that involves accumulation of fluid in the pleural space. Which of the following conditions is the nurse likely suspecting?

Empyema
Pleural effusion
Atelectasis
Pulmonary embolism

Mr. Johnson is at risk for the development of atelectasis due to his immobility and shallow breathing. Which of the following nursing interventions is most appropriate to prevent atelectasis?

Encourage deep breathing and coughing exercises
Administer bronchodilator medications
Apply oxygen via nasal cannula
Perform chest physiotherapy

Mr. Johnson’s condition deteriorates, and he develops sudden chest pain and dyspnea. The nurse suspects a possible pneumothorax. Which of the following findings would support this suspicion?

Hyperresonance on percussion
Decreased tactile fremitus
Crackles on auscultation
Increased vocal resonance

After confirming a pneumothorax, the nurse anticipates the need for intervention to remove the air from the pleural space. Which of the following interventions is the primary treatment for a pneumothorax?

Chest tube insertion
Administration of antibiotics
High-flow oxygen therapy
Percutaneous needle aspiration

Mr. Johnson develops sudden dyspnea, tachycardia, and pleuritic chest pain. The nurse suspects a pulmonary embolism. Which of the following diagnostic tests would be most appropriate to confirm this suspicion?

Chest X-ray
Electrocardiogram (ECG)
Pulmonary angiography
D-dimer blood test

Mrs. Anderson complains of shortness of breath and fatigue upon exertion. Which of the following assessments is most important for the nurse to perform to evaluate her heart failure status?

Blood pressure measurement
Respiratory rate assessment
Electrocardiogram (ECG) monitoring
Daily weight measurement

Mrs. Anderson is prescribed furosemide (Lasix) for the management of her heart failure. Which of the following is the primary action of furosemide?

Reducing preload
Increasing afterload
Enhancing myocardial contractility
Dilating coronary arteries

Ms. Johnson, a 68-year-old patient, is admitted to the hospital with a diagnosis of left-sided heart failure. The nurse assesses crackles in the patient’s lung bases and reports this finding to the healthcare provider. Which of the following nursing interventions would be most appropriate to manage the patient’s respiratory symptoms?

Administering supplemental oxygen
Assisting with chest physiotherapy
Encouraging deep breathing exercises
Administer diuretics

Mrs. Anderson’s laboratory results show elevated levels of brain natriuretic peptide (BNP). The nurse recognizes this as a diagnostic marker for heart failure. Which of the following statements best explains the role of BNP in heart failure?

BNP causes peripheral vasoconstriction.
BNP increases myocardial contractility.
BNP promotes fluid retention.
BNP acts as a vasodilator.

Mrs. Anderson has a history of hypertension and is prescribed an angiotensin-converting enzyme (ACE) inhibitor for heart failure management. Which of the following is the primary action of ACE inhibitors in heart failure?

Dilating coronary arteries
Reducing systemic vascular resistance
Enhancing myocardial contractility
Increasing sodium and water retention

Mr. Johnson complains of severe chest pain radiating to his left arm and jaw. The nurse suspects myocardial ischemia. Which of the following laboratory tests is most commonly used to diagnose AMI?

Troponin
C-reactive protein (CRP)
Brain natriuretic peptide (BNP)
Creatine kinase (CK)

Mr. Johnson is prescribed aspirin as part of his treatment plan for AMI. Which of the following is the primary action of aspirin in this context?

Inhibiting platelet aggregation
Reducing myocardial oxygen demand
Dilating coronary arteries
Enhancing myocardial contractility

Mr. Johnson undergoes percutaneous coronary intervention (PCI) to restore blood flow to the affected coronary artery. Which of the following nursing interventions is most important immediately after PCI?

Monitoring vital signs every 4 hours
Administering anticoagulant medications
Assessing the puncture site for bleeding
Encouraging early ambulation

Mr. Johnson is prescribed nitroglycerin for the relief of angina symptoms. Which of the following statements best explains the action of nitroglycerin in angina?

Nitroglycerin dilates coronary arteries.
Nitroglycerin reduces myocardial oxygen demand.
Nitroglycerin enhances myocardial contractility.
Nitroglycerin inhibits platelet aggregation.

Mr. Johnson is at risk for developing heart failure following his AMI. Which of the following manifestations would the nurse expect to assess in a patient with heart failure?

Bradycardia and hypotension
Jugular vein distention and peripheral edema
Increased urine output and weight loss
Hyperactive bowel sounds and diarrhea

Mr. Thompson presents with dyspnea at rest, orthopnea, and paroxysmal nocturnal dyspnea. The nurse recognizes these symptoms as indicative of:

Left-sided heart failure
Right-sided heart failure
Diastolic heart failure
Systolic heart failure

Mr. Thompson is prescribed digoxin as part of his heart failure management. The nurse understands that digoxin primarily works by:

Enhancing myocardial contractility
Dilating coronary arteries
Reducing systemic vascular resistance
Inhibiting platelet aggregation

Mr. Thompson’s blood work reveals low levels of potassium (hypokalemia). The nurse understands that this is a potential side effect of which medication commonly used in heart failure?

Furosemide (Lasix)
Lisinopril (Zestril)
Metoprolol (Lopressor)
Spironolactone (Aldactone)

Mr. Thompson is educated on dietary modifications to manage his heart failure. Which of the following foods should the nurse advise him to limit in his diet?

Lean protein sources
Fresh fruits and vegetables
Whole grains
Sodium-rich foods

Which structure warms and filters inspired air in the upper respiratory tract?

Trachea
Nasal cavity
Bronchi
Alveoli

What is the primary function of the paranasal sinuses?

Resonating chamber in speech
Gas exchange
Production of mucus
Airway protection

Which structure covers the opening to the larynx during swallowing?

Epiglottis
Glottis
Vocal cords
Thyroid cartilage

What is the primary function of the trachea?

Gas exchange
Vocalization
Airway protection
Passage of air between larynx and bronchi

Which structure is responsible for gas exchange in the lower respiratory tract?

Alveoli
Trachea
Bronchi
Larynx

Which respiratory assessment finding is associated with crackles?

Harsh high-pitched sound on inspiration
Low-pitched wheezing or snoring sound
Soft, high-pitched popping sounds during inspiration
Abnormal increase in clarity of transmitted voice sounds

Which respiratory assessment finding is associated with rhonchi?

Harsh high-pitched sound on inspiration
Soft, high-pitched popping sounds during inspiration
Low-pitched wheezing or snoring sound
Abnormal increase in clarity of transmitted voice sounds

What is the term for a subjective experience that describes difficulty breathing?

Dyspnea
Apnea
Tachypnea
Orthopnea

Which respiratory assessment finding is associated with egophony?

Harsh high-pitched sound on inspiration
Soft, high-pitched popping sounds during inspiration
Whispered sounds heard loudly and clearly upon auscultation
Vibrations of speech felt as tremors of the chest wall during palpation

Which respiratory assessment finding is associated with fremitus?

Harsh high-pitched sound on inspiration
Soft, high-pitched popping sounds during inspiration
Whispered sounds heard loudly and clearly upon auscultation
Vibrations of speech felt as tremors of the chest wall during palpation

What is the term for expectoration of blood from the respiratory tract?

Apnea
Rhonchi
Hemoptysis
Tachypnea

Which respiratory assessment finding is associated with stridor?

Harsh high-pitched sound on inspiration
Low-pitched wheezing or snoring sound
Soft, high-pitched popping sounds during inspiration
Abnormal increase in clarity of transmitted voice sounds

Which respiratory assessment finding is associated with wheezes?

Harsh high-pitched sound on inspiration
Low-pitched wheezing or snoring sound
Soft, high-pitched popping sounds during inspiration
Abnormal increase in clarity of transmitted voice sounds

What is the term for a decrease in arterial oxygen tension in the blood?

Hypoxia
Orthopnea
Hypoxemia
Tidal volume

What is the term for a decrease in oxygen supply to the tissues and cells?

Hypoxia
Orthopnea
Hypoxemia
Tidal volume

What is the term for the temporary absence of breathing during sleep due to transient upper airway obstruction?

Sleep apnea
Apnea
Orthopnea
Dyspnea

What is the term for shortness of breath when lying flat, relieved by sitting or standing?

Hypoxemia
Orthopnea
Tachypnea
Hemoptysis

What is the term for the percentage of hemoglobin that is bound to oxygen?

Oxygen saturation
Compliance
Physiologic dead space
Pulmonary diffusion

What is the term for the portion of the tracheobronchial tree that does not participate in gas exchange?

Compliance
Physiologic dead space
Pulmonary perfusion
Respiration

What is the term for gas exchange between atmospheric air and the blood, and between the blood and cells of the body?

Compliance
Physiologic dead space
Pulmonary perfusion
Respiration

A nurse is assessing a newborn infant’s temperature. The nurse knows that newborns are at risk for hypothermia and need to be kept warm and dry to maintain their body temperature. Which site should the nurse use to obtain an accurate temperature reading in a newborn?

Oral
Tympanic
Rectal
Axillary

A nurse is assessing a 3-month-old infant’s temperature. The nurse wants to use a method that is fast and convenient. Which site should the nurse use to obtain a temperature reading in this infant?

Oral
Tympanic
Rectal
Axillary

A nurse is assessing the temperature of a 6-year-old child. The nurse wants to use a method that is preferred for this age group. Which site should the nurse use to obtain a temperature reading in this child?

Oral
Tympanic
Rectal
Axillary

A nurse is assessing the temperature of an older adult. The nurse knows that older adults’ temperatures tend to be lower than those of middle-aged adults. Which factor contributes to this difference?

Increased environmental temperature
Increased metabolic rate
Decreased efficiency of thermoregulation control processes
Increased cardiac output

A nurse is assessing a patient’s vital signs and notices an elevated pulse rate. The nurse understands that various factors can influence the pulse rate. Which of the following factors is most likely responsible for the increased pulse rate in this patient?

Anxiety
Hypothermia
Hypoglycemia
Dehydration

A nurse is performing a temperature assessment on a 2-year-old child. The nurse wants to use a noninvasive method that is suitable for this age group. Which site should the nurse use to obtain a temperature reading in this child?

Oral
Tympanic
Rectal
Axillary

A nurse is assessing the temperature of an older adult. The nurse notices that the client has a buildup of ear cerumen (earwax). How can this affect the accuracy of tympanic thermometer readings in older adults?

It may cause a falsely elevated temperature reading.
It may cause a falsely decreased temperature reading.
It may have no effect on the temperature reading.
It may cause discomfort to the client.

A nurse is assessing the temperature of a client and notes that the client has hemorrhoids. How should the nurse proceed when obtaining a rectal temperature reading in this client?

Insert the thermometer gently to avoid causing discomfort.
Avoid taking a rectal temperature due to the presence of hemorrhoids.
Inspect the anus before taking a rectal temperature.
Use a different method to obtain the client’s temperature.

A nurse is assessing the temperature of a client and notices that the client has confusion and restlessness, but only a slight temperature elevation. The nurse suspects there may be an underlying process. What should the nurse do next?

Administer antipyretic medication to reduce the temperature.
Monitor the client’s vital signs and observe for any further changes.
Discontinue temperature assessment as it may not be a valid indication of pathology.
Consult with the healthcare provider for further evaluation.

A nurse is assessing the temperature of an adult client and finds that the client has a fever. What is the most likely reason for the client’s elevated body temperature?

Increased metabolic rate
Decreased cardiac output
Increased environmental temperature
Decreased efficiency of thermoregulation control processes

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