A 38-year old patient’s vital signs at 8 a.m. are axillary temperature 99.6 F (37.6 C); pulse rate, 88; respiratory rate, 30. Which findings should be reported?
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Solution
Option D: Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a minute. Thus, a respiratory rate of 30 would be abnormal. A normal adult body temperature, as measured on an oral thermometer, ranges between 97° and 100°F (36.1° and 37.8°C); an axillary temperature is approximately one degree lower and a rectal temperature, one degree higher. Thus, an axillary temperature of 99.6°F (37.6°C) would be considered abnormal. The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal.
Which of the following parameters should be checked when assessing respirations?
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Solution
Option D: The quality and efficiency of the respiratory process can be determined by appraising the rate, rhythm, depth, ease, sound, and symmetry of respirations.
A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates:
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Solution
Option D: A slightly elevated temperature in the immediate preoperative or postoperative period may result from the lack of fluids before surgery rather than from infection.
Option C: Anxiety will not cause an elevated temperature. Hypothermia is an abnormally low body temperature.
If a patient’s blood pressure is 150/96, his pulse pressure is:
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Solution
Option A: The pulse pressure is the difference between the systolic and diastolic blood pressure readings – in this case, 54.
During a Romberg test, the nurse asks the patient to assume which position?
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Solution
Option B: During a Romberg test, which evaluates for sensory or cerebellar ataxia, the patient must stand with feet together and arms resting at the sides—first with eyes open, then with eyes closed. The need to move the feet apart to maintain this stance is an abnormal finding.
For a rectal examination, the patient can be directed to assume which of the following positions?
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Solution
Option D: All of these positions are appropriate for a rectal examination. In the genupectoral (knee-chest) position, the patient kneels and rests his chest on the table, forming a 90-degree angle between the torso and upper legs. In Sims’ position, the patient lies on his left side with the left arm behind the body and his right leg flexed. In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward.
A patient about to undergo abdominal inspection is best placed in which of the following positions?
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Solution
Option C: The supine position (also called the dorsal position), in which the patient lies on his back with his face upward, allows for easy access to the abdomen.
Option A: In the prone position, the patient lies on his abdomen with his face turned to the side.
Option B: In the Trendelenburg position, the head of the bed is tilted downward to 30 to 40 degrees so that the upper body is lower than the legs.
Option D: In the lateral position, the patient lies on his side.
High-pitched gurgles head over the right lower quadrant are:
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Solution
Option C: High-pitched gurgles head over the right lower quadrant are normal bowel sounds.
Option A: Hyperactive sounds indicate increased bowel motility.
Option B: Two or three sounds per minute indicate decreased bowel motility.
Option D: Abdominal cramping with hyperactive, high pitched tinkling bowel sounds can indicate a bowel obstruction.
The correct sequence for assessing the abdomen is:
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Solution
Option D: Because percussion and palpation can affect bowel motility and thus bowel sounds, they should follow auscultation in abdominal assessment.
Option A: Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen.
Option B: Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis.
A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract?
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Solution
Option B: To assess for GI tract bleeding when frank blood is absent, the nurse has two options: She can test for occult blood in vomitus, if present, or in stool – through guaiac (Hemoccult) test.
Option A: A complete blood count does not provide immediate results and does not always immediately reflect blood loss.
Option C: Changes in vital signs may be caused by factors other than blood loss.
Option D: Abdominal girth is unrelated to blood loss.