Chapter 29 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 29

Question 1

Type: MCSA

An older client has an oral temperature reading of 97.2 degrees F. The nurse realizes that this clients low temperature could be due to:

1. Anxiety level of the client has increased.

2. Hormones have fluctuated in this client.

3. Muscle activity has increased during the clients therapy session.

4. Loss of subcutaneous fat is noted.

Correct Answer: 4

Rationale 1: If a client is anxious or stressed, this response stimulates the sympathetic nervous system. This in turn increases the production of epinephrine and norepinephrine, which increases metabolic and heat production, causing the temperature to rise.

Rationale 2: Women experience more hormonal fluctuations than men, and this is usually true with the secretion of progesterone at the time of ovulation. Since this client is older, hormone fluctuations and ovulation will not impact the temperature.

Rationale 3: Exercise, which represents hard work or strenuous activity, increases body temperature. That is not the case with this client. No reference has been made to a therapy session, and the temperature is decreased.

Rationale 4: This client is older and research shows that older people are at risk for hypothermia. When one ages, subcutaneous fat is lost.

Global Rationale: Page Reference: 538, 545

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 01 Describe factors that affect the vital signs and accurate measurement of them.
02 Identify the variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to old age.

Question 2

Type: MCSA

What is the first thing that the nurse should do to ensure an accurate temperature reading for a client?

1. Assess that the equipment used is working properly.

2. Place the client in a position that is most comfortable for the health care provider.

3. Take the temperature with a chemical disposable thermometer when the client is perspiring.

4. Wait at least 10 minutes before taking the temperature after a client has been smoking.

Correct Answer: 1

Rationale 1: If the equipment is not working properly, no accuracy will be obtained in the readings.

Rationale 2: The type of equipment or method that is chosen will dictate client position, not the position of the health care provider.

Rationale 3: If the equipment is not working properly, no accuracy will be obtained in the readings. The type of equipment or method that is chosen will dictate client position, not the position of the health care provider. In order to use a chemical disposable thermometer, the clients skin must be dry for the thermometer to adhere to the skin.

Rationale 4: The recommended time to wait to assess an oral temperature is 30 minutes after one smokes, not 10 minutes.

Global Rationale: Page Reference: 542

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Verbalize the steps used in:
a. Assessing body temperature.

Question 3

Type: MCSA

Which of the following sites would be the most appropriate choice to use to measure a clients temperature who has a history of heart disease and has eaten a bowl of vegetable soup 45 minutes ago?

1. Axilla

2. Oral

3. Popliteal

4. Rectal

Correct Answer: 2

Rationale 1: Axilla is the preferred site for newborns, not adults.

Rationale 2: Body temperature is frequently measured orally even if the client has eaten or drank something cold or hot. One only needs to wait 30 minutes, and then this site can be used.

Rationale 3: The popliteal site would not be used given the history of heart disease. There could be circulatory issues that might affect accurate reading since this site is much farther away from the heart.

Rationale 4: Rectal would be contraindicated in this client given the history of heart disease. With the diagnosis of heart disease, the nurse would need to assess for the presence of hemorrhoids.

Global Rationale: Page Reference: 539

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify nine sites used to assess the pulse and state the reasons for their use.

Question 4

Type: MCSA

While waiting for the physician to respond regarding a clients elevated temperature, what can the nurse do to assist the client?

1. Bathe the client with ice water.

2. Give the client an antipyretic.

3. Increase fluid intake.

4. Lower room temperature.

Correct Answer: 3

Rationale 1: Bathing the client in ice water would lower the clients temperature too fast, possibly causing hypothermia.

Rationale 2: Giving a client an antipyretic requires a doctors order.

Rationale 3: Elevated body temperature contributes to dehydration, which leads to body tissues drying out and malfunctioning. Rehydrating the clients tissues will allow the temperature to return to normal.

Rationale 4: Dropping the temperature of the room would lower the clients temperature too fast, possibly causing hypothermia.

Global Rationale: Page Reference: 538

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Describe appropriate nursing care for alterations in vital signs.

Question 5

Type: MCSA

While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds capillary refilling time. How would the nurse explain these findings?

1. A change in the clients health status has occurred.

2. The client has thrown a blood clot in that extremity.

3. The RNs watch has stopped working.

4. Too much pressure was applied over the pulse site.

Correct Answer: 4

Rationale 1: The information provided gives no indication that any health change has occurred.

Rationale 2: The assessment data given (warm, pink, etc.) are not symptoms of a blood clot.

Rationale 3: There is no data given in regard to equipment malfunction like a watch.

Rationale 4: Too firm of pressure on a pulse site will obliterate that pulse since assessing the dorsalis pedis pulse requires one to apply some pressure over the dorsalis pedis artery, making contact with the cones in the foot.

Global Rationale: Page Reference: 548

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Verbalize the steps used in:
b. Assessing a peripheral pulse.

Question 6

Type: MCSA

The RN assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which of the following nursing interventions would be most appropriate for the nurse to use?

1. Ask another nurse to assess the pulses.

2. Document the findings.

3. Obtain a Doppler ultrasound stethoscope.

4. Wait and just try again later.

Correct Answer: 3

Rationale 1: If one nurse is having difficulty with the pulse and accuracy, getting another nurse is not going to be the best choice.

Rationale 2: Just documenting the findings does not address the problem of getting an accurate pulse reading.

Rationale 3: Obtaining a Doppler ultrasound stethoscope is the appropriate action to take. The Doppler will ensure accuracy by helping to exclude environmental sounds.

Rationale 4: Waiting until later may be harmful to the client, creating an unsafe environment.

Global Rationale: Page Reference: 551

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Verbalize the steps used in:
b. Assessing a peripheral pulse.

Question 7

Type: MCSA

When assessing a clients peripheral pulse, the health care provider is also assessing which of the following?

1. Depth

2. Rhythm

3. Sound

4. Stress

Correct Answer: 2

Rationale 1: Depth is a term used when assessing edema.

Rationale 2: When assessing peripheral pulses, one of the characteristics being assessed is rhythm along with rate, volume, and equality.

Rationale 3: Heart sounds are assessed with the apical pulse.

Rationale 4: Stress will affect the rate of both pulse and respiration, but it is not a characteristic of pulse assessment.

Global Rationale: Page Reference: 548

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06 List the characteristics that should be included when assessing pulses.

Question 8

Type: MCSA

The nurse is going to assess the apical-radial pulse off a client with a cardiovascular disorder. Which rationale did the RN use to make this decision?

1. A forceful radial pulse is much too difficult to count correctly.

2. Both arteriole and venous sounds were heard simultaneously.

3. The pulse was bounding and easily obliterated.

4. The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site.

Correct Answer: 4

Rationale 1: A forceful radial pulse would be ideal for assessing a clients peripheral pulse.

Rationale 2: Arteriole and venous sounds would be detected when using the Doppler, but there is no indication for Doppler use given this situation.

Rationale 3: A bounding pulse is not easily obliterated.

Rationale 4: Knowing there is a history of a cardiovascular disorder would alert the RN to the importance of the utmost accuracy for the clients pulse assessment. The apical-radial pulse is used to assess this type of client due to the feebleness of the wave of blood flow felt at the peripheral sites.

Global Rationale: Page Reference: 553, 554

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify nine sites used to assess the pulse and state the reasons for their use.

Question 9

Type: MCSA

A client in a motor vehicle crash has arrived at the trauma unit in respiratory distress and unconscious. Which factor would cause a change in this clients respiratory rate?

1. Exercise

2. Increased intracranial pressure

3. Increased environmental temperature

4. Stress

Correct Answer: 2

Rationale 1: Exercise increases respiration rates.

Rationale 2: Factors that decrease respirations include increased intracranial pressure.

Rationale 3: Increased environmental temperature increase respiration rates.

Rationale 4: Stress increases respiration rates.

Global Rationale: Page Reference: 557

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 01 Describe factors that affect the vital signs and accurate measurement of them.
07 Describe the mechanics of breathing and the mechanisms that control respirations.

Question 10

Type: MCSA

Which of the following positions does the RN assist the client in to best assess respiratory status?

1. Prone

2. Semi-Fowlers

3. Side-lying

4. Supine

Correct Answer: 2

Rationale 1: The prone position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the clients respirations.

Rationale 2: Persons in a semi-Fowlers position will better aid themselves and the nurse to assess their respiratory status.

Rationale 3: The side-lying position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the clients respirations.

Rationale 4: The supine position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the clients respirations.

Global Rationale: Page Reference: 559

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Verbalize the steps used in:
d. Assessing respirations.

Question 11

Type: MCSA

A client is being treated for congestive heart failure. Which of the following physical findings would lead the RN to believe the clients condition has not improved?

1. Temperature of 98.6F (37C)

2. Moderate amount of clear thin mucus

3. Pulse oximetry reading of 96%

4. Wheezing of breath sounds in all lobes

Correct Answer: 4

Rationale 1: A temperature reading of 98.6F is a normal finding and not an indication of heart failure.

Rationale 2: Moderate amount of clear mucus is a normal finding and not an indication of heart failure.

Rationale 3: A pulse oximetry reading of 96% is a normal findings and not an indication of heart failure.

Rationale 4: Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic in congestive heart failure.

Global Rationale: Page Reference: 558

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Describe the mechanics of breathing and the mechanisms that control respirations.

Question 12

Type: MCSA

Which determinant of blood pressure would explain a clients blood pressure reading of 120/100?

1. Blood viscosity

2. Blood volume

3. Pumping action of the heart

4. Peripheral vascular resistance

Correct Answer: 4

Rationale 1: Determinants of blood pressure such as blood viscosity mainly affect the systolic reading portion of the blood pressure.

Rationale 2: Determinants of blood pressure such as blood volume mainly affect the systolic reading portion of the blood pressure.

Rationale 3: Determinants of blood pressure such as pumping action of the heart mainly affect the systolic reading portion of the blood pressure.

Rationale 4: Peripheral vascular resistance especially affects diastolic blood pressure readings. A reading of 120/100 would be indicative of peripheral vascular resistance.

Global Rationale: Page Reference: 560

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 02 Identify the variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to old age.

Question 13

Type: MCSA

What will the nurse hear during phase 2 of Korotkoffs sounds?

1. A muffled, whooshing, or swishing sound

2. Disappearance of sound

3. Faint, clear tapping sound

4. Increased intensity of sound

Correct Answer: 1

Rationale 1: Phase 2 produces a muffled, whooshing, or swishing sound.

Rationale 2: Phase 5, the final phase, is where the sound disappears.

Rationale 3: Phase 1 of Korotkoffs sounds starts with a faint, clear tapping sound.

Rationale 4: Phase 3 is marked by an increased intensity of sound.

Global Rationale: Page Reference: 563

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Verbalize the steps used in:
e. Assessing blood pressure.

Question 14

Type: MCSA

When assessing a clients blood pressure, the nurse will use which artery?

1. Brachial

2. Femoral

3. Radial

4. Ulnar

Correct Answer: 1

Rationale 1: The brachial is the most common artery used to assess a blood pressure reading because it is the most accessible.

Rationale 2: The femoral is not as accessible as the brachial.

Rationale 3: The radial could be used but it is not as accurate as the brachial artery.

Rationale 4: The ulnar could be used but it is not as accurate as the brachial artery.

Global Rationale: Page Reference: 563

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Verbalize the steps used in:
e. Assessing blood pressure.

Question 15

Type: MCSA

In the palpatory method of blood pressure determination, instead of listening for the blood flow sounds, light to moderate pressure is used over the artery as the pressure in the cuff is released. When will the nurse read the pressure from the sphygmomanometer?

1. When the cuff is applied

2. When the cuff is being deflated

3. When the first pulsation is felt

4. When the second pulsation is felt

Correct Answer: 3

Rationale 1: Assessing the pulse before the cuff is inflated is not the pressure.

Rationale 2: This is not the clients blood pressure if the cuff is just being deflated.

Rationale 3: The first pulsation that is felt after the cuff is slowly deflated is the blood pressure reading that is recorded if the palpatory method is used to assess a clients blood pressure.

Rationale 4: If the second pulsation is recorded, that would be an inaccurate reading.

Global Rationale: Page Reference: 566

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Verbalize the steps used in:
e. Assessing blood pressure.

Question 16

Type: MCSA

Which condition would lead the RN to choose the dorsalis pedis pulse as the site for further assessing the clients status?

1. Altered level of consciousness

2. Decreased urine output

3. Irregular radial pulse

4. Toes cool to touch

Correct Answer: 4

Rationale 1: To assess an altered level of consciousness, the nurse would most likely assess the clients apical pulse.

Rationale 2: To assess for decreased urine output, the nurse would most likely assess the apical pulse.

Rationale 3: For an irregular radial pulse, the nurse would most likely assess the apical pulse.

Rationale 4: The dorsalis pedis pulse site is in the foot, so this is the ideal site to assess the pulse for toes that are cool to touch.

Global Rationale: Page Reference: 547

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify nine sites used to assess the pulse and state the reasons for their use.

Question 17

Type: MCSA

When assessing a clients oxygen saturation reading, the nurse realizes that what will affect this reading?

1. Activity

2. Environmental conditions

3. Nutrition

4. Skin color

Correct Answer: 1

Rationale 1: Factors affecting oxygen saturation readings are hemoglobin, circulation, and activity. If there is shivering or excessive movement of the sensor site, this will interfere with an accurate reading.

Rationale 2: Environmental conditions do not affect an accurate oxygen saturation reading.

Rationale 3: Nutrition does not affect an oxygen saturation reading.

Rationale 4: Skin color does not affect an oxygen saturation reading.

Global Rationale: Page Reference: 568

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Verbalize the steps used in:
f. Assessing blood oxygenation using pulse oximetry.

Question 18

Type: MCSA

As the RN is suctioning a client, the pulse oximetry reading drops to 83%. What would be the next action taken by the RN?

1. Allow the client to take some extra deep breaths.

2. Continue to suction but only intermittently.

3. Keep the catheter in place and wait a few minutes.

4. Stop suctioning and give supplemental oxygen.

Correct Answer: 4

Rationale 1: Allowing the client to take a few deep breaths will help but not quickly enough to compensate for the hypoxia experienced.

Rationale 2: Continuing to suction continuously or intermittently will only decrease the saturation levels more.

Rationale 3: Leaving the catheter in place obstructs air flow, thus compromising an already poor situation.

Rationale 4: Not only does suctioning remove secretions, but it also removes the clients air. By stopping suctioning, the RN stops removing both. This allows the client to recoup from the procedure, and giving oxygen will also increase the saturation ability back to a normal range.

Global Rationale: Page Reference: 657-568

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Verbalize the steps used in:
f. Assessing blood oxygenation using pulse oximetry.
07 Describe the mechanics of breathing and the mechanisms that control respirations.

Question 19

Type: MCSA

The RN needs vital signs assessed for four clients. Which client should the nurse address and not assign to the UAP?

1. Cardiac catheterization client returning to the nursing unit

2. COPD client on 2 Lpm oxygen via nasal cannula

3. Pneumonia client nearing discharge

4. Post-op client of 2 days from gallbladder surgery

Correct Answer: 1

Rationale 1: The cardiac catheterization client will need a thorough assessment since she is just returning to the nursing unit. Invasive procedures, such as a catheterization, will need to be closely assessed. More than likely a Doppler will be needed to ensure the pedal pulse is present and stable in the extremity used during the procedure. Unlicensed personnel are not usually delegated Doppler ultrasound device use.

Rationale 2: The COPD client is a chronic condition client, and her vital signs would be considered routine.

Rationale 3: The client with pneumonia nearing discharge would be considered medically stable. Therefore, this client is within the UAPs capability.

Rationale 4: The client who is 2 days post-op from gallbladder surgery would be considered medically stable. Therefore, this client is within the UAPs capability.

Global Rationale: Page Reference: 549

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 08 Recognize when it is appropriate to delegate measurement of vital signs to unlicensed assistive personnel.

Question 20

Type: MCMA

Prior to assessing a clients blood pressure, the nurse reviews factors that could affect the reading. Which factors could impact blood pressure?

Standard Text: Select all that apply.

1. Stress.

2. Race.

3. Obesity.

4. Medications.

5. Employment.

Correct Answer: 1,2,3,4

Rationale 1: Stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of the arterioles, increasing the blood pressure reading.

Rationale 2: African-Americans over 35 years of age tend to have higher blood pressures than do European Americans of the same age.

Rationale 3: Both childhood and adult obesity predispose to hypertension.

Rationale 4: Many medications, including caffeine, can increase or decrease the blood pressure.

Rationale 5: Employment is not a factor that affects blood pressure.

Global Rationale: Page Reference: 561

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 01 Describe factors that affect the vital signs and accurate measurement of them.
03 Verbalize the steps used in:
e. Assessing blood pressure.

Question 21

Type: MCMA

When assessing the pulse of a client, the nurse will include which characteristics?

Standard Text: Select all that apply.

1. Rate.

2. Rhythm.

3. Volume.

4. Tone.

5. Viscosity.

Correct Answer: 1,2,3

Rationale 1: When assessing the pulse, the nurse collects data about the rate.

Rationale 2: When assessing the pulse, the nurse collects data about the rhythm.

Rationale 3: When assessing the pulse, the nurse collects data about the volume.

Rationale 4: Tone is not a characteristic of a pulse.

Rationale 5: Viscosity is not a characteristic of a pulse.

Global Rationale: Page Reference: 548

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06 List the characteristics that should be included when assessing pulses.

Question 22

Type: MCMA

When assessing a clients respirations, the nurse realizes that the respiratory centers and chemoreceptors respond to changes in:

Standard Text: Select all that apply.

1. Oxygen concentration.

2. Carbon dioxide concentration.

3. Hydrogen ions.

4. Potassium level.

5. Serum calcium level.

Correct Answer: 1,2,3

Rationale 1: The respiratory centers and chemoreceptors respond to changes in the concentration of oxygen.

Rationale 2: The respiratory centers and chemoreceptors respond to changes in the concentration of carbon dioxide.

Rationale 3: The respiratory centers and chemoreceptors respond to changes in the concentration of hydrogen ions.

Rationale 4: The respiratory centers and chemoreceptors do not respond to changes in the potassium level.

Rationale 5: The respiratory centers and chemoreceptors do not respond to changes in the serum calcium level.

Global Rationale: Page Reference: 556

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Describe the mechanics of breathing and the mechanisms that control respirations.

Question 23

Type: MCMA

Even though a UAP is available to assist with vital sign assessment, the nurse is going to conduct these assessments himself on which clients?

Standard Text: Select all that apply.

1. Client complains of chest pain.

2. Client returning from surgery.

3. Prior to administering a medication that affects blood pressure.

4. Client complains of dizziness after ambulating.

5. Client being admitted to the care area.

Correct Answer: 1,2,3,4

Rationale 1: When a client reports symptoms such as chest pain, the nurse should conduct the assessment.

Rationale 2: When a client returns from surgery, the nurse should conduct the assessment.

Rationale 3: When the client is prescribed a medication that could affect the vital signs, the nurse should conduct the assessment.

Rationale 4: When the client reports symptoms such as dizziness after ambulation, the nurse should conduct the assessment.

Rationale 5: When the client is being admitted to a care area, the nurse could delegate the vital sign assessment to the UAP.

Global Rationale: Page Reference: 542, 549, 554, 559, 565, 569

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 08 Recognize when it is appropriate to delegate measurement of vital signs to unlicensed assistive personnel.

Question 24

Type: MCSA

When documenting a clients axillary temperature on the graphic sheet, how should the nurse identify the method of assessing the temperature?

1. AX.

2. O.

3. R.

4. SL.

Correct Answer: 1

Rationale 1: When documenting the temperature in the client record, an axillary temperature should be recorded with an AX.

Rationale 2: The letter O is not used when documenting a clients temperature.

Rationale 3: The letter R would indicate a rectal temperature and not an axillary temperature.

Rationale 4: The letters SL are not used when documenting a clients temperature.

Global Rationale: Page Reference: 543

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 09 Demonstrate appropriate documentation and reporting of vital signs.

Question 25

Type: MCSA

The nurse assesses phase 1 Korotkoffs sound occurring at 136 and phase 5 Korotkoffs sound occurring at 72. How should the nurse document this clients blood pressure reading?

1. 136/72.

2. 72/136.

3. 136 72.

4. 72 136.

Correct Answer: 1

Rationale 1: The first tapping phase 1 Korotkoffs sound is the systolic blood pressure. The last sound heard during phase 5 Korotkoffs sound is the diastolic blood pressure. The nurse would document the blood pressure as being 136/72.

Rationale 2: The diastolic blood pressure is not documented before the systolic blood pressure.

Rationale 3: The systolic blood pressure and diastolic blood pressure are not separated by a minus sign.

Rationale 4: This places the diastolic reading first and uses the minus sign, which is incorrect to use.

Global Rationale: Page Reference: 566

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 09 Demonstrate appropriate documentation and reporting of vital signs.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

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