Deck 17: Vital Signs

Question 1

A client is diagnosed with congestive heart failure.For which reason will this client have a low cardiac output?

A)An expected increase in stroke volume
B)A long history of pain and fatigue
C)The low blood volume that accompanies congestive heart failure
D)Weakened and damaged heart muscle

Answer 1

Weakened and damaged heart muscle

Question 2

A client accidentally receives an entire liter of intravenous fluid over 3 hours.Which should the nurse expect when assessing this client's pulse?

A)Weak and thready
B)Full and bounding
C)Regular and thready
D)Irregular and slower

Answer 2

Full and bounding

Question 3

The nurse reviews the vital signs assessed on a group of clients.Which client should have these signs remeasured within 4 hours? Select all that apply.

A)Blood pressure (BP)164/90, temperature (T)98.4°F, pulse rate (P)89 bounding and regular, respiration rate (R)26
B)BP 116/72, T 100.6°F, P 88 strong and regular, R 32
C)BP 110/74, T 97.8°F, P 74 strong and regular, R 19
D)BP 128/68, T 98.6°F, P 80 strong and regular, R 20
E)BP 112/86, T 97.8°F, P 48 weak and irregular, R 24

Answer 3

Blood pressure (BP)164/90, temperature (T)98.4°F, pulse rate (P)89 bounding and regular, respiration rate (R)26
BP 116/72, T 100.6°F, P 88 strong and regular, R 32
BP 112/86, T 97.8°F, P 48 weak and irregular, R 24

Question 4

The nurse notes that a client is experiencing respirations that are increased in rate and depth with long blowing exhalations.Which respiratory pattern should the nurse document for this client?

A)Bradypnea
B)Biot's respirations
C)Kussmaul's respirations
D)Cheyne-Stokes respirations

Question 5

The nurse is preparing to measure a client's blood pressure.Which should the nurse do before taking the client's blood pressure? Select all that apply.

A)Select the correct size of cuff.
B)Ask the client if there is a reason to not take the blood pressure on either arm.
C)Change the ear pieces of the stethoscope.
D)Assess the client's peripheral pulses.
E)Lower the bed to its lowest position.

Question 6

The nurse prepares to count a client's breathing rate.Which should the nurse count when completing this assessment?

A)The number of times the chest falls
B)The number of times the chest rises
C)The length of time between breathing in and breathing out
D)The number of times the client breathes in and breathes out

Question 7

The nurse is asked to explain the difference between core temperature and the temperature measured through the tympanic route.Which response should the nurse make?

A)"A tympanic temperature is obtained using sterile technique and is more time consuming."
B)"The core temperature is more reflective of the environment the internal organs are being exposed to."
C)"Obtaining a core temperature far outweighs the benefits of a tympanic temperature because it is less invasive."
D)"Measuring a tympanic temperature is uncomfortable and more invasive."

Question 8

A client is prescribed to have core body temperature measurements twice a day.For which client situation should the nurse discuss this measurement with the health-care provider?

A)Wearing oxygen
B)Wearing leg splints
C)Experiencing diarrhea
D)Receiving intravenous fluids

Question 9

In which situation should the nurse assess vital signs instead of delegating it to unlicensed assistive personnel (UAP)? Select all that apply.

A)A client is being admitted to the facility.
B)A client is in an unstable postoperative condition.
C)A client is obese.
D)A client is being administered intravenous (IV)medications that may affect the vital signs.
E)A client has pale, cold, and clammy skin.

Question 10

The nurse is concerned that a client's respiratory rate is 8 breaths per minute.Which should the nurse consider as a reason for this slow respiratory rate? Select all that apply.

A)Pain
B)Sleeping
C)Cold environment
D)Narcotic pain medication
E)Increased intracranial pressure

Question 11

The nurse suspects that a client is experiencing orthostatic hypotension.Which blood pressure did the nurse measure to make this clinical determination? Select all that apply.

A)20 mm Hg higher when sitting than when lying down
B)20 mm Hg lower when sitting than when lying down
C)20 mm Hg higher when lying down than when sitting
D)20 mm Hg lower when standing than when sitting
E)20 mm Hg higher when standing than when lying down

Question 12

The nurse reviews care needed for a group of clients.For which client should the nurse expect to monitor vital signs more frequently?

A)Client with a foot wound
B)Client ambulating with a walker
C)Client receiving a blood transfusion
D)Client eating food for the first time after surgery

Question 13

The nurse gently squeezes a client's nailbed and counts the number of seconds until color returns to the nailbed.What is the nurse assessing in this client?

A)Pulse deficit
B)Pain response
C)Capillary refill
D)Skin temperature

Question 14

The nurse is called to the room of a client who is having audible, high-pitched crowing sounds.For which reason should the nurse notify the health-care provider?

A)Rales
B)Stridor
C)Rhonchi
D)Wheezes

Question 15

The nurse is assessing a client who is experiencing pain.Which finding supports the client has chronic pain? Select all that apply.

A)Blood pressure (BP)116/84, pulse rate (P)76, respiration rate (R)18
B)Sudden sharp, stabbing pain
C)Dull, aching pain over past 7 months
D)Dilated pupils
E)Withdrawn with loss of appetite

Question 16

The nurse prepares information on actions to control blood pressure for a client.Which assessment finding caused the nurse to make this clinical determination?

A)Body mass index 19
B)Manager of a finance firm
C)Smokes 1 pack per day of cigarettes
D)Mother diagnosed with hypertension
E)Ingests a six-pack of beer every 2 nights

Question 17

The nurse is preparing to measure a client's blood pressure.Which should the nurse explain that blood pressure measures?

A)The amount of blood volume within the blood vessels
B)The amount of resistance within the veins during heart contractions
C)The amount of force being placed on arteries by blood
D)The amount of pressure exerted by the veins and arteries on the heart

Question 18

The nurse prepares to assess a client's temperature.Which should the nurse keep in mind that can falsely lower the body temperature? Select all that apply.

A)Drinking something cold
B)Exercising
C)An outdoor temperature of 99°F
D)A cold climate
E)Physical inactivity

Question 19

The nurse measures the vital signs of a client experiencing a new health problem.For which reason might the client's body temperature be elevated?

A)Snow storm occurring
B)Stress about the health problem
C)Air conditioning on in the room
D)Time of measurement before noon

Question 20

While assessing a client, the nurse notes that the pulse is easily detected, feels strong, and is easily counted, but can be obliterated with moderate pressure.How should the nurse document this pulse?

A)1+
B)2+
C)3+
D)Thready