ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 29 : Complementary and Integrative Health Questions
Question 1 of 5
The patient with heart failure is restless with a temperature of 102.2?°F (39?°C). Which action will the nurse take?
Correct Answer: A
Rationale: Heart failure with fever (102.2?°F) and restlessness suggests increased oxygen demand. Applying oxygen (
A) addresses potential hypoxemia, a priority in heart failure exacerbation. Coughing (
B) is irrelevant without respiratory symptoms. Restricting fluids (
C) may worsen dehydration in fever. Increasing metabolic rate (
D) exacerbates stress.
Choice A is correct, aligning with nursing priorities to support oxygenation in cardiac patients with fever-induced strain.
Question 2 of 5
What is the primary purpose of pulse assessment?
Correct Answer: C
Rationale: Pulse assessment primarily evaluates cardiac status (
C), reflecting heart rate and rhythm, key indicators of cardiovascular function. Blood pressure (
A) relates but requires a cuff. Temperature (
B) isn't pulse-related. Respiratory status (
D) is secondary.
Choice C is correct, per nursing fundamentals, as pulse directly monitors heart performance, guiding cardiac care.
Question 3 of 5
The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient's temperature?
Correct Answer: D
Rationale: For a confused, agitated patient with seizures, tympanic (
D) is safest and fastest, avoiding oral risks (biting) or rectal invasiveness (agitation, seizure risk). Oral (
A) is unreliable with agitation. Rectal (
B) risks injury or vagal stimulation. Axillary (
C) is slow and less accurate.
Choice D is correct, per nursing safety protocols, balancing accuracy and patient stability.
Question 4 of 5
The nurse needs to take the temperature of a patient who had a cardiac arrest. Which route will the nurse use?
Correct Answer: C
Rationale: Post-cardiac arrest, tympanic (
C) provides a quick, non-invasive core temperature estimate, critical for monitoring hypothermia or hyperthermia in resuscitation. Oral (
A) risks inaccuracy post-arrest. Rectal (
B) is invasive and slow. Temporal (
D) is less reliable in emergencies.
Choice C is correct, aligning with ACLS emphasis on rapid, safe temperature assessment.
Question 5 of 5
The nurse is caring for an infant and is obtaining the patient's vital signs. Which artery will the nurse use to best obtain the infant's pulse?
Correct Answer: B
Rationale: In infants, the brachial artery (
B) is preferred for pulse due to accessibility and strength; radial (
A) is weak and hard to palpate. Femoral (
C) and popliteal (
D) are less practical.
Choice B is correct, per pediatric norms, ensuring accurate infant pulse assessment.