Deck 21: Measuring Vital Signs

Question 1

The nurse taking an apical pulse would place the stethoscope at:

A) the left of the sternum at the third intercostal space.
B) directly below the sternum.
C) slightly above the left nipple.
D) the left midclavicular line at the fifth intercostal space.

Answer 1

the left midclavicular line at the fifth intercostal space.

Question 2

To ensure an accurate reading when using a glass oral thermometer, it is necessary to:

A) rinse the thermometer with water.
B) wipe the thermometer with alcohol.
C) shake down the galinstan alloy to below normal.
D) dry the thermometer with a dry cotton ball.

Answer 2

shake down the galinstan alloy to below normal.

Question 3

A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

A) a breathing pattern of dyspnea followed by a short period of apnea.
B) rapid wheezing respirations for two or three breaths with short periods of apnea.
C) quick shallow respirations with long periods of apnea.
D) respirations gradually decreasing in rate and depth.

Answer 3

a breathing pattern of dyspnea followed by a short period of apnea.

Question 4

The nurse would record a pulse as bradycardic if the rate were _____ beats/min.

A) 64
B) 62
C) 60
D) 59

Question 5

The nurse covers a newborn baby's head with a cap, because the head:

A) is wet and needs to be dried.
B) has large fontanels.
C) allows loss of body heat.
D) can be reshaped more quickly.

Question 6

The nurse anticipates that if the stroke volume of a patient is reduced, the pulse will be:

A) stronger.
B) weaker.
C) bradycardic.
D) irregular.

Question 7

The nurse documents vital signs on a newly admitted patient as: "blood pressure is 148/94 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min." The nurse would record the pulse pressure as _____ mm Hg.

A) 14
B) 54
C) 64
D) 80

Question 8

For the nurse to assess the most accurate respiration count, the nurse should:

A) inform the patient about his respirations and ask him to breathe normally.
B) count each inhalation and expiration for 1 full minute.
C) watch the patient's chest rise and fall from a distance.
D) continue to hold the patient's radial pulse, and count the respirations for 30 seconds and multiply them by 2.

Question 9

The nurse is aware that the use of an oral glass thermometer would be contraindicated in a:

A) 5-year-old with a facial laceration.
B) 12-year-old patient with a recent seizure.
C) 15-year-old with an abscessed tooth.
D) 20-year-old with severe dehydration.

Question 10

The nurse explains to a patient that the pulse oximeter can measure the arterial oxygen by:

A) assessing the amount of blood passing through the sensor.
B) assessing the relative warmth of the skin on the monitored part.
C) measuring the oxygenated hemoglobin through a capillary bed.
D) measuring the respirations to the blood pressure via infrared rays.

Question 11

Elderly patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:

A) continue to listen until the cuff is deflated.
B) pump up the cuff until no sound is heard and then let the air out.
C) make sure the bell of the stethoscope is placed firmly over the artery.
D) stop midway and begin to inflate again.

Question 12

The nurse using either a regular or an electronic sphygmomanometer would ensure that the cuff is the correct size by:

A) using a narrow cuff for an obese patient.
B) making sure the width of the bladder is at least 3 inches.
C) confirming that the bladder goes around three fourths of the arm.
D) always using a wide cuff.

Question 13

An elderly patient has a tympanic temperature of 96.2° F (35.7° C). What nursing intervention would best meet this patient's need?

A) Take the patient's vital signs every 4 hours, including temperature.
B) Provide fluids to increase circulation.
C) Increase room temperature to 72° F (22.2° C) and add blankets to the bed.
D) Check the temperature orally to confirm the accuracy of the reading.

Question 14

Regarding the blood pressure in children, the diastolic pressure is assessed by the auscultation of a:

A) clear tapping that gradually grows louder.
B) murmur or swishing sound that increases with depression of the cuff.
C) sudden change or muffling of the sound.
D) louder knocking sound that occurs with each heartbeat.

Question 15

Because the elderly have non-elastic blood vessels, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:

A) keep the patient in bed in a high Fowler's position.
B) allow the patient to sit on the side of the bed for a minute before standing.
C) instruct the patient to use the wheelchair for all mobility activity.
D) help the patient to rise quickly and support the patient for a minute.

Question 16

A patient has been admitted with hypothermia after lying unconscious overnight in an unheated apartment. The most appropriate route to assess the patient's core temperature would be:

A) rectal.
B) tympanic arterial thermometer.
C) axillary.
D) tympanic.

Question 17

The nurse would document a patient as being febrile if the patient's temperature was over _____° F.

A) 99.5
B) 99.8
C) 100
D) 100.5

Question 18

When caring for a victim with a gunshot wound to the abdomen who has lost a significant amount of blood, the nurse would anticipate the vital signs to reflect:

A) increase in temperature.
B) decrease in blood pressure.
C) decrease in pulse.
D) decrease in respirations.

Question 19

The nurse would anticipate a patient diagnosed with damage to the hypothalamus after suffering a head injury from a fall to exhibit:

A) a blood pressure elevation.
B) a temperature abnormality.
C) a decrease in pulse rate.
D) depressed respirations.

Question 20

When a frail 83-year-old patient whose temperature was 96.8° F at 8:00 AM shows a temperature of 98.6° F at 4:00 PM, the nurse is:

A) pleased that the temperature has come up to normal.
B) satisfied that the patient is warm enough.
C) concerned about the evidence of fever.
D) relieved that the patient is improving.

Question 21

The nurse converts the Fahrenheit temperature of 99.2° to a Celsius reading of ______°.

Question 22

The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

A) dizziness upon rising to a standing position.
B) a drop of 15 to 20 mm Hg from baseline when changing position.
C) nausea.
D) syncope.
E) blurred vision.

Question 23

The accuracy in measuring the apical pulse is enhanced when the nurse:

A) counts the radial pulse at the same time.
B) counts the beats for one minute.
C) keeps the patient warm.
D) uses the bell of the stethoscope.

Question 24

The nurse explains that one method of environmental heat loss is convection, which is exemplified by body heat being reduced by:

A) being transferred to ice packs.
B) production of sweat.
C) being removed by fast air currents from a fan.
D) exposure to a cool environment.

Question 25

The nurse clarifies the average cardiac output in the adult is about _____ L/minute.

Question 26

The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a: (Select all that apply.)

A) previous mastectomy.
B) patent IV line.
C) injured hand.
D) 2-year-old hand amputation.
E) dialysis shunt.

Question 27

The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction is warranted when the caregiver states, "I will:

A) offer warm fluids to the patient, if permitted."
B) instruct the patient to remain on strict bed rest."
C) provide the patient with additional blankets."
D) encourage the patient to increase his muscle activity."

Question 28

The nurse is caring for a patient who had a cardiac catheterization 2 hours ago and has a pressure dressing to his left groin. In addition to taking routine vital signs, the nurse should also check the:

A) strength of the femoral pulse.
B) presence of the pedal pulse.
C) temperature of the right foot.
D) ability to move the left toes.

Question 29

A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:

A) listens to the apical pulse for 1 full minute.
B) takes the pulse for 30 seconds on the other wrist.
C) records the findings on the graphic sheet.
D) takes the pulse for 1 full minute on the other wrist.

Question 30

The nurse caring for a 30-year-old postsurgical patient would assess that the patient is in pain as indicated by:

A) a temperature of 102° F.
B) respirations of 16 breaths/min.
C) a pulse rate of 120 beats/min.
D) blood pressure of 128/86 mm Hg.

Question 31

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

A) notify the charge nurse of the hypotension.
B) notify the doctor of the bradycardia.
C) check medications that might be the cause of the irregularity.
D) check the patient's record to determine his baseline blood pressure.

Question 32

Standards of the Joint Commission state that pain is the fifth vital sign and should be documented by assessments of: (Select all that apply.)

A) location.
B) duration.
C) usual methods of relief.
D) character.
E) intensity.