Nursing Chapter 29 Rhythm Sound Stress Correct Answer Rationale Depth

Kozier & Erb’s Fundamentals of Nursing, 10/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 client’s low

temperature could be due to which observation?

1. The anxiety level of the client has increased.

2. Hormones have fluctuated in this client.

3. Muscle activity has increased during the client’s therapy session.

4. Loss of subcutaneous fat is noted.

Question 2

Type: MCSA

The nurse is preparing to measure a client’s temperature. What is the first thing that the nurse should do to ensure

an accurate temperature reading?

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.

Question 3

Type: MCSA

The nurse needs to measure the temperature of a client who has a history of heart disease and has eaten a bowl of

vegetable soup 45 minutes ago. Which site should the nurse use?

1. Axilla

2. Oral

3. Popliteal

4. Rectal

Question 4

Type: MCSA

While waiting for the physician to respond regarding a client’s 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 the room temperature.

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 of capillary refilling time. How would the

nurse explain these findings?

1. A change in the client’s health status has occurred.

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

3. The RN’s watch has stopped working.

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

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 nursing intervention 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 try again later.

Question 7

Type: MCSA

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

1. Depth

2. Rhythm

3. Sound

4. Stress

Question 8

Type: MCSA

The nurse is going to assess the apical-radial pulse of 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.

Question 9

Type: MCSA

A client is unconscious and in respiratory distress after being in a motor vehicle crash. Which should the nurse

realize as being a factor that caused a change in this client’s respiratory rate?

1. Exercise

2. Increased intracranial pressure

3. Increased environmental temperature

4. Stress

Question 10

Type: MCSA

The nurse needs to assess a client’s respiratory status. Which client position would be the best for this

assessment?

1. Prone

2. Semi-Fowler’s

3. Side-lying

4. Supine

Question 11

Type: MCSA

A client is being treated for congestive heart failure. Which physical finding would lead the RN to believe the

client’s condition has not improved?

1. Temperature of 98.6°F (37°C)

2. Moderate amount of clear thin mucus

3. Pulse oximetry reading of 96%

4. Wheezing of breath sounds in all lobes

Question 12

Type: MCSA

Which determinant of blood pressure would explain a client’s blood pressure reading of 120/100?

1. Blood viscosity

2. Blood volume

3. Pumping action of the heart

4. Peripheral vascular resistance

Question 13

Type: MCSA

The nurse is assessing a client’s blood pressure. What should the nurse hear during phase 2 of Korotkoff’s

sounds?

1. A muffled, whooshing, or swishing sound

2. Disappearance of sound

3. Faint, clear tapping sound

4. Increased intensity of sound

Question 14

Type: MCSA

The nurse is preparing to assess a client’s blood pressure. Which artery will the nurse use for this assessment?

1. Brachial

2. Femoral

3. Radial

4. Ulnar