CLINICAL NURSING SKILLS AND TECHNIQUES, 10TH EDITION BY ANNE GRIFFIN PERRY ISBN- 978-0323708630 Chapter 5: Vital Signs Verified 2024 Practice Questions and 100% Correct Answers with Explanations for Exam Preparation, Graded A+

CLINICAL NURSING SKILLS AND TECHNIQUES, 10TH EDITION BY ANNE GRIFFIN PERRY ISBN- 978-0323708630 Chapter 5: Vital Signs Verified 2024 Practice Questions and 100% Correct Answers with Explanations for Exam Preparation, Graded A+ MULTIPLE CHOICE 1. The patient is brought to the emergency department complaining of severe shortness of breath. She is cyanotic and her extremities are cold. In an attempt to quickly assess the patient’s respiratory status, the nurse should: a. remove the patients nail polish to get a pulse oximetry reading. b. use a forehead probe to get a pulse oximetry reading. c. use a finger probe to get a pulse oximetry reading. d. check the color of the patients nail polish before attempting a reading. ANS: B Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacologic vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Assess for factors that influence measurement of SpO2 (e.g., oxygen therapy; respiratory therapy such as postural drainage and percussion; hemoglobin level; hypotension; temperature; nail polish [Cieck et al., 2010]; medications such as bronchodilators). DIF: Cognitive Level: Analysis REF: Text reference: p. 101 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Pulse Oximetry KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. A person’s core temperature is considered the most accurate since it is: a. reflective of the surrounding environment. b. the same for everyone. c. controlled by the hypothalamus. d. independent of external influences. ANS: C The core temperature, or the temperature of the deep body tissues, is under the control of the hypothalamus and remains within a narrow range. Skin or body surface temperature rises and falls as the temperature of the surrounding environment changes, and it fluctuates dramatically. Body tissues and cells function best within a relatively narrow temperature range, from 36 C to 38 C (96.8 F to 100.4 F), but no single temperature is normal for all people. For healthy young adults, the average oral temperature is 37 C (98.6 F). An acceptable temperature range for adults depends on age, gender, range of physical activity, hydration status, and state of health. DIF: Cognitive Level: Analysis REF: Text reference: p. 67 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Core Temperature KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity