Solutions
What will the nurse instruct nursing assistive personnel (NAP) to do when
measuring a patient's rectal temperature using an electronic thermometer? –
ANSWER Use the probe with the red tip.
what contraindicates taking a rectal temperature measurement – ANSWER
Patient has painful and swollen hemorrhoids.
Which nursing action best evaluates the effectiveness of an antipyretic
medication in a patient with an oral temperature of 101.6°F? – ANSWER Assess
oral temperature 30 minutes after the agent is administered.
Which instruction might the nurse give to nursing assistive personal (NAP) that
is applicable only to tympanic temperature assessment? – ANSWER Gently tug the
pinna backward, up, and out before inserting the probe.
Which instruction might the nurse give to nursing assistive personnel (NAP) that
is applicable only to temporal artery temperature assessment? – ANSWER Place
the sensor flush on the patient's forehead.
During the admissions process, the nurse initially assesses the patient's radial
pulse primarily for what purpose? – ANSWER Establishment of a baseline as part
of the patient's vital signs
What will the nurse instruct nursing assistive personal (NAP) to do when
measuring an adult patient's radial pulse? – ANSWER Palpate the patient's inner
wrist on the thumb side with the fingertips of your two middle fingers.
, NUR 311 Hygiene Questions With Step -By Step -
Solutions
What is the nurse's priority action if a patient's radial pulse has an irregular
rhythm? – ANSWER Assess the patient for a pulse deficit.
A patient with type 2 diabetes mellitus tells the nurse that he has been testing his
own blood glucose level six times per day for the past 3 years. What is the most
appropriate action for the nurse to take? – ANSWER Observe the patient's testing
technique for accuracy. It is useful to evaluate the patient's technique to ensure that
he receives accurate results.
Which action would the nurse carry out first when performing a blood glucose
test on a patient with type 1 diabetes mellitus? – ANSWER Assess the patient's
skin for possible puncture sites. The nurse's first action would be to assess possible
puncture sites.
What is the nurse's primary goal for appropriate, effective pain management
when considering the patient's risk for injury? – ANSWER To maximize pain relief
while maintaining the patient's ability to function
What is one step the nurse would take if a patient receiving patient-controlled
analgesia (PCA) were difficult to arouse? – ANSWER Assess respiration, and then
notify the health care provider immediately
, NUR 311 Hygiene Questions With Step -By Step -
Solutions
When a patient is using PCA, which statement is appropriate for the nurse to
make to nursing assistive personnel (NAP)? – ANSWER "Tell me if the patient is
in too much pain to assist with his bath."
Which patient outcome best reflects adequate management for pain originally
rated as 8 out of 10 on a pain scale? – ANSWER The patient rates current pain as 4
out of 10
What will the nurse do when discontinuing PCA? – ANSWER Ensure that the
main intravenous line is intact
Inadequate oxygenation to the body will cause the radial pulse to become: -
ANSWER Tachycardic
Which action would best assess the effect of exercise on a patient's radial pulse
measurement? – ANSWER Measuring the patient's radial pulse before and after
exercise
Which action can the nurse take to keep a patient from consciously controlling
his or her breathing during an assessment? – ANSWER Assess respiration after
measuring the pulse.
On the last assessment of a patient's respiration, her respiratory rate was 10
breaths per minute. What should the nurse do when conducting the next assessment
of this patient's respiratory rate? – ANSWER Count breaths for 60 seconds.