Which instruction might the nurse give to nursing assistive personnel that is applicable only to temporal artery?

Answer :

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Answer:

an artery is part of the heart that works differently than a vein

Explanation:

sunasuna38 sunasuna38

Explanation:

an artery is part of the heart that works differently than a vein

The nurse observes a nursing student taking a blood pressure (BP) on a patient. The nurse notes that the student very slowly deflates the cuff in an attempt to hear the sounds. The patient’s BP range over the past 24 hours is 132/64 to 126/72 mm Hg. Which of the following BP readings made by the student is most likely caused by an incorrect technique?   156/82 mm Hg   110/66 mm Hg   96/40 mm Hg Incorrect   130/90 mm Hg CorrectTerm

130/90 mm Hg Correct
Deflating the cuff too slowly will result in a false-high diastolic blood pressure.

A 55-year-old female patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. Which sites do you instruct the nursing assistant to use for obtaining the patient’s blood pressure and temperature?   Left antecubital and oral   Right popliteal and rectal Incorrect   Right antecubital and tympanic membrane Correct   Left popliteal and temporal artery

Right antecubital and tympanic membrane Correct
IV in right arm can be turned off while blood pressure is obtained. Blood pressure should not be measured on fractured extremities that have compromised circulation. Sequential stocking should remain on all the time while the patient is in bed to promote blood flow in lower right extremity. Tympanic membrane temperature is not affected by oxygen; the oxygen would need to be removed to take an oral temperature. Forehead laceration excludes temporal measurement. Rectal temperature is more invasive.Definition

A patient has been admitted for a cerebrovascular accident (stroke). She cannot move her right arm, and she has a right-sided facial droop. She is able to eat with her dentures in place and swallow safely. The nursing assistive personnel (NAP) reports to you that the patient will not keep the oral thermometer probe in her mouth. What direction do you provide to the NAP?   Direct the NAP to switch the thermometer probe to the left sublingual pocket   Direct the NAP to use a temporal artery thermometer from right to left Correct   Direct the NAP to obtain a right tympanic temperature   Direct the NAP to hold the thermometer in place with her gloved hand Incorrect

A temporal artery temperature verifies the forehead temperature in back of the left ear, which is the side not affected by the altered blood flow related to the stroke. Holding the thermometer or switching locations will not help the patient close her mouth during temperature assessment. The patient’s right side has vascular changes related to the stroke.

A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant reports his admitting vital signs to the nurse. Which measurements should the nurse reassess? (Select all that apply.)   Respiratory rate: 28 Correct   Temporal temperature: 37.4° C (99.3° F)   Oxygen saturation: 99% Correct   Right arm BP: 118/72   Radial pulse rate: 72 and irregular Correct

Irregular pulse and elevated respiratory rate are outside of expected values and require further assessment by the nurse. Pneumonia and shortness of breath can cause low oxygen saturation; an assessment of 99% may be a false-high value. Blood pressure and temperature are within expected values for the patient history.

Which of the following patients are at most risk for tachypnea? (Select all that apply.)   Adult who has consumed alcoholic beverages   Adolescent waking from sleep   Woman who is 9 months’ pregnant Correct   Patient just admitted with four rib fractures Correct   Three-pack–per-day smoker with pneumonia CorrectTerm

Patient with rib fractures is unlikely to breathe deeply and a large fetus restricts diaphragmatic movement, leading to decreased ventilatory volume. Pneumonia decreases gas exchange surface area. Tachypnea occurs to increase minute ventilation. Alcohol is a respiratory depressant.

The nursing assistive personnel (NAP) reports to you that the blood pressure (BP) of the patient in Question 11 is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? (Select all that apply.)   Obtain blood pressure measurements on lower extremities Incorrect   Repeat the measurements on both arms using a stethoscope Correct   Verify that the correct cuff size was used during the measurements Incorrect   Review the patient’s record for her baseline vital signs Correct   Notify the health care provider immediately   Ask the patient if she has taken her blood pressure medications recently   Compare right and left radial pulses for strength

The systolic BP measurements are significantly different and may reflect the vascular and muscular changes caused by the stroke. However, unexpected findings require reassessment by the nurse with a comparison to previous values. It is premature to notify the provider; differences are not caused by medications; inappropriate cuff size would reflect similar systolic pressures; pulse strength would be similar for these BP measurements.

A healthy adult patient tells the nurse that he obtained his blood pressure in "one of those quick machines in the mall" and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/92? (Select all that apply.)   Slow inflation of the cuff by the machine   Patient did not remove his long-sleeved shirt Incorrect   Insufficient time between measurements Correct   Arm positioned above heart level   Cuff too small Correct

Using too small of a cuff and not allowing for insufficient time between measurements will result in false-high readings. Arm above heart level and slow inflation result in false low readings.

Which instruction might the nurse give to nursing assistive personnel that is applicable only to temporal artery temperature assessment?

What will the nurse instruct nursing assistive personnel to do regarding the management of a patients pain?

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What instruction should the nurse give nursing assistive personnel NAP regarding the appropriate technique when measuring the adult patient's apical pulse?