The nurse is auscultating the lungs and hears a high-pitched sound during expiration. What does this finding most likely indicate?

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Vital Signs Assessment Chapter 7 Questions

Question 1 of 5

The nurse is auscultating the lungs and hears a high-pitched sound during expiration. What does this finding most likely indicate?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 5

Core body temperature is highest at:

Correct Answer: C

Rationale: Late afternoon, is correct because core body temperature peaks around 4 pm to 6 pm due to circadian rhythms governed by the hypothalamus. It rises throughout the day from a low of ~97°F (4-6 am) to a high of ~98.6°F-100°F, reflecting increased metabolic activity. Early morning, is the nadir, not peak. Noon, is midway, not the highest. Evening, sees a decline post-peak. Studies show this diurnal pattern in healthy adults, with late afternoon aligning with maximal alertness and physical performance. Nurses consider this when assessing fevere.g., a 99°F reading at 5 pm might be normal variation. Thus, C is accurate based on physiological circadian evidence.

Question 3 of 5

A nurse notices a student is taking a blood pressure measurement on a patient with a cuff that is too large. What should be the nurses response to the student?

Correct Answer: A

Rationale: A cuff too large underestimates blood pressure, leading to an incorrect reading , as it doesnt compress the artery properly. It wont cause significant injury or dangerous pressure , though a too-small cuff might. Korotkoff sounds remain audible but may be misread. Choice A is correct, emphasizing accuracy in measurement technique, a key teaching point for nursing students.

Question 4 of 5

The patient is lying in bed under a ceiling fan. Which technique is the nurse using when the fan produces heat loss?

Correct Answer: C

Rationale: A ceiling fan moves air over the patient, causing heat loss via convection , where warm air around the body is replaced by cooler moving air. Radiation involves heat emission without contact, not fan-driven. Conduction requires direct contact (e.g., cold pack), not air movement. Evaporation involves moisture loss, not primarily fan-related here. Choice C is correct because convection matches the mechanism of air circulation enhancing heat dissipation, a principle nurses apply in thermoregulation strategies to cool patients effectively in clinical settings.

Question 5 of 5

The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

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