NURS 311 Final Exam | Answered with complete solutions

NURS 311 Final Exam | Answered with complete solutions What will the nurse instruct nursing assistive personnel (NAP) to do when measuring a patient's rectal temperature using an electronic thermometer? Use the probe w ...

NURS 311 Final Exam | Answered with complete solutions What will the nurse instruct nursing assistive personnel (NAP) to do when measuring a patient's rectal temperature using an electronic thermometer? Use the probe with the red tip. What contraindicates taking a rectal temperature measurement? 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? 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? 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? 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? 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? Palpate the patient's inner wrist on the thumb side with the fingertips of your two middle fingers. What is the nurse's priority action if a patient's radial pulse has an irregular rhythm? Assess the patient for a pulse deficit. Inadequate oxygenation to the body will cause the radial pulse to become: Tachycardic Which action would best assess the effect of exercise on a patient's radial pulse measurement? 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? 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? Count breaths for 60 seconds. When measuring a patient's respiratory rate, the nurse will count the number of completed respiratory cycles per minute. What is the definition of a respiratory cycle? The number of inspirations and expirations per minute. During the assessment of a patient's respiratory rate, when the second hand reaches the 15-second mark, the respiratory count is 8. What should the nurse do at this time? Continue to count the patient's breaths for a full 60 seconds. The nurse plans to assess a patient's respiratory rate; however, the patient has just returned from ambulating to the bathroom. What should the nurse do to minimize the effect of exercise on the patient's respiratory rate? Encourage the patient to rest for 10 minutes before assessing respiration. The nurse is preparing to assess a patient's blood pressure. What would cause the blood pressure reading to be inaccurately high? Blood pressure cuff is too loose around the arm What would cause the nurse to delay the assessment of a patient's blood pressure? Patient has just finished having a cigarette The nurse has just measured a patient's blood pressure and is waiting 2 minutes to measure the pressure again. What is the purpose of taking two measurements? Minimize the effect of anxiety The nurse is teaching a patient about ways to reduce blood pressure. What will the nurse include in these instructions? Ensure that your diet has an adequate daily intake of calcium. Where should the nurse measure the blood pressure of a patient recovering from a left-sided mastectomy? Use the right arm to take the blood pressure. The nurse is planning to measure a patient's blood pressure. What does the systolic measurement represent? The pressure exerted against the arterial wall. You have assigned a new nursing assistive personnel (NAP) to take routine vital signs. You notice that the NAP's last three patients have had unusually low blood pressure that you have had to confirm. What is the most likely reason the NAP is obtaining falsely low blood pressure readings? The blood pressure cuff is too wide for arm circumference. What should the nurse do if the patient's blood pressure is not within normal limits? This is the correct response, because the patient must be assessed for possible cardiovascular problems. What would the nurse do to prevent the spread of infection when assessing a patient's blood pressure? Clean the stethoscope with alcohol before and after using it. You have assigned a new nursing assistive personnel (NAP) to take routine vital signs. An experienced NAP has been asked to retake a blood pressure that the newly hired NAP has taken three times this week. As the nurse, what action do you take? Observe the NAP as she obtains a blood pressure and pulse on a patient. Which of the following is a risk factor for decreased oxygen saturation level in a patient? Chest wall injury What should the nurse teach nursing assistive personnel (NAP) about selecting the appropriate site for measuring a patient's oxygen saturation level? "I've checked her capillary refill, and it's acceptable in both her hands and feet." The nurse measures a patient's oxygen saturation level as being 83%. What would the nurse do first? Ask the patient whether he or she is having trouble breathing. The nurse is preparing to measure the oxygen saturation level of a patient with obesity. Which action would help ensure an adequate measurement? Use a disposable tape-on sensor. A patient is prescribed continuous oxygen saturation monitoring. The nurse would confirm that the alarms have been set to which limits? Low of 85% and high of 100% A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of his colon. What is the most reliable sign that the patient has significant postoperative pain? The patient rates his pain a 7 on a scale of 0 to 10. What will the nurse instruct nursing assistive personnel (NAP) to do regarding the management of a patient's pain? "Let me know at least 30 minutes before you transport her so I can administer her pain medication. Which observation indicates that a patient's analgesic has been effective in managing pain that she rated a 6 out of 10 on a pain rating scale before the intervention? The patient rates her current pain as 3 out of 10 on the pain rating scale. A patient with a herniated disk is scheduled for surgery to fuse two vertebrae in her cervical spine. Which activity is most likely to be a palliative factor for this patient? Performing neck, back, and shoulder exercises prescribed by a physical therapist The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as diaphoresis, tachycardia, and hypertension. The patient does, however, seem moody and a bit uncooperative. What conclusion does the nurse draw? The absence of physiological signs and symptoms is associated with chronic pain. The nurse has selected a finger as the puncture site to measure the blood glucose level of a female patient with type 2 diabetes mellitus and peripheral vascular disease (PVD). Although all of the actions listed below are appropriate, which one would be of particular benefit to this patient given her medical history? Keeping the finger in a dependent position during the puncture The nurse would keep the finger in a dependent position to encourage blood flow to the intended puncture site. Blood flow to the extremities is compromised in patients with PVD. For which patient can the nurse delegate to nursing assistive personnel (NAP) the task of routine blood glucose monitoring? Patient with type 2 diabetes who has had a closed reduction of a fracture of the right wrist. This patient's condition would affect his or her ability to self-perform blood glucose testing but would not affect his or her blood glucose level. The skill of blood glucose testing may therefore be delegated to NAP. For which situation would the procedure of glucose testing be interrupted? An unused lancet is not available.The unavailability of an unused lancet would preclude proceeding with blood glucose testing. A used lancet can never be reused, because of the risk for infection. The nurse must locate an unused lancet for the procedure. 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? 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? 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? 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? Assess respiration, and then notify the health care provider immediately When a patient is using PCA, which statement is appropriate for the nurse to make to nursing assistive personnel (NAP)? "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? The patient rates current pain as 4 out of 10 What will the nurse do when discontinuing PCA? Ensure that the main intravenous line is intact When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to help maintain good skin integrity? Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift When caring for a patient who is receiving oxygen by simple face mask, which action ensures that the rate of oxygen being delivered is appropriate? Assessing for proper placement of the mask on the patient's face When caring for a patient for whom oxygen by nonrebreathing mask has been ordered, which action ensures appropriate oxygen delivery? Assessing that the reservoir bag stays inflated When caring for a patient who is receiving supplemental oxygen by face tent, which action ensures that the oxygen is flowing? Ensuring that a mist is always present What would the nurse do when receiving an order to increase the delivery rate of a patient's oxygen per nasal cannula from 1 L/min to 3 L/min? Adjust the float ball on the flow meter to 3 L/min. What would the nurse do first when preparing to begin oxygen therapy for a patient? Review the medical prescription for delivery method and flow rate. When preparing the patient's environment for safe oxygen therapy, which intervention is a priority to minimize the patient's risk for injury? Inspect all electrical equipment in the patient's room for the presence of safety-check tags. When a patient is receiving oxygen at home, which instruction to the family would help them understand how to use the oxygen safely? Place a "No Smoking" sign at the entrance to the house. What would the nurse do first when preparing to educate the patient about safe administration of oxygen therapy at home? Assess the patients emotional readiness and physical ability to provide autonomous care. Which statement by the patient would indicate that he or she understands the safe use of oxygen? "I'll alert the nurse immediately if I have any increased difficulty breathing." Why is it important for the nurse to set the correct flow rate for a patient to whom oxygen is prescribed? To provide the correct amount of oxygen to the patient What would be the nurse's priority in order to minimize a patient's risk for injury during oxygen therapy? Observing the six rights of medication administration What can the nurse do to evaluate a patient's response to continuous oxygen therapy delivered at 4 L/min by nasal cannula? Regularly measure and trend the patient's pulse oximetry (SpO2) values. What should the nurse do when a patient is ordered to receive 4 L/min oxygen by nasal cannula? Ensure that humidification is present. What would the nurse monitor frequently to ensure that the prescribed amount of oxygen is being delivered to a patient? Oxygen flow meter setting A patient is told the home care nurse will be measuring and recording intake and output (I&O) at home. What will the home care nurse do first? Explain to the patient why I&O has been ordered. What output will the nurse direct nursing assistive personnel (NAP) to measure for a hospitalized patient for whom I&O measurement is prescribed? Urine collection drainage. The nurse may safely delegate the measurement of urine collection drainage to NAP. The nurse is responsible for monitoring nasogastric tube drainage, chest tube drainage, and ileostomy bag drainage. Which statement reflects the nurse's understanding of the importance of accurate urinary output measurement for a patient with acute renal failure? "I will use a collection system with an hourly measurement device added."