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.