Case Study. &nbs
Case Study. Mr. Stan Kercheval is being admitted to the medical-surgical unit after oral surgery. He is 57 years old and had his mandible reset and wired after he sustained a blow to the face in a bar fight. He is resting quietly in his room. Byung-soon is the student nurse assigned to Mr. Kercheval. She is a first _semester nursing student, she cleans and prepares the vital sign equipment cart before entering Mr. Kercheval room to take vital signs. 1. Given Mr. Kercheval condition, which site is most appropriate for Byung-soon to measure his temperature?a.oral,b.axillary ,c. rectal, d. tympanic membrane. 2. Byung-soon measures Mr. Kercheval apical pulse by listening to heart sounds. The S2 heart sound is low pitched and dull. true or false? 3. Byung-soon measures Mr. Kercheval respiratory rate. The normal respiratory rate for an adult is ___ to____ breaths/min. 4. Byung-soon takes Mr. Kercheval blood pressure, which is 118/76mm Hg. What is Byung-soon priority action?a, elevate the head of the bed? b. notify the health care provider,c. provide cardiopulmonary resuscitation (cpr). d. continue taking vital signs.
Homework Answers
ANSWER :-
1. D. Tympanic membrane
Rationale: Since Mr. Kercheval has undergone oral surgery, he
should not have his temperature taken by the oral route. The
axillary route takes too long, and the rectal route is invasive.
The tympanic membrane route is easily accessible and fast.
2. B. False
Rationale: The S2 heart sound is high pitched and short ("dub"
sound), whereas the S1 heart sound is low pitched and dull ("lub"
sound).
3. 12-20 breaths/min
4. D. Continue taking vital signs
A blood pressure of 118/76 mm Hg is normal in an adult; therefore
Byung-soon may continue taking vital signs. Elevating the head of
the bed, notifying the health care provider, and providing CPR are
not necessary.
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