DETAILED ANSWERS GRADED A +
the nurse is measuring blood pressure as a part of community health fair. which blood pressure
reading would cause the nurse to refer the patient for follow-up regarding hypertension?
a- 108/70
b- 116/78
c- 128/80
d- 138/88 - ANSWER-d
the nurse is admitting a stable patient for a minor outpatient procedure. what site would the
nurse most commonly use to assess pulse rate?
a- radial site
b- apical site
c- brachial site
d- carotid site - ANSWER-a
the UAP reports vital signs for a patient to the nurse: temp of 99.2 oral, pulse of 88bpm and
regular respirations of 18bpm, BP 178/112mmHg, O2 sat of 96%. which vital sign should the
nurse be most concerned about?
a- temp
b- pulse
c- respiration
,d- BP - ANSWER-d
From the nurse's understanding, which statements regarding temperature and heat production
in the body are accurate? (Select all that apply.)
a. Heat generates energy for cellular functions.
b. Hormones, such as the thyroid, decrease metabolism and heat production.
c. Exercise decreases heat production through muscular activity.
d. Body temperature is 1º to 2º higher in the morning than in late afternoon.
e. Expected temperature readings vary by the route selected for measurement.
f. Women tend to have more fluctuations in temperature than do men. - ANSWER-a, d, e
the nurse is performing an initial assessment of a patient with a severe infection at hospital
admission. vital signs for the patient indicate hypotension and tachycardia. which data would
support this evaluation?
a- pulse 78, BP 140/88
b- pulse 86, BP 120/76
c- pulse 100, BP 118/68
d- pulse 114, BP 88/56 - ANSWER-d
The nurse places a patient with a high fever on a cooling blanket. How is heat loss achieved with
this treatment?
a. Radiation
b. Convection
c. Conduction
d. Evaporation - ANSWER-c
, which clinical patient scenario is associated with the most critical need for the nurse to obtain
vital signs?
a- ambulating for the first time after surgery
b- complaining of pressure in the chest
c- completing ambulating 100ft after a stroke
d- complaining of hunger while NPO (nothing by mouth) - ANSWER-b
the nurse understands that which statement is correct regarding respiratory rates?
a- infants have a lower respiratory rate
b- healthy adults breathe between 12-20 times a minute
c- a compensatory response to a fever is to breathe at a slower rate
d- an increase in intracranial pressure results in an increase rate - ANSWER-b
the nurse is caring for a patient who has a blood pressure of 184/110. an hour after
administering an antihypertensive med, the nurse returns to recheck the BP, only to find the
patient in the chair pale, sweaty, feeling faint. which is the expected explanation for the nurse's
observation?
a- the BP is 184/110; medication has no effect
b- the BP is 118/76; the sudden drop has caused the signs
c- the BP is 174/96; the medication has made the patient sick
d- the BP is 13-/82; the symptoms are from another cause - ANSWER-b
it is 6am and the UAP reports to the nurse that the patient has a temp of 96.7F tympanic. Which
factor explains the reading?
a- the pts room is cold
b- the pt was drinking cold water
c- the pt is exhibiting a normal circadian rhythm