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NURS 200 Foundations of Nursing I Module 2 Quiz Vital Signs – Group Assignment. Reviewed and Rationale

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NURS 200 Foundations of Nursing I Module 2 Quiz Vital Signs – Group Assignment Instructions: Answer the following questions as a group and provide a reference from your textbook for your ra... tionale (including the page number) and submit your assignment on Canvas. Rationales should be included for all correct and incorrect answers. Why did you choose the option that you chose? Outcome 1: Define the key terms and normal ranges related to vital sign assessment. 1. Body temperature may be measured in all of the following ways except which of the following? a. Axillary b. Rectal c. Temporal d. Radial 2. A sleeping patient has the following vital signs: respiratory rate of 10, temperature 98.5, blood pressure 135/75, heart rate 78, and oxygenation 98%. Which of the following actions should the nurse take? a. Continue to monitor the patient b. Call the physician to report the vital signs c. Arouse the patient from sleep d. Call the charge nurse for assistance 3. Factors that can affect the body temperature include which of the following? (select all that apply) a. Environment b. Race c. Circadian rhythms d. Exercise e. Hormones 4. Which determinant of blood pressure would best explain a patient's blood pressure reading of 120/100? a. Blood viscosity b. Blood volume c. Pumping action of the heart d. Peripheral vascular resistance Outcome 2: Discuss the importance of noticing trends in vital signs. 5. A patient’s admission vital signs are: temperature 99.1 degrees F, pulse 75, respirations 16 and unlabored, and blood pressure 185/110. Which of the following vital signs is the most concerning to the nurse? a. Pulse b. Respirations c. Blood pressure d. Temperature 6. Before discharge from the hospital a patient is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the patient to monitor to determine whether to increase or decrease the exercise level? a. Blood pressure b. Pulse rate c. Body temperature d. Respiratory rate 7. While assessing the dorsalis pedis pulse of a patient, the nurse determines that the pulse is not palpable. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds of capillary refilling time. Which of the following is likely cause of these findings? a. A change in the patient's health status has occurred. b. The patient has thrown a blood clot in that extremity. c. The nurse's watch has stopped working. d. Too much pressure was applied over the pulse site Outcome 3: Recognize lifespan considerations when obtaining vital signs. 8. An older patient has an oral temperature reading of 97.2 degrees F. The nurse realizes that this patient’s low temperature could be due to which observation? a. The anxiety level of the patient has increased. b. Hormones have fluctuated in this patient. c. Muscle activity has increased during the patient's therapy session. d. Loss of subcutaneous fat is noted. Outcome 4: Identify variables influencing pulse rate, blood pressure, and body temperature. 9. The nurse notices the pulse oximetry of the client is 85% oxygen saturation. What is the first action the nurse should take? a. Notify the physician b. Call the respiratory therapist c. Ensure that the pulse oximeter is working correctly d. Assess the pulse at the oximeter site for one minute 10. When preparing a patient for discharge the nurse notes that the patient has a temperature of 101.8. Which phrase is most appropriate for the nurse to use when speaking with the healthcare provider? a. “This patient should not be discharged because he has a temperature of 101.8.” b. “I am concerned about the patient’s readiness for discharge because his most recent temperature was 101.8.” c. “I called the nursing home and cancelled this patient’s discharge because he has a temperature of 101.8.” d. “This patient has a temperature of 101.8. Don’t you think we should cancel his discharge?” Outcome 5: Recognize the role of delegation as it pertains to obtaining vital signs. 11. The nurse needs vital signs assessed for four patients. Which patient should the nurse assess and not assign to the UAP? a. Patient returning to the nursing unit after cardiac catherization b. Patient on 2 liters of oxygen via nasal cannula c. Pneumonia patient nearing discharge d. Post-operative patient of 2 days from gallbladder surgery Outcome 6: Describe hygienic care that nurses provide patients. 12. The nurse is shampooing a patient’s hair. Which assessment finding should the nurse consider as expected? a. Dry, dark, thin b. Smooth, taut, shiny c. Smooth texture and not oily or dry d. Tender, warm scalp Outcome 7: Identify factors influencing personal hygiene. 13. When preparing for a bed bath why should the nurse offer the patient a bedpan, urinal, or the commode prior to performing the procedure? a. Warm water and activity can stimulate the need to void b. Increase in air current in the room can promote voiding c. The patient should be offered toileting prior to any procedure d. So the nurse does not have to change the bed linens Outcome 8: Identify normal and abnormal assessment findings while providing hygiene care. 14. The nurse understands that redness of the skin associated with a variety of conditions is described as which of the following? a. Excessive dryness b. Abrasion c. Erythema d. Hirsutism Outcome 9: Recognize when it is appropriate to delegate hygiene skills for clients to unlicensed assistive personnel. 15. The nurse has delegated the making of unoccupied beds to unlicensed assistive personnel. What should the nurse assess regarding patient safety once the beds are completed? a. Folding of the top sheet b. Direction of the pillow c. Call light being readily available d. Presence of mitered corners [Show More]

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