When taking a blood pressure, it is best practice to...

Correct Answer: C

Rationale: Best practice places the BP cuff on bare skin, upper arm above the elbow , ensuring accurate artery compression. Thick clothing muffles sounds. Crossed legs may elevate readings. Forearm is less reliable. Choice C is correct, per AHA guidelines, critical for nurses to obtain precise BP measurements avoiding common errors.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Hemoglobin level of 8.0. Shortness of breath and chest discomfort are common symptoms of anemia, which is characterized by low hemoglobin levels. Hemoglobin is responsible for carrying oxygen from the lungs to the rest of the body. A low hemoglobin level indicates a decreased ability to transport oxygen, leading to symptoms like shortness of breath. Option B) Hematocrit level of 45% is less likely to be the cause of the symptoms because it measures the percentage of red blood cells in the total blood volume, not the actual amount of hemoglobin present. Option C) Red blood cell count of 5.0 million/mm3 is not directly related to the symptoms described. While it is within the normal range, it does not provide information about the oxygen-carrying capacity of the blood. Option D) Pulse oximetry of 95% indicates adequate oxygen saturation in the blood, which rules out hypoxemia as the primary cause of the symptoms. Educationally, understanding the relationship between laboratory values and clinical presentation is crucial for nurses to make accurate assessments and provide appropriate interventions for patients. Recognizing the significance of hemoglobin levels in oxygen transport can help nurses prioritize care and implement timely interventions for patients experiencing respiratory distress.

Correct Answer: D

Rationale: Tympanic thermometers measure ear canal temperature , reflecting core readings via the tympanic membrane. Oral and rectal are for different devices. Forehead is for temporal thermometers. Choice D is correct, per the explanation and manufacturer guidelines, ensuring accurate placement by aligning with the eardrum for reliable, non-invasive core temperature assessment.

Correct Answer: B

Rationale: In nursing assessment, understanding vital signs is crucial for evaluating a patient's overall health status. When a nurse assesses a client's oxygen saturation and obtains a reading of 100%, the correct interpretation is hyperoxia, which means an excess of oxygen in the blood. This reading indicates that the patient is receiving more oxygen than their body requires, which can potentially lead to oxygen toxicity. Option A, hypoxemia, is incorrect because it refers to low oxygen levels in the blood, which would be indicated by a lower oxygen saturation reading, not 100%. Option C, hypocapnia, is also incorrect as it pertains to low carbon dioxide levels in the blood, not oxygen saturation levels. Option D, hypercapnia, is inaccurate as it signifies high levels of carbon dioxide in the blood, not high levels of oxygen. Educationally, it is important for nurses to understand the significance of oxygen saturation readings to provide appropriate care for patients. Hyperoxia can lead to harmful effects such as oxygen toxicity, which can damage the lungs and other organs. Nurses need to be vigilant in monitoring and interpreting vital signs accurately to prevent complications and deliver safe, effective care to their patients.

Correct Answer: B

Rationale: The sinoatrial node regulates pulse rate and force as the heart's pacemaker, per the answer key. The thermoregulatory center controls temperature. Atria and valves don't set rhythm. Chemoreceptors adjust respiration. The SA node's electrical impulses drive heartbeats, a critical nursing concept for understanding pulse dynamics in health assessments.