ECPI 164 exam 3 Questions and Answers 2024

ECPI 164 exam 3 Questions and Answers 2024 A nurse receives information during shift report that a patient is afebrile. What action will the nurse take in response? A. Checking the MAR for prescribed antipyretic medication B. Reporting the finding to the primary care provider C. Taking the patient's temperature using a different method D. No action is necessary; this is a normal reading D. No action is necessary; this is a normal reading A nurse is assessing the vital signs of a group of patients in the emergency department. Which patients require follow-up by the nurse? Select all that apply. A. Infant whose temperature is 100.5°F (38.1°C) B. Toddler whose blood pressure is 118/80 C. School-age child whose temperature is 102.2°F (39°C) D. Adolescent whose pulse rate is 70 beats/min E. Adult whose respiratory rate is 20 breaths/min F. Older adult whose pulse rate is 42 beats/min A. Infant whose temperature is 100.5°F (38.1°C), D. Adolescent whose pulse rate is 70 beats/min E. Adult whose respiratory rate is 20 breaths/min F. Older adult whose pulse rate is 42 beats/min A nurse is caring for a newborn with hypothermia. What action does the nurse take to prevent heat loss from convection? A. Wrapping the newborn in a blanket B. Placing the newborn on a warmed surface C. Reducing the temperature in the room D. Increasing the temperature in the room A. Wrapping the newborn in a blanket A charge nurse working on a medical-surgical unit stops the AP from taking rectal temperatures on patients with which problems? Select all that apply. A. Hypothermia B. Pneumonia C. Bradycardia D. Leukemia E. Thrombocytopenia F. Pancreatitis C. Bradycardia D. Leukemia E. Thrombocytopenia While taking an adult patient's pulse, a nurse obtains a heart rate of 140 beats/min. What should the nurse do next? A. Reassess the pulse in 1 hour B. Measure the blood pressure C. Document the information, noting tachycardia D. Report the rate to the health care provider D. Report the rate to the health care provider During assessment of vital signs, a patient reports severe abdominal pain. Which pain-related changes in vital signs may be present? Select all that apply. A. Pulse rate of 102 B. Body temperature 98.8°F C. Blood pressure 154/86 D. Increased respiratory depth E. Respiratory rate of 24 F. Body temperature 100.8°F A. Pulse rate of 102, C. Blood pressure 154/86, E. Respiratory rate of 24 A nurse is caring for a group of patients on a cardiac unit. Which finding will prompt the nurse to assess the apical-radial pulse? A. Bounding radial pulse B. Immediately postoperative C. Rapid, irregular pulse D. Fluid volume deficit A. Bounding radial pulse A nurse is assessing the blood pressure of a patient with traumatic injuries using a Doppler device. Which information does the nurse expect to obtain? A. Amplitude of the brachial pulse B. Mean arterial blood pressure C. Estimation of the systolic blood pressure D. Apical-radial pulse rate B. Mean arterial blood pressure A nurse enters a room and finds a patient who is unable to catch their breath, has a respiratory rate of 28, and is using accessory muscles to breathe. What intervention will the nurse use to relieve dyspnea? A. Remove pillows from under the head B. Raise the head of the bed C. Elevate the foot of the bed D. Reassess the respiratory rate B. raise the head of the bed A nurse has assessed an older adult for orthostatic hypotension as shown in the electronic health record (EHR). What action will the nurse take? Exhibit: Electronic health record (EHR) Graphic sheet 8:00 AM BP lying 124/76 BP sitting 118/74 BP standing 98/58 A. Encourage the patient to rise from a sitting position quickly to improve blood flow B. Suggest that in the future the patient "dangle" for a few minutes before standing C. Return the patient to bed and place them in Fowler position D. Administer medication to increase blood pressure B. Suggest that in the future the patient "dangle" for a few minutes before standing A nurse is caring for a postoperative patient who experienced hypovolemic shock necessitating transfer to the ICU. The nurse manager reviews the medical record and suspects which situation contributed to the emergency? Exhibit: Electronic health record (EHR) Graphic sheet 2:00 PM T 99.2, P 88, RR 16, BP 106/54 2:15 PM T 99.6, P 94, RR 16, BP 100/52 2:30 PM T 99.4, P 110, RR 18, BP 96/50 2:45 PM T 99.2, P 120, RR 20, BP 84/48 A. Using an inappropriate format to document the vital signs B. Failing to report tachycardia and hypotension to the provider C. Not following the postoperative vital sign protocol D. Failing to reflect a pain assessment in the documentation B. Failing to report tachycardia and hypotension to the provider A patient has a blood pressure reading of 130/90 mm Hg during a clinic visit. What recommendation for follow-up will the nurse make? A. Follow-up measurements of blood pressure B. Immediate treatment by a health care provider C. No action, because the nurse considers this reading is due to anxiety D. Change in dietary intake A. Follow-up measurements of blood pressure A nurse participating in community blood pressure screening tells the patient their blood pressure is 120/80 mm Hg. When the patient asks what the numbers mean, what information does the nurse provide? A. Rhythmic distention of the arterial walls from increased pressure due to surges of blood with ventricular contraction B. Systolic pressure represents ventricular contraction causing high pressure on arterial walls; the bottom number or diastolic pressure reflects ventricular relaxation with a lower pressure on the arteries C. Normal blood pressure D. Difference between the pressure on arterial walls with ventricular contraction and relaxation C. Normal blood pressure A nurse observes a nursing student is taking the blood pressure on a patient with a cuff that is too large for the patient's arm. What explanation does the nurse give to the student for why errors of measurement may result? A. "Using the wrong cuff will result in an incorrect reading." B. "This cuff will cause an elevation in diastolic blood pressure." C. "Using the wrong cuff will cause dangerous pressure on the arm." D. "An overly large cuff will cause an inaccurate low reading." A. "Using the wrong cuff will result in an incorrect reading." A nursing student is caring for a patient who has intravenous fluids infusing in the right arm. What action will the student take to correctly obtain the blood pressure? A. Take the blood pressure in the right arm B. Assess blood pressure using the left arm C. Use the smallest possible cuff D. Document an inability to take the blood pressure B. Assess blood pressure using the left arm