BSN 205
The NAP reports to the nurse the pts RR is 32 and the pt is complaining of SOB. What
is the best action by the nurse at this time? - answerAssess the pt, including the pulse
oximetry reading.
Which pt is at high risk for the pulse oximetry alarm to sound? - answerA pt with a
continuous pulse oximetry reading of 84%
The nurse is ambulating the patient for the first time following the patient's lengthy time
of being on bed rest. Which of the following would be an appropriate action by the nurse
to determine the patient's activity tolerance? - answerAssess vital signs before and after
ambulating the patient.
You take a patient's vital signs on admission to the hospital. Why is it important to take
vital signs at this time? - answerTo obtain a baseline measurement for comparison with
subsequent vital sign measurements
You are preparing to take a patient's temperature. Which of the following factors may
affect the patient's oral temperature reading? - answerIf the patient has recently
consumed a hot or cold beverage,
If the patient has recently exercised,
Warmth of the room, If the patient has recently smoked
The NAP reports to you that a patient is "feeling different" and appears less alert. Your
first action should be to: - answerObtain the vital signs yourself.
Which of the following patients is exhibiting abnormal vital sign values for their age?
1. Newborn: Temperature 98.6º F, pulse 130, respiration 35, mean BP 65/41, pulse
oximetry 99%
2. Adolescent: Temperature 37º C, pulse 84, respiration 16, BP 110/65, pulse oximetry
100%
3. Adult: Temperature 96.7º F, pulse 55, respiration 24, BP 160/90, pulse oximetry 84%
4. Older adult: Temperature 96.8º F, pulse 98, respiration 12, BP 116/76, pulse oximetry
95% - answerAdult: Temperature 96.7º F, pulse 55, respiration 24, BP 160/90, pulse
oximetry 84%
,You check the patient's baseline temperature reading and note that it was recorded as
98.6° F (37 °C). What would you expect the temperature reading to be if it was obtained
using the rectal route? - answer99.5° F (37.5 °C)
You check the patient's temperature using the axillary route, and the thermometer reads
97.9° F (36.6 °C). Which of the following would be the most accurate documentation of
the reading? - answer97.9° F (36.6 °C) Ax
Easy to read thermometer and provides results in 4 to 15 seconds - answerElectric
thermometer
Good thermometer for patients in isolation - answerChemical thermometer
Disposable thermometer - answerchemical thermometer
Provides core temperature measurement in a patient with tachypnea - answertympanic
thermometer
Sensor thermometer cover not required - answertemporal artery thermometer
Often underestimates temperature - answerchemical thermometer
Risk of transferring nosocomial Clostridium infections rectally; also expensive
thermometer - answerElectronic thermometer
Otitis media and cerumen can lead to false readings with this thermometer -
answertympanic thermometer
Affected by skin moisture such as diaphoresis or sweating - answerTemporal artery
thermometer
what is likely to result in a higher temperature reading? - answerThe temperature of a
teenager who just ran a mile.
The temperature of a college student taking an exam
A temperature taken in the evening
Which of the following patients may require more frequent temperature measurement
and nursing assessment because they are at risk for an alteration in temperature?
(Select all that apply.)
1. A patient who is in the recovery room after having his gallbladder removed
2. A patient with pneumonia
3. A patient receiving a blood transfusion
4. A patient who is receiving physical therapy
5. A patient with cancer whose white blood cell (WBC) count is 2500 per mm³ - answerA
patient who is in the recovery room after having his gallbladder removed
A patient with pneumonia
, A patient receiving a blood transfusion
A patient with cancer whose white blood cell (WBC) count is 2500 per mm³
thermometers (and corresponding route) would be most accurate for monitoring rapid
changes in core body temperature? - answerOral electronic thermometer
Temporal artery thermometer
How far should a rectal thermometer be inserted in an adult? - answer1.5 in (3.8 cm)
How far should a rectal thermometer be inserted in a child? - answer0.5 in (1.3 cm)
In what direction should the nurse pull the pinna of the adult when taking a tympanic
temperature? - answerBackward, up, and out
At the end of the clinical day, the nursing instructor notices that a student nurse has
documented a resident having a temperature of 99.8° F (37.7° C) and that the student
administered a flu shot. What should the student nurse have done? - answerHeld the flu
vaccine; notify supervisor or instructor of increase in temperature.
A temperature reading obtained at noon will likely be ________ the 6 PM reading. -
answerlower than
Because older adults often maintain a ________ body temperature, a temperature
within an acceptable range in an adult may reflect a fever in an older adult. -
answerlower
A young adult has been admitted to the hospital with a fever of unknown origin.
Intravenous (IV) fluids have been started, and the patient is feeling much better. You
are going to take the patient's temperature. Which of the following would be the best
thermometer selection? - answerAn electronic thermometer with a blue probe end
The patient's temperature is 102.2 ºF (39 ºC). What action should you take? -
answerAdminister an antipyretic as ordered.
Before taking the patient's temperature, the patient tells you they just drank some ice
water. What is your best action? - answerRequest that the patient refrain from eating or
drinking until you return in 20 minutes to assess their oral temperature
The skill of radial pulse measurement can or can not be delegated to NAP. - answercan
If the patient is to receive a medication that requires an apical pulse before
administration, it should or should not be delegated to NAP. - answershould not
NAP should be instructed to report any abnormalities that should be ________ by the
nurse. - answerconfirmed
The NAP reports to the nurse the pts RR is 32 and the pt is complaining of SOB. What
is the best action by the nurse at this time? - answerAssess the pt, including the pulse
oximetry reading.
Which pt is at high risk for the pulse oximetry alarm to sound? - answerA pt with a
continuous pulse oximetry reading of 84%
The nurse is ambulating the patient for the first time following the patient's lengthy time
of being on bed rest. Which of the following would be an appropriate action by the nurse
to determine the patient's activity tolerance? - answerAssess vital signs before and after
ambulating the patient.
You take a patient's vital signs on admission to the hospital. Why is it important to take
vital signs at this time? - answerTo obtain a baseline measurement for comparison with
subsequent vital sign measurements
You are preparing to take a patient's temperature. Which of the following factors may
affect the patient's oral temperature reading? - answerIf the patient has recently
consumed a hot or cold beverage,
If the patient has recently exercised,
Warmth of the room, If the patient has recently smoked
The NAP reports to you that a patient is "feeling different" and appears less alert. Your
first action should be to: - answerObtain the vital signs yourself.
Which of the following patients is exhibiting abnormal vital sign values for their age?
1. Newborn: Temperature 98.6º F, pulse 130, respiration 35, mean BP 65/41, pulse
oximetry 99%
2. Adolescent: Temperature 37º C, pulse 84, respiration 16, BP 110/65, pulse oximetry
100%
3. Adult: Temperature 96.7º F, pulse 55, respiration 24, BP 160/90, pulse oximetry 84%
4. Older adult: Temperature 96.8º F, pulse 98, respiration 12, BP 116/76, pulse oximetry
95% - answerAdult: Temperature 96.7º F, pulse 55, respiration 24, BP 160/90, pulse
oximetry 84%
,You check the patient's baseline temperature reading and note that it was recorded as
98.6° F (37 °C). What would you expect the temperature reading to be if it was obtained
using the rectal route? - answer99.5° F (37.5 °C)
You check the patient's temperature using the axillary route, and the thermometer reads
97.9° F (36.6 °C). Which of the following would be the most accurate documentation of
the reading? - answer97.9° F (36.6 °C) Ax
Easy to read thermometer and provides results in 4 to 15 seconds - answerElectric
thermometer
Good thermometer for patients in isolation - answerChemical thermometer
Disposable thermometer - answerchemical thermometer
Provides core temperature measurement in a patient with tachypnea - answertympanic
thermometer
Sensor thermometer cover not required - answertemporal artery thermometer
Often underestimates temperature - answerchemical thermometer
Risk of transferring nosocomial Clostridium infections rectally; also expensive
thermometer - answerElectronic thermometer
Otitis media and cerumen can lead to false readings with this thermometer -
answertympanic thermometer
Affected by skin moisture such as diaphoresis or sweating - answerTemporal artery
thermometer
what is likely to result in a higher temperature reading? - answerThe temperature of a
teenager who just ran a mile.
The temperature of a college student taking an exam
A temperature taken in the evening
Which of the following patients may require more frequent temperature measurement
and nursing assessment because they are at risk for an alteration in temperature?
(Select all that apply.)
1. A patient who is in the recovery room after having his gallbladder removed
2. A patient with pneumonia
3. A patient receiving a blood transfusion
4. A patient who is receiving physical therapy
5. A patient with cancer whose white blood cell (WBC) count is 2500 per mm³ - answerA
patient who is in the recovery room after having his gallbladder removed
A patient with pneumonia
, A patient receiving a blood transfusion
A patient with cancer whose white blood cell (WBC) count is 2500 per mm³
thermometers (and corresponding route) would be most accurate for monitoring rapid
changes in core body temperature? - answerOral electronic thermometer
Temporal artery thermometer
How far should a rectal thermometer be inserted in an adult? - answer1.5 in (3.8 cm)
How far should a rectal thermometer be inserted in a child? - answer0.5 in (1.3 cm)
In what direction should the nurse pull the pinna of the adult when taking a tympanic
temperature? - answerBackward, up, and out
At the end of the clinical day, the nursing instructor notices that a student nurse has
documented a resident having a temperature of 99.8° F (37.7° C) and that the student
administered a flu shot. What should the student nurse have done? - answerHeld the flu
vaccine; notify supervisor or instructor of increase in temperature.
A temperature reading obtained at noon will likely be ________ the 6 PM reading. -
answerlower than
Because older adults often maintain a ________ body temperature, a temperature
within an acceptable range in an adult may reflect a fever in an older adult. -
answerlower
A young adult has been admitted to the hospital with a fever of unknown origin.
Intravenous (IV) fluids have been started, and the patient is feeling much better. You
are going to take the patient's temperature. Which of the following would be the best
thermometer selection? - answerAn electronic thermometer with a blue probe end
The patient's temperature is 102.2 ºF (39 ºC). What action should you take? -
answerAdminister an antipyretic as ordered.
Before taking the patient's temperature, the patient tells you they just drank some ice
water. What is your best action? - answerRequest that the patient refrain from eating or
drinking until you return in 20 minutes to assess their oral temperature
The skill of radial pulse measurement can or can not be delegated to NAP. - answercan
If the patient is to receive a medication that requires an apical pulse before
administration, it should or should not be delegated to NAP. - answershould not
NAP should be instructed to report any abnormalities that should be ________ by the
nurse. - answerconfirmed
