Chapter 2

Answer Key to Chapter 2 Learning Activities



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


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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