Chapter 2

Answer Key to Chapter 2 Learning Activities

1. Select the assessment findings requiring immediate follow-up by the nurse.

 

Vital Signs
Temperature 98.9 °F (37.2°C)
Heart Rate *182 beats/min*
Respirations *36 breaths/min*
Blood Pressure 152/90 mm Hg
Oxygen Saturation *88% on room air*
Capillary Refill Time *>3*
Pain 9/10 chest discomfort

 

Physical Assessment Findings
Glasgow Coma Scale Score 14
Level of Consciousness Alert
Heart Sounds *Irregularly regular*
Lungs Sounds Clear bilaterally anterior/posterior
Pulses-Radial *Rapid/bounding*
Pulses-Pedal *Weak*
Bowel Sounds Present and active x 4
Edema Trace bilateral lower extremities
Skin Cool, clammy

2. Indicate whether the actions are “Indicated” (i.e., appropriate or necessary), “Contraindicated” (i.e., could be harmful), or “Nonessential” (i.e., makes no difference or are not necessary).

Nursing Action Indicated Contraindicated Nonessential
Apply oxygen at 2 liters per nasal cannula. X    
Call imagining for a STAT lung CT.     X
Perform the National Institutes of Health (NIH) Stroke Scale Neurologic Exam.     X
Obtain a comprehensive metabolic panel (CMP). X    
Obtain a STAT EKG. X    
Raise head-of-bed to less than 10 degrees.   X  
Establish patent IV access. X    
Administer potassium 20 mEq IV push STAT.   X  

Answers to interactive elements are given within the interactive element.

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