Deck 29: Vital Signs

Question 1

Which of the following actions would promote accuracy when taking a client's temperature?

A)Place the client in a position that is most comfortable
B)Wait the required length of time required by the selected thermometer before reading the results
C)Use a chemical disposable thermometer when the client is perspiring
D)Wait 10 minutes after a client has been smoking before taking an oral temperature

Answer 1

Wait the required length of time required by the selected thermometer before reading the results

Question 2

Which of the following would the nurse recommend to a client to reduce a fever?

A)Bathe with ice water
B)Reduce physical activity
C)Restrict fluid intake
D)Lower room temperature

Answer 2

Reduce physical activity

Question 3

When the warmth-sensitive receptors of the hypothalamus are stimulated,what physiological processes would be initiated?

A)Shivering and vasoconstriction
B)Peripheral vasodilation and shivering
C)Sweating and peripheral vasodilation
D)Sweating and vasoconstriction

Answer 3

Sweating and peripheral vasodilation

Question 4

Which of the following sites would be the most appropriate choice to use to measure a 55-year-old's temperature who has a history of heart disease and who finished drinking a hot cup of tea 30 minutes ago?

A)Axilla
B)Oral
C)Core
D)Rectal

Question 5

Mrs.Newton begins to shiver during her bed bath and asks the nurse why it happens.What is the nurse's best response?

A)The hot water has triggered a shiver response in your brain but it will stop in a couple of minutes.
B)The body shivers to increase heat production because your skin is cold.
C)Older people are more sensitive to cold temperatures and they shiver easily.
D)The bath water is still really warm but I will change it and get fresh hotter water for your bath.

Question 6

Which of the following characteristics is assessed when taking a client's peripheral pulse?

A)Depth
B)Rhythm
C)Sound
D)Stress

Question 7

Mr.Addison is one day post-operative from a right knee replacement.The RN is unable to assess his dorsalis pedis pulse.What would be the most appropriate action for the nurse to take?

A)Ask another nurse to assess the pulses
B)Document the findings as an absent pulse
C)Use a Doppler ultrasound stethoscope
D)Wait and evaluate in 2 hours

Question 8

What is the correct procedure the nurse should use when taking an 18-month-old's tympanic temperature?

A)Pull the pinna of the ear up and back
B)Pull the pinna straight back and slightly angled to the right
C)Hold the pinna gently while pulling it downward
D)Pull the pinna of the ear back and down

Question 9

Mrs.Davis is a 77-year-old woman weighing 45 kg,who is recovering from a hip fracture after a fall at home.She is being cared for by Maureen,a student nurse,who is preparing the client to have her blood pressure checked.Maureen wraps the blood pressure cuff around Mrs.Davis's right arm ensuring that the cuff is wrapped snugly from her elbow to axilla.Her blood pressure reading (checked twice)is 84/56,significantly lower than her usual pressure of 116/76.What should the instructor advise Maureen to do?

A)Check BP on the left arm
B)Document and call physician
C)Check BP using smaller cuff
D)Wait 5 minutes and recheck

Question 10

A client is hospitalized for pneumonia.Auscultation of breath sounds indicate there are high pitched sounds occurring on inspiration and expiration,and the client states he is having a hard time breathing.Which documentation terms best represent these findings?

A)Crackles and cyanosis
B)Orthopnea and costal tugging
C)Wheezing and dyspnea
D)Wheezing and tachypnea

Question 11

On the diagram below,place an X over the point of maximal impulse (PMI)where the stethoscope is placed to assess the apical pulse.

Question 12

Mr.Geary is a 25-year-old who has been outside playing soccer on a hot summer day.In the late afternoon he is pale,nauseated,and begins to vomit.His temperature is 38.6 C.Which of the following best describes his current condition?

A)Heat exhaustion
B)Heat stroke
C)Malignant hyperthermia
D)Hyperpyrexia

Question 13

Which of the following determinants of blood pressure would explain a client's blood pressure reading of 130/100?

A)Blood viscosity
B)Blood volume
C)Pumping action of the heart
D)Peripheral vascular resistance

Question 14

Which of the following factors will result in a decrease in respiratory rate?

A)Exercise
B)Increased intracranial pressure
C)Increased environmental temperature
D)Stress

Question 15

A newly admitted client with right sided weakness,age 75 years,is assessed for the following vital signs: 35.8 C - P.68-R.18-BP 130/70.Which of the following rationales would explain this client's temperature?

A)The anxiety level of the client has increased.
B)This elderly client's hormones have fluctuated.
C)The muscle activity has increased his circulation.
D)It is normal for elderly adults to have lower temperatures.

Question 16

Why would the RN choose to complete an apical-radial check on a client with heart disease?

A)A forceful radial pulse is too difficult to count correctly.
B)Both arterial and venous sounds can be heard simultaneously.
C)The pulse is bounding and easily obliterated.
D)A peripheral pulse may be inaccurate due to weakness of the heart.

Question 17

Madeline has just completed a 5 km run.Her respiratory rate is 28 and regular.Which of the following terms most accurately describes her respirations?

A)Cheyne-stokes
B)Bradypnea
C)Orthopnea
D)Tachypnea

Question 18

Mrs.Winston,72 years old,is one day post-operative from an appendectomy.How would the RN position her for maximum aeration of her lungs?

A)Prone
B)Supine
C)Semi Fowlers
D)Left lateral

Question 19

What depth should a rectal thermometer be inserted in an adult?

A)2 cm
B)2)5 cm
C)3 cm
D)3)5 cm

Question 20

Kyla is a student nurse who is asked by her instructor to identify the correct method for obtaining an infant's heart rate.What should Kyla respond?

A)Apical
B)Femoral
C)Radial
D)Carotid

Question 21

Which of the following factors can affect oxygen saturation readings?

A)Hand tremors
B)Environmental conditions
C)Nutrition and hydration
D)Skin colour

Question 22

What immediate assessment would the nurse complete on a client who has pale and cold toes?

A)Femoral pulse
B)Popliteal pulse
C)Apical pulse
D)Dorsalis pedis pulse

Question 23

What rationale should an RN provide a student nurse who asks why she should wait 1-2 minutes between checking and rechecking a BP on a client?

A)This allows for complete deflation of the cuff.
B)It would be unsafe to apply pressure on the arteries too quickly.
C)The wait time permits blood trapped in the veins to be released.
D)This reduces the chance of a systolic auscultation gap to develop.

Question 24

Prior to attaching the fingertip oximeter sensor to a 4-year-old child,what teaching should the nurse provide to the child and parents?

A)The sensor will not hurt.
B)This sensor will pinch but you will hardly feel it.
C)After the child is breathing better,the sensor will be discontinued.
D)The doctor has ordered us to use the sensor to check the oxygen level.

Question 25

When is the systolic pressure read from the sphygmomanometer when palpating for a blood pressure?

A)When the cuff is applied
B)When the cuff is completely deflated
C)When the first pulsation is felt
D)When the cuff is completely inflated

Question 26

Which of the following arterial sites is most commonly used to obtain a blood pressure reading?

A)Brachial
B)Femoral
C)Radial
D)Ulnar

Question 27

The RN is ambulating a client with pneumonia.During the walk,the client's oxygen saturation drops to 83% and her respiratory rate increases to 32.What action should the RN take?

A)Allow the client to take some extra deep breaths
B)Continue to ambulate but slow the pace
C)Notify the charge nurse to call for the Early Response Team
D)Stop ambulating,encourage the client to take slow deep breaths,and administer oxygen

Question 28

Which of the following will be heard during phase 2 of Korotkoff's sounds?

A)Thumping sound
B)Disappearance of sound
C)Faint,clear tapping sound
D)A murmur or swishing sound