Deck 19: Vital Signs

Question 1

A nurse is caring for a patient who has orthopnea. What action by the nurse is most appropriate?

A) Encourage deep breathing and coughing.
B) Medicate the patient for pain as needed.
C) Keep the head of the bed elevated.
D) Monitor the length of time the patient doesn't breathe.

Answer 1

Keep the head of the bed elevated.

Question 2

The student nurse is assessing a patient's pulses. What action by the student requires the nurse to intervene?

A) Assessing apical pulse between the fifth and sixth intercostal spaces
B) Assessing the dorsalis pedis pulse by palpating behind the patient's knee
C) Assessing the radial pulse on the patient's wrist
D) Assessing the brachial pulse on the patient's inner elbow

Answer 2

Assessing the dorsalis pedis pulse by palpating behind the patient's knee

Question 3

A nurse observes a student taking an adult patient's tympanic temperature. What action by the student requires the nurse to intervene?

A) Student washes hands prior to patient contact.
B) Student pulls the pinna of the patient's ear down and back.
C) Student explains the procedure to the patient.
D) Student pulls the pinna of the patient's ear up and back.

Answer 3

Student pulls the pinna of the patient's ear down and back.

Question 4

A nurse is told in the hand-off report that a patient is afebrile. What assessment finding correlates with this statement?

A) Blood pressure 152/98 mm Hg
B) Temperature 98.4 °F (36.8 °C)
C) Apical pulse 82 beats/min
D) Respirations 16 breaths/min

Question 5

A nurse is going to take an oral temperature on a patient who has just consumed a cup of coffee. What action by the nurse is best?

A) Have the patient drink room temperature water.
B) Return in 30 minutes to take the patient's temperature.
C) Take the patient's temperature rectally instead.
D) Document that temperature is unable to be obtained.

Question 6

The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The pulse oximeter does not provide a good reading. What action by the nurse is best?

A) Move the oximeter probe to another finger.
B) Assess the fingers for good circulation.
C) Document that the reading cannot be obtained.
D) Remove any fingernail polish present on the fingernail.

Question 7

The nurse is caring for a woman who had a right-sided mastectomy 2 years ago. What action by the nurse is most appropriate?

A) Place a sign above the bed: "No blood pressures on the right arm."
B) Place a sign above the bed: "No continuous blood pressures on the right arm."
C) Place a sign above the bed: "Blood pressures in legs only."
D) No specific action is needed for this situation.

Question 8

The nursing faculty member is observing a student taking a patient's carotid pulse. What action by the student requires intervention by the faculty member?

A) Counts pulse for 30 seconds and multiplies by two.
B) Performs hand hygiene prior to patient contact.
C) Compares pulses in both carotid arteries at the same time.
D) Assesses pulse on one side then assesses the other side.

Question 9

Which patient assessment result would require the nurse to assess that patient further?

A) A 40-year-old woman with a radial pulse of 68
B) A 65-year-old man with a respiratory rate of 10
C) A 12-year-old with a pulse of 92 after ambulating in the hallway
D) A 50-year-old man with a BP of 112/60 upon awakening in the morning

Question 10

A nursing student is caring for a patient with metabolic acidosis. The student asks the registered nurse why the patient's respiratory rate is so high. What response by the nurse is best?

A) "The patient's metabolic rate is increased from being ill."
B) "The lungs are trying to rid the body of extra carbon dioxide."
C) "The patient is trying to reduce his temperature through panting."
D) "Patients who are acutely ill often have abnormal vital signs."

Question 11

The nurse receives a hand-off report on four patients. Which patient finding should the nurse assess first?

A) Pulse oximetry 96%
B) Blood pressure 102/62 mm Hg
C) Pulse 42 beats/min
D) Respiratory rate 18 breaths/min

Question 12

The nurse is delegating taking vital signs to an unlicensed assistive personnel (UAP). What instructions does the nurse provide the UAP?

A) "Let me know if Mr. Smith's blood pressure is low."
B) "Take Mrs. Jones' blood pressure every 15 minutes."
C) "Call me if Ms. Walsh's systolic blood pressure drops to under 100 mm Hg."
D) "Do you want me to demonstrate using the electronic blood pressure cuff?"
E) "I'll take Mr. Derby's blood pressure since he is not stable."

Question 13

A patient's blood pressure is 142/76 mm Hg. What does the nurse chart as the pulse pressure?

A) 28
B) 42
C) 58
D) 66

Question 14

A nurse assesses a patient's radial pulse rate to be 110 beats/min and regular. What action by the nurse is best?

A) Assess the patient for causes of tachycardia.
B) Take an apical heart rate and compare the two.
C) Document the findings in the patient's chart.
D) Notify the patient's health care provider.

Question 15

A nurse notes a patient has abnormal vital signs. What action by the nurse is best?

A) Document the findings.
B) Notify the provider.
C) Compare with prior readings.
D) Retake the vital signs in 15 minutes.

Question 16

The nursing student learns that the purpose of measuring a patient's vital signs includes which of the following rationale?

A) Monitor body systems functioning.
B) Identify early signs of problems.
C) Evaluate effectiveness of interventions.
D) Determine if a cure has been obtained.
E) Provide a baseline to compare against.

Question 17

A nurse is caring for a patient who has an elevated temperature. The nurse plans to help the patient regain a normal temperature through conduction. What technique does the nurse use?

A) Placing a cooling fan in the patient's room
B) Putting ice packs in the patient's axillae
C) Spraying the patient with a fine mist of water
D) Turning the temperature down in the room

Question 18

A nurse performs orthostatic blood pressure readings on a patient with the following results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best?

A) Instruct the patient not to get up without help.
B) Document the findings and continue to monitor.
C) Reassure the patient that these findings are normal.
D) Reassess the blood pressures in 1 hour.

Question 19

The nurse assesses a patient's pulse and finds it hard to obliterate with palpation. What action by the nurse is the most appropriate?

A) Assess the patient for fluid volume overload.
B) Assess the patient for fluid volume deficit.
C) Assess the patient's apical heart rate.
D) Assess the patient's pulse deficit.

Question 20

A patient returned from a procedure and has vital sign measurements ordered every hour. The patient's blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg. What priority action by the nurse is most appropriate?

A) Take the vital signs again in another hour.
B) Document the findings in the patient's chart.
C) Have another nurse recheck the vital signs.
D) Plan to take the vital signs more often.

Question 21

A nurse is teaching a patient and the patient's family about self-care measures for hypertension. Which topics should the nurse include?

A) Increase exercise on most days.
B) Maintain a normal body weight.
C) Abstain from any alcohol.
D) Reduce dietary sodium to 2.4 g/day.
E) Follow the DASH diet.

Question 22

The nurse understands that which factors can increase blood pressure?

A) Head injury
B) Decreased fluid volume
C) Increasing age
D) Recent food intake
E) Pain

Question 23

Which patient-specific factors does the nurse include when assessing pulse?

A) Age
B) Gender
C) Religion
D) Exercise
E) Medications

Question 24

The nurse is performing a morning assessment and notes the patient to be experiencing dyspnea. Which patient assessment findings would most indicate this respiratory condition?

A) Occasional productive cough
B) Pulse oximetry 89%
C) Patient in orthopneic position
D) Respirations 26 & shallow
E) Temperature 100.1 °F

Question 25

The nurse assessing respirations understands that problems in what organs can directly affect the process of respiration?

A) Brain
B) Lungs
C) Heart
D) Liver
E) Skeletal muscle