Module II Test with rationale

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                  TRINITY VALLEY COMMUNITY COLLEGE
                       ASSOCIATE DEGREE NURSING

                             ASSESSING VITAL SIGNS

1. The nurse is taking the 35-year old client’s 0800 temperature with a tympanic
   thermometer. Which intervention should the nurse implement?

       a.   Have the client close the mouth and hold the thermometer with the lips.
       b.   Ensure that the thermometer remains in contact with the axillary skin.
       c.   Pull the client’s auricle up and back prior to taking to the temperature.
       d.   Place the thermometer with numbers positioned to read from left to right.

CORRECT ANSWER C. Tympanic temperature is taken in the ear and since this is
an adult client the auricle must be pulled up and back which will straighten the ear
canal and help to direct the probe toward the tympanic membrane (errors in
measurement occur when it is directed toward the wall of the ear canal), a child’s
auricle should be pulled down and back; (A) the nurse would not put the thermometer
in the mouth; (B) this would be appropriate for the axillary (under the arm)
temperature; (D) reading numbers is done with a glass thermometer.

2. The nurse took the client’s oral temperature with an electronic thermometer. The
   client’s temperature is 99.6 F. Which intervention should the nurse implement?

       a.   Document the temperature on the graph sheet and take no action.
       b.   Report this abnormal temperature to the charge nurse.
       c.   Ask the client if they have had anything to eat in last hour.
       d.   Retake the client’s temperature axillary to verify the temperature.

CORRECT ANSWER B. A normal oral temperature is 98.6 F (37 C), rectal 99.6 F
(37.5 C), and axillary 97.6 F (36.5 C) therefore the nurse should report this elevated
temp to the charge nurse or health care provider; (A) this is not a normal temperature
so some action should be taken; (C) eating will not effect the temperature; (D) oral
temperature is an accurate route and does not need to verified by another route.

3. The nurse is taking a rectal temperature on the client. Which intervention should
   the nurse implement first?

       a.   Place the client in the left Fowler’s position.
       b.   Lubricate the bulb of the thermometer with Vaseline.
       c.   Gently insert the thermometer about 1 inch into the rectum.
       d.   Hold the thermometer in place for 2-4 minutes.

CORRECT ANSWER A: The nurse should first place the client in the correct
position which is the Left Sim’s position for easy access to anus; (B) lubricate with
water-soluble jelly; (C,D) the nurse should insert the thermometer about 1 inch and
should always hold the thermometer in place when putting it into the rectum to
prevent damage to the rectum for at least 2-4 minutes to get an accurate reading but
the first action of the nurse is to place the client in the correct position.
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4. The nurse is assessing the client’s radial pulse and notes that the pulse is
   skipping beats. Which intervention should the nurse implement?

       a. Count the number of beats for 30 seconds and multiply by two (2) and
          report pulse.
       b. Auscultate the pulse with the stethoscope over the client’s wrist and listen
          for the rhythm and strength of the pulse.
       c. Place the pads of middle finger on client’s wrist and count for one (1) full
          minute.
       d. Ensure the client is in a left-lying position or forward-leaning position
          prior to assessing the pulse.

CORRECT ANSWER C. Since the pulse is missing a beat it is irregular therefore
the nurse should count for one (1) full minute, the middle fingers should be used
because thumb and first finger has a pulse; (A) this would be done if the pulse was
regular; (B) the radial pulse is palpated not ausculatated; (D) this would be
appropriate when taking an apical pulse not a radial pulse.

5. The 55-year old client’s radial pulse is 110 beats per minute. Which intervention
   should the nurse implement first?

       a.   Assess the client to determine the reason why pulse is elevated.
       b.   Notify the charge nurse that the pulse is elevated.
       c.   Take no action since this pulse is within normal limits.
       d.   Attempt to calm the client and take pulse again in one hour.

CORRECT ANSWER A: The nurse should always assess (check) the client prior to
doing anything; if the client is upset then calm the client but nothing in the stem
makes you think the client is upset (D); the nurse could then go through the chain of
command which would be the charge nurse (B); normal pulse for the adult is 60-100
beats a minute.

6. The client is complaining of severe abdominal pain. The nurse needs to assess the
   client’s respirations. Which intervention should the nurse implement first?

       a. Wait for at least ten (10) minutes prior to assessing the client’s
          respirations.
       b. Place the nurse’s hand on the client’s lower thorax and palpate the chest
          movement.
       c. Count the respirations for 30 seconds and multiply the result by two (2).
       d. Hold the client’s wrist after finish assessing the radial pulse and assess the
          client’s respirations.

CORRECT ANSWER A. The stem asks which would the nurse implement first and
anxiety, discomfort, or exercise will increase the respiratory rate and result in a false
reading therefore the nurse should first wait prior to taking client’s respirations; (B,
C, D) are all correct interventions but the nurse should first wait until client is not so
upset.
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7. When assessing a client’s respiration, the nurse should make sure the client does
   not realize that the respirations are being assessed. Which scientific rationale is
   most appropriate for this intervention?

       a. The client may alter the respirations or concentrate on them which may
          alter the natural count.
       b. The nurse may not obtain the correct respiratory rate if the client is
          observing the nurse assessing the respirations.
       c. The client should be relaxed and quiet therefore the nurse should make
          sure the client doesn’t realize the respirations are being counted.
       d. The nurse must be able to hear the sounds in the stethoscope therefore the
          client must not realize the respirations are being assessed.

CORRECT ANSWER A: This is the correct scientific rationale for this intervention;
(B) the nurse should always obtain the correct respiratory rate even if the client is
observing the nurse; (C) the respiratory may need to be assessed even if the client is
not relaxed and quiet; (D) the respiratory rate is not assessed with the stethoscope.

8. The nurse is assessing the client’s blood pressure. Which intervention is most
   appropriate when taking the client’s blood pressure?

       a. Select a cuff width that is about one-half the length of the client’s upper
          arm.
       b. Wrap the cuff snugly around the client’s arm which allows space to place
          stethoscope over the radial artery.
       c. Wait at least 30 seconds to take the blood pressure when client is changing
          from a lying to a sitting position.
       d. Position the client’s arm so it is level with the heart, palm up, in a relaxed
          and comfortable position.

CORRECT ANSWER D. Positioning the arm below heart will result in false high
reading, arm above heart will result in a false low reading, palm up exposes the
brachial artery; (A) cuff should be about two-thirds the length; (B) stethoscope is over
brachial artery not radial artery; (C) the nurse should wait two (2) minutes to allow
the body’s compensatory mechanisms to stabilize the blood pressure.

9. The client’s blood pressure is 130/70 mm Hg in the left arm. Which intervention
   should the nurse implement?

       a.   Document the finding in the client’s chart and take no action.
       b.   Notify the charge nurse of the abnormal reading.
       c.   Reassess the client’s blood pressure in 15 minutes.
       d.   Take the blood pressure in the right arm to verify the results.

CORRECT ANSWER A. Normal systolic blood pressure is 100 to 140 mm Hg.,
normal diastolic blood pressure is 60 to 90 mm Hg therefore this is a normal blood
pressure; (B, C, D) no further intervention should be taken by the nurse since blood
pressure reading is within normal limits.
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    10. The nurse assesses vital signs on the following clients. Which vital sign should be
        reported to the health care provider?

            a.   The newborn that has a pulse rate of 80.
            b.   The preschooler that has an oral temperature of 98.2.
            c.   The adult that has a respiratory rate of 18.
            d.   The older adult that has a blood pressure of 140/88.

    CORRECT ANSWER A: The normal pulse rate for a newborn is 100-180 (mean
    125) therefore 80 is very low and should be reported to the health care provider; (B) a
    normal oral temperature for a preschooler is 98.6; (C) the normal respiratory rate for
    an adult is 12-20; (D) the normal blood pressure for an older adult is no higher than
    140/90.




J:ADN/1ststeps/1st Steps DVD/Module II Test with rationale                  Reviewed 04/10

				
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