TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 07: Vital Signs Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The patient’s oral temperature is 39 C (102.2 F). Which conclusion can the nurse make
about the patient on the basis of this information? a. The patient is febrile. b. The patient is afebrile. c. An infection is present. d. Inflammation is present. ANS: A
A temperature of 39 C is above normal, and the patient with an above-average temperature is febrile. Afebrile indicates a lack of fever but does not necessarily imply a subnormal temperature. An infection often causes a fever in the patient, but a physical examination and laboratory work or culture are necessary before concluding that the patient has an infection. A patient with an inflammation can have a fever, but the patient can have an inflammation without being febrile. DIF: Cognitive Level: Understanding TOP: Nursing Process: Diagnosis
OBJ: NCLEX: Physiological Integrity
2. The nurse is preparing to obtain a set of vital signs. Which is the most important factor for the
nurse to consider when measuring patient vital signs? a. Documentation of vital signs N requires timely and accurate recording. b. Normal limits are very narrow and are generally the same for all patients. c. Measuring equipment must be used correctly and appropriately. d. Environmental factors play a minor role on patient vital signs. ANS: C
It is important that each device be used correctly and appropriately to ensure patient safety and to obtain correct, complete patient information. Improper equipment distorts the results, increasing the risk of patient injury. If data are obtained with improper equipment and patient treatment is based on the faulty data, the people who use the improper equipment and the faulty data are liable for the results. Documentation is an important part of taking vital signs; however, if the nurse uses improper equipment or technique to obtain vital signs, accurate and prompt recording is to no avail. Depending on the parameter, the normal limits are not relatively narrow. The benefit of a wider normal range is that the body is able to respond to stress and recover while remaining within normal limits. Environmental factors play a significant role on vital signs (e.g., an overly warm room affects patient temperature). DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation
OBJ: NCLEX: Physiological Integrity
3. A patient has a severe upper respiratory and ear infection and has been experiencing diarrhea.
Assessment of the temperature would be most accurate if the nurse checked the temperature using which site? a. The rectum b. The axilla
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