Deck 4: Vital Signs

Question 1

The nurse uses the diaphragm of the stethoscope to best assess:

A) carotid sounds.
B) lung sounds.
C) vascular sounds.
D) low-pitched sounds.

Answer 1

lung sounds.

Question 2

Using the tympanic thermometer for a child,the nurse should pull the ear pinna:

A) upward and back.
B) parallel.
C) downward and back.
D) upward and forward.

Answer 2

downward and back.

Question 3

The nurse explains that the pulse-the expansion and contraction of an artery-is produced by contraction of the:

A) right atrium.
B) right ventricle.
C) left atrium.
D) left ventricle.

Answer 3

left ventricle.

Question 4

If a peripheral pulse needs to be assessed quickly,the nurse should select the:

A) radial pulse.
B) brachial pulse.
C) carotid pulse.
D) pedal pulse.

Question 5

The respirations of a patient who is demonstrating pursed-lip breathing,flared nostrils,and retractions are described as:

A) tachypnea.
B) stertorous.
C) dyspnea.
D) Cheyne-Stokes.

Question 6

Because a cardiac arrhythmia is suspected,the nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80.The difference between the two rates is termed:

A) pulse pressure.
B) unequal pulses.
C) pulse deficit.
D) tachycardia.

Question 7

A nurse assesses a patient's dorsalis pedis pulse.If the pulse is difficult to feel and not palpable when only slight pressure is applied,the nurse should document this finding as a:

A) weak pulse.
B) normal pulse.
C) thready pulse.
D) bounding pulse.

Question 8

A nurse assesses a patient's dorsalis pedis pulse.If the pulse is not palpable when light pressure is applied,the nurse should document this finding as a:

A) weak pulse.
B) normal pulse.
C) thready pulse.
D) bounding pulse.

Question 9

A fever that rises and falls but does not return to normal until the patient is well is classified as:

A) constant.
B) intermittent.
C) remittent.
D) elevated.

Question 10

The nurse is alarmed when a patient with a severe head injury of the occipital lobe has a respiratory rate of 10 breaths per minute because this may indicate an injury to the:

A) cerebellum.
B) medulla oblongata.
C) cortex.
D) cerebrum.

Question 11

A nurse assesses a neonate's temperature by using a temporal artery scanner.If the neonate's temperature is 99.5° F,the nurse should:

A) record the findings.
B) notify the physician.
C) check the axillary temperature.
D) check the tympanic temperature.

Question 12

When assessing vital signs on a 40-year-old male,the nurse identifies a pulse rate of 120.This pulse is:

A) normal.
B) bradycardic.
C) dysrhythmic.
D) tachycardic.

Question 13

The nurse uses cooling techniques to keep the body temperature below 105° F because such elevated temperature can:

A) cause excessive thirst.
B) cause excessive perspiration.
C) damage body cells.
D) increase heart rate.

Question 14

The patient's pulse is below 60.Because the nurse is aware that the patient is not receiving digoxin,the nurse believes that the bradycardia might be caused by:

A) low exercise tolerance.
B) unrelieved severe pain.
C) excessive bed rest.
D) a prone position.

Question 15

A nurse assesses a neonate's temperature by using a temporal artery scanner.If the neonate's temperature is 96° F,the nurse should:

A) record the findings.
B) notify the physician.
C) check the axillary temperature.
D) check the tympanic temperature.

Question 16

The part of the body that maintains a balance between heat production and heat loss,regulating body temperature,is the:

A) thymus.
B) thyroid.
C) hypothalamus.
D) adrenal glands.

Question 17

The emergency department nurse quickly assesses the temperature of an unconscious patient who has been outside all night in below-freezing temperatures.The nurse is aware that death can occur if the temperature falls below:

A) 95.2° F.
B) 93.0° F.
C) 93.2° F.
D) 90.8° F.

Question 18

The exchange of carbon dioxide and oxygen that takes place at the alveolar level is termed:

A) tachypnea.
B) internal respiration.
C) external respiration.
D) bradypnea.

Question 19

The type of body temperature that remains relatively constant is the:

A) surface.
B) rectal.
C) oral.
D) core.

Question 20

To ensure optimum reception from a stethoscope,the nurse should place the earpieces pointing:

A) backward.
B) parallel to the ears.
C) toward the face.
D) downward.

Question 21

If a patient has an axillary temperature of 96.2°F,the nurse understands that the correct temperature is ______.

Question 22

The nurse assesses the blood pressure as 192/86,noting that the patient has a pulse pressure of ________.

Question 23

When assessing factors that may influence the patient's pulse rate,what should the nurse take into consideration? (Select all that apply.)

A) Age
B) Sex
C) Emotion
D) Temperature
E) Physical activity

Question 24

The nurse assesses for the fifth vital sign,which is______________.

Question 25

A nurse assesses a patient's dorsalis pedis pulse.If the pulse feels full and springlike even under moderate pressure,the nurse should document this finding as a:

A) weak pulse.
B) normal pulse.
C) thready pulse.
D) bounding pulse.

Question 26

When instructing a primary caregiver about keeping a daily log of blood pressure readings,the nurse should include what instruction(s)? (Select all that apply.)

A) Take the reading at different times during the day.
B) Apply the cuff approximately 2 inches above the antecubital fossa.
C) If unable to get a reading the first time,immediately reinflate the cuff.
D) Assess pulse with the bell of the stethoscope.
E) Apply the cuff snugly.

Question 27

A nurse assesses a patient's dorsalis pedis pulse.If the pulse is easily felt but not palpable when moderate pressure is applied,the nurse should document this finding as a:

A) weak pulse.
B) normal pulse.
C) thready pulse.
D) bounding pulse.