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1. The unlicensed assistive personnel reports a patient's D
vital signs to the nurse: temperature of 37.3° C (99.2°
F ) oral, pulse of 88 bpm and regular, respirations of 18
BPM and regular, blood pressure of 178/112 mm Hg,
and oxygen saturation of 96%. Based on these cues,
which vital sign should the nurse be most concerned
about?
a. Temperature
b. Pulse
c. Respirations
d. Blood pressure
2. From the nurse's understanding, which statements re- A,D,E
garding temperature and heat production in the body
are accurate? (Select all that apply.)
a. Heat generates energy for cellular functions.
b. Hormones, such as thyroid hormones, decrease
metabolism and heat production.
c. Exercise decreases heat production through muscu-
lar activity.
d. Expected temperature readings vary by the route
selected for measurement.
e. Women tend to have more fluctuations in tempera-
ture than do men.
3. the nurse is performing an initial assessment of a D
patient with a severe infection at hospital admission.
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Vital signs for the patient indicate hypotension and
tachycardia. Which data would support this evalua-
tion?
a. Pulse 78, blood pressure 140/88
b. Pulse 86, blood pressure 120/76
c. Pulse 100, blood pressure 118/68
d. Pulse 114, blood pressure 88/56
4. The nurse places a patient with a high fever on a C
cooling blanket. How is heat loss achieved with this
treatment?
a. Radiation
b. Convection
c. Conduction
d. Evaporation
5. Which clinical patient scenario is associated with the B
most critical need for the nurse to obtain vital signs?
a. Complaining of feeling "chilled" after a shower
b. Complaining of pressure in the chest
c. Completing ambulation of 100 feet after a stroke
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d. Complaining of hunger while NPO (nothing by
mouth)
6. The nurse understands that which statement is cor- B
rect regarding respiratory rates?
a. Infants have a lower respiratory rate than adults.
b. Healthy adults breathe between 12 and 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
increased respiratory rate.
7. The nurse is caring for a patient who has a blood pres- B
sure of 184/110. An hour after administering an anti-
hypertensive medication, the nurse returns to recheck
the blood pressure, only to find the patient in the chair
pale, sweaty, and feeling faint. Which is the expected
explanation for the nurse's observations?
a. The blood pressure is 184/110; the medication has
not had an effect.
b. The blood pressure is 118/76; the sudden drop has
caused the signs.
c. The blood pressure is 174/96; the medication has
made the patient sick.
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d. The blood pressure is 130/82; the symptoms are
from another cause.
8. It is 6 a.m. and the unlicensed assistive personnel re- C
ports to the nurse that the patient has a temperature
of 96.7° F (35.9° C) tympanic. Which factor explains
this reading?
a. The patient's room is cold.
b. The patient was drinking cold water.
c. The patient is exhibiting a normal circadian rhythm.
d. The patient just completed a warm shower
9. Objective data can be gathered from the patient dur- A,B,C,D,E
ing which aspects of the physical assessment process?
(Select all that apply.)
a. Patient interview
b. Health history
c. General survey
d. Physical examination
e. Laboratory testing
10. Which sequence best identifies the order in which the D
nurse should complete an abdominal assessment?
a. Inspection, palpation, percussion, auscultation
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