The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction when the caregiver states, "I will

instruct the patient to remain on strict bed rest

provide the patient with additional blankets"

encourage the patent to increase his muscle activity”

offer fluids to the patient if permitted

Answer and Explanation

The Correct Answer is C

A.   Keeping the patient on bed rest is appropriate as it conserves energy and helps prevent further heat loss.
B.   Providing additional blankets is a correct intervention to warm the patient gradually.
C.   Increasing muscle activity is contraindicated because it could cause vasoconstriction and worsen hypothermia, as the body focuses on preserving core temperature.
D.   Offering fluids (if permitted) is correct as hydration can help restore normal body temperature regulation.

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Correct Answer is C

Explanation

A. The area directly below the sternum is not the location for the apical pulse.
B. The third intercostal space is too high for the apical pulse, which is best heard at the fifth intercostal space.
C. The left midclavicular line at the fifth intercostal space is the proper location for auscultating the apical pulse.
D. Placing the stethoscope above the left nipple does not ensure accurate assessment of the apical pulse.

A. bell of the stethoscope on top of the patient's gown. B. diaphragm of the stethoscope directly on the patient's skin. C. diaphragm of the stethoscope on top of the patient's gown. D. bell of the stethoscope directly on the patient's skin.

Correct Answer is B

Explanation

A. The bell is used to detect low-pitched sounds, but abnormal heart sounds are often high-pitched, requiring the diaphragm.
B. The diaphragm of the stethoscope is best for detecting high-pitched heart sounds, such as murmurs or abnormal rhythms.
C. The diaphragm on top of the gown would create interference and prevent proper auscultation of heart sounds.
D. The bell is used for lower-pitched sounds and is not the best choice for auscultating abnormal heart sounds.

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The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction when the caregiver states, "I will

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Naxlex Comprehensive Predictor Exams

The nurse taking an apical pulse would place the stethoscope at:

Correct Answer is C

Explanation

The nurse is informed that a patient had abnormal heart sounds during the night shift. When auscultating abnormal heart sounds, the nurse knows to listen to heart sounds with the:

Correct Answer is B

Explanation

The nurse documents vital signs on a newly admitted patient as: "blood pressure is 170/90 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min." The nurse would record the pulse pressure as:

If a patient's blood pressure measures 146/92 on the left arm and 138/84 on the right arm, what would you do?

When educating a patient about the warning signs of cancer, the nurse includes which of the following? (Select all that apply.)

An older adult American Indian patient has been admitted to the hospital with abdominal pain. Along with performing a physical assessment, the nurse should also perform a:

When performing an initial assessment on a patient, which piece of information is of highest priority?

If a silence is heard between sounds when auscultating blood pressure, it is termed a(n)

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

If dehydration occurs, the blood pressure will