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2. When taking John’s blood pressure, you should make certain that
4. When counting the pulse rate, you may use the pulse at what points?
5. A client has developed pneumonia, and his temperature has increased to 37. 7° C. The client
is shivering and “feels uncomfortable. ” Which of the following is true concerning the
physiology of heat production in this client?
a. The increased BMR is probably causing the febrile condition
b. Encouraging the client to ambulate would help decrease heat production
c. The shivering is likely the cause of the increase in temperature
d. The client may need to consume more nutrients during the febrile condition
6. A 74-year-old client currently has a temperature reading of 36° C. The client walks 1 mile
every day and takes naps during the day. Which of the following is most likely the reason for
the lowered body temperature?
7. A construction worker comes to the emergency room with low blood pressure, normal
pulse, cool skin temperature, diaphoresis, and weakness. These are clinical signs of:
a. Heat exhaustion
b. Heat stroke
c. Heat cramp
d. Hypothermia
8. The nurse is ready to take vital signs on a 6-year-old child. The child has just enjoyed a grape
popsicle. An appropriate action would be to:
a. Take the rectal temperature
b. Take the oral temperature as planned
c. Have the child rinse out the mouth with warm water
d. Wait 30 minutes and take the oral temperature
10. Which of the following is an appropriate site for taking the pulse of a 2-year-old?
a. Radial
b. Apical
c. Femoral
d. Pedal
11. The client begins to breathe rapidly. The nurse should:
a. Ask the client if there have been any stressful visitors
b. Measure the oxygen saturation level
c. Count the rate of respirations
d. Take the radial pulse
12. A client complains of pain and asks the nurse for pain medication. The nurse first assesses
vital signs: blood pressure, 134/92; pulse, 100; and respiration 32. The nurse’s most appropriate
action is to:
a. Ask if the client is anxious
b. Check the client's dressing for bleeding
c. Give the medication as ordered by the physician
d. Recheck the client's vital signs in 30 minutes
13. If measuring blood pressure is necessary in the leg, the nurse expects the
diastolic pressure to be:
148/90, 68, 16
B. 94/52, 68, 30
C. 108/80, 112, 15
D. 132/74, 90, 24