Deck 3: Vital Signs and Vital Measurements

Question 1

A student asks: How often should the nurse take vital signs? Which response by the nurse is best?

A) Every 4 hours
B) As prescribed
C) Depends on the unit
D) Depends on the client's status

Answer 1

Depends on the client's status

Question 2

The nurse takes a client's temperature. What action is most important?

A) Comparing it to the client's baseline
B) Documenting it as soon as possible
C) Medicating for fever if it is high
D) Warming the client up if it is low

Answer 2

Comparing it to the client's baseline

Question 3

The nurse needs to take a client's oral temperature. The client just drank a cup of coffee. What action by the nurse is best?

A) Obtain a rectal temperature.
B) Return in 30 minutes.
C) Chart "unable to obtain."
D) Take the temperature anyway.

Answer 3

Return in 30 minutes.

Question 4

Which method is the correct way to use a tympanic thermometer?

A) Pull the pinna up and back on an adult.
B) Pull the pinna down and forward on a child under 3.
C) Pull the tragus straight up on an adult.
D) Pull the tragus straight down on a child under 3.

Question 5

A nurse is applying conductive heating therapy. What action does the nurse perform?

A) Applies a heating blanket connected to circulating warm water.
B) Blows warm air over the client.
C) Applies a blanket with warm air circulating through it.
D) Places the client in a warm bathing.

Question 6

A client using a thermal heating unit developed a skin burn. In completing the variance report, what question does the charge nurse ask the client's nurse?

A) "Did you use distilled water or tap water?"
B) "Was the skin under the warming unit dry?"
C) "Did you program the set-point too low?"
D) "Were all the connector hoses clamped tightly?"

Question 7

The nurse takes the pulse of several clients. Which client would the nurse need to assess further?

A) Newborn, 158 beats/minute
B) 1 year old, 124 beats/minute
C) Teenager, 94 beats/minute
D) Older adult, 50 beats/minute

Question 8

The student reports that an adult client's pulse is 138 beats/minute at rest and thready. What instruction does the faculty give to the student?

A) "Have your backup nurse verify your findings."
B) "What do you think that signifies for your client?"
C) "Re-check the pulses in 10 minutes and inform me."
D) "Go take the client's blood pressure right now."

Question 9

A client who has been resting quietly all day becomes restless and anxious. What action by the nurse takes priority?

A) Ask the client to rate his or her pain.
B) Administer a mild sedative.
C) Ask if the client would like to talk.
D) Check the client's oxygen saturation.

Question 10

A client asks why the provider wants a weekly blood pressure taken at home. "What's the big deal if my blood pressure is a little high?" What response by the nurse is best?

A) "The provider is concerned that your blood pressure may get worse."
B) "By reporting your blood pressure, the provider will know when to start medication."
C) "High blood pressure is the second leading cause of death and a risk for cardiovascular problems."
D) "Your provider wants to make sure it doesn't go any higher."

Question 11

A nurse assesses a client's blood pressure to be much higher than usual. What action by the nurse is best?

A) Document the findings.
B) Assess the client for pain.
C) Have someone verify the reading.
D) Notify the provider.

Question 12

Two nurses are counting the older client's pulse. The nurse taking the radial pulse obtains 102 beat/minute. The nurse counting the apical pulse obtains 86 beats/minute. What do the nurses surmise about this discrepancy?

A) This is a normal finding in the older population.
B) The pulse deficit of 16 warrants further assessment.
C) The client has decreased perfusion to the brain.
D) A pulse deficit of 20 warrants more assessment.

Question 13

The nurse has assessed four adult clients. Which client is the priority for the nurse to assess more thoroughly?

A) Pulse: 4+, 102 beats/minute
B) Pulse: unable to feel radially; skin pink, warm, and dry
C) Pulse: 1+, 110 beats/minute
D) Pulse: 2+, 88 beats/minute

Question 14

Which is the correct procedure for obtaining a dorsalis pedis pulse?

A) Use the tip of 2 to 3 fingers to palpate the medial aspect of the client's malleolus.
B) Use the fingertips in the popliteal fossa to compress the artery to the bone.
C) Using gloves, palpate midway between the anterior iliac spine and the symphysis pubis.
D) Use 2 to 3 finger pads to palpate the groove midway or just distal to the arch of the foot.

Question 15

A nurse is counting an 8-month old's respiratory rate. Which is the correct technique?

A) Have the parent hold the child and count them for you.
B) Stand nearby and count abdominal excursions.
C) Palpate the brachial artery with baby on the exam table.
D) While baby is sleeping, place your stethoscope lightly on its chest.

Question 16

A client's pulse oximeter reading is 97%; however the client is reporting shortness of breath. What action does the nurse take first?

A) Review today's laboratory values
B) Reassure the client he/she is fine
C) Replace the probe with a new one
D) Move the probe to another location

Question 17

A client is in the hospital after having an operation. The client's fasting blood glucose is 186 mg/dL. The client is alarmed and says "Oh, no! Do I have diabetes now?" What response by the nurse is best?

A) "There is no way to be sure with only one reading."
B) "This is an emergency reading. I have to notify your provider."
C) "Many things can influence blood glucose, including surgery."
D) "I will return in 20 minutes and recheck it at that time."

Question 18

The new nurse is obtaining a finger-stick blood glucose reading. What action by the nurse shows good understanding of this technique?

A) Selects the pad of the client's index finger for testing
B) Quickly collects the first drop of blood after piercing the skin
C) Checks the expiration date on the bottle of strips
D) Cleans the chosen site with soap and water

Question 19

Which action by the nurse shows understanding of age-related differences in obtaining vital signs?

A) The brachial pulse is used for heart rate in children under 2.
B) Rectal temperatures are appropriate up to age 3.
C) Older adults may need the cuff placed over their clothes.
D) Temporal artery thermometers are not reliable in the older adult.

Question 20

The client's pulse oximeter is not providing a reliable reading. What actions are appropriate for the nurse to take? (Select all that apply.)

A) Remove any nail polish present.
B) Check the circulation to the probe site.
C) Wash and reapply the probe.
D) Remove the probe if the client is not short of breath.
E) Take the client's temperature.

Question 21

The nursing student learns about taking blood pressures. Which actions by the student demonstrate the need to review this skill? (Select all that apply.)

A) Ensures the cuff size is appropriate for the client
B) Holds client's arm up to a level comfortable for the student
C) Places the cuff and stethoscope over clothing to avoid hurting the client
D) Inflates the cuff to 30 mm Hg over the palpated systolic blood pressure
E) Listens for the emergence of the phase I Korotkoff sound
F) Waits 20 minutes before repeating the blood pressure if needed

Question 22

The student nurse is obtaining an apical pulse. What anatomical landmarks does the student use to place the stethoscope? (Select all that apply.)

A) 5th left intercostal space
B) Right Mid-axillary line
C) 2nd right intercostal space
D) Left midclavicular line
E) Anterior chest
F) Posterior chest

Question 23

Which statements related to blood pressure are accurate? (Select all that apply.)

A) Decreased blood volume will decrease blood pressure.
B) Autonomic nervous system stimulation will lower blood pressure.
C) Sitting blood pressures are lower than those taken with the client supine.
D) Anxiety, fear, and pain can increase blood pressure.
E) Isolated systolic hypertension is common in older adults.

Question 24

The student learns that which of these factors make newborns so vulnerable to hypothermia? (Select all that apply.)

A) They have fewer fat reserves.
B) They have more stored glycogen.
C) They shiver too readily.
D) They have a higher surface area to body mass.
E) They have underdeveloped muscles.

Question 25

The nurse knows that vital sign measurements can be influenced by which of the following factors? (Select all that apply.)

A) Pain
B) Infections
C) Activity
D) Emotions
E) Medications
F) Compensation