NSG 1400 Unit 2 Exam Questions and Answers| New Update with 100% Correct Answers
A patient with hypothermia is brought to the emergency department. The nurse should explain
which most likely treatment to the family members?
A. Core rewarming with warm fluids
B. Ambulation to increase metabolism
C. Frequent oral temperature assessment
D. Gastric tube feedings to increase fluids A. Core rewarming with warm fluids
Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is
the preferred method of treatment. The patient would be too weak to ambulate. Oral
temperatures are not the most accurate assessment of core temperature because of
environmental influences. Warmed oral feedings are advised; gastric gavage is unnecessary.
What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia?
A. Dyspnea
B. Precordial pain
C. Increased pulse rate
D. Elevated blood pressure C. Increased pulse rate
The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever
may increase but does not cause difficulty in breathing. Pain is not related to fever. Blood
pressure is not necessarily elevated in fever.
The nurse identifies which priority nursing invention for a patient with hyperthermia?
A. Initiating seizure precautions
B. Limiting oral intake
,C. Providing a blanket
D. Removing excess clothing D. Removing excess clothing
The priority nursing intervention would be removal of excess clothing. Seizures may occur
because of a high body temperature, so decreasing heat absorption through clothing is the
highest priority. Oral intake, especially of fluids, should not be limited for a patient with
hyperthermia, because of the dangers of dehydration. Blanketing, like clothing, should be
removed.
The nurse admitting a patient to the emergency room on a cold winter night would suspect
hypothermia when the patient demonstrates
A. increased respirations.
B. rapid pulse rate.
C. red, sweaty skin.
D. slow capillary refill. D. slow capillary refill.
With hypothermia, there is slow capillary refill. There is an increased respiration rate with
hyperthermia. The heart rate increases with hyperthermia. The skin is usually pale or cyanotic
with hypothermia.
A homeless person is brought to the emergency department after prolonged exposure to cold
weather. The nurse would assess the patient for what manifestations of hypothermia?
A. Stupor
B. Erythema
C. Increased anxiety
D. Rapid Respirations A. Stupor
, Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor,
not erythema, would be present as a result of peripheral vasoconstriction. Drowsiness occurs;
the patient would be unable to focus on anxiety-producing aspects of the situation.
Respirations would be decreased.
A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for
removal of a tumor in the hypothalamic region of the brain. The nurse manager should
intervene immediately when observing the child's nurse perform which action?
A. Places a hypothermia blanket at the bedside
B. Adjusts the bed to the Trendelenburg position
C. Obtains electronic equipment for monitoring the vital signs
D. Secures a pump to administer the ordered intravenous fluids B. Adjusts the bed to the
Trendelenburg position
It is not safe to put the bed in the Trendelenburg position, because raising the foot increases
blood flow to the brain, thereby increasing intracranial pressure. Temperature elevations may
occur after a craniotomy because of stimulation of the hypothalamus. A hypothermic blanket
should be ready if the temperature becomes precipitously elevated. Monitoring vital signs is a
critical component of postoperative care. Intravenous infusions must be regulated precisely to
minimize the possibility of cerebral edema.
A patient with breast cancer asks the nurse why 6 weeks of daily radiation treatments is
necessary. What is the nurse's best response?
A. "Your cancer is widespread and requires more than the usual amount of radiation
treatment."
B. "The cost of larger doses of radiation for a shorter period of time is justified by the results."
C. "Research has shown more cancer cells are killed if the radiation is given in smaller doses
over a longer period of time."
A patient with hypothermia is brought to the emergency department. The nurse should explain
which most likely treatment to the family members?
A. Core rewarming with warm fluids
B. Ambulation to increase metabolism
C. Frequent oral temperature assessment
D. Gastric tube feedings to increase fluids A. Core rewarming with warm fluids
Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is
the preferred method of treatment. The patient would be too weak to ambulate. Oral
temperatures are not the most accurate assessment of core temperature because of
environmental influences. Warmed oral feedings are advised; gastric gavage is unnecessary.
What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia?
A. Dyspnea
B. Precordial pain
C. Increased pulse rate
D. Elevated blood pressure C. Increased pulse rate
The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever
may increase but does not cause difficulty in breathing. Pain is not related to fever. Blood
pressure is not necessarily elevated in fever.
The nurse identifies which priority nursing invention for a patient with hyperthermia?
A. Initiating seizure precautions
B. Limiting oral intake
,C. Providing a blanket
D. Removing excess clothing D. Removing excess clothing
The priority nursing intervention would be removal of excess clothing. Seizures may occur
because of a high body temperature, so decreasing heat absorption through clothing is the
highest priority. Oral intake, especially of fluids, should not be limited for a patient with
hyperthermia, because of the dangers of dehydration. Blanketing, like clothing, should be
removed.
The nurse admitting a patient to the emergency room on a cold winter night would suspect
hypothermia when the patient demonstrates
A. increased respirations.
B. rapid pulse rate.
C. red, sweaty skin.
D. slow capillary refill. D. slow capillary refill.
With hypothermia, there is slow capillary refill. There is an increased respiration rate with
hyperthermia. The heart rate increases with hyperthermia. The skin is usually pale or cyanotic
with hypothermia.
A homeless person is brought to the emergency department after prolonged exposure to cold
weather. The nurse would assess the patient for what manifestations of hypothermia?
A. Stupor
B. Erythema
C. Increased anxiety
D. Rapid Respirations A. Stupor
, Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor,
not erythema, would be present as a result of peripheral vasoconstriction. Drowsiness occurs;
the patient would be unable to focus on anxiety-producing aspects of the situation.
Respirations would be decreased.
A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for
removal of a tumor in the hypothalamic region of the brain. The nurse manager should
intervene immediately when observing the child's nurse perform which action?
A. Places a hypothermia blanket at the bedside
B. Adjusts the bed to the Trendelenburg position
C. Obtains electronic equipment for monitoring the vital signs
D. Secures a pump to administer the ordered intravenous fluids B. Adjusts the bed to the
Trendelenburg position
It is not safe to put the bed in the Trendelenburg position, because raising the foot increases
blood flow to the brain, thereby increasing intracranial pressure. Temperature elevations may
occur after a craniotomy because of stimulation of the hypothalamus. A hypothermic blanket
should be ready if the temperature becomes precipitously elevated. Monitoring vital signs is a
critical component of postoperative care. Intravenous infusions must be regulated precisely to
minimize the possibility of cerebral edema.
A patient with breast cancer asks the nurse why 6 weeks of daily radiation treatments is
necessary. What is the nurse's best response?
A. "Your cancer is widespread and requires more than the usual amount of radiation
treatment."
B. "The cost of larger doses of radiation for a shorter period of time is justified by the results."
C. "Research has shown more cancer cells are killed if the radiation is given in smaller doses
over a longer period of time."
