Deck 5: Vital Signs

Question 1

The patient has been in the hospital for several days for urosepsis.He has been responding favorably to treatment,and his vital signs have been "normal" for 2 days.When the nurse takes his vital signs,however,the patient's apical pulse is 152 and regular.The nurse suspects that:

A) He is having a reaction to his narcotic medication
B) He may be suffering from hypothermia
C) His fever may have returned
D) The patient may be an athlete

Answer 1

His fever may have returned

Question 2

An appropriate method for assessing a patient's respirations is for the nurse to:

A) Place the bed flat
B) Remove all supplemental oxygen sources from documentation
C) Explain to the patient that respirations are being assessed
D) Relax and gently place the patient's hand over the upper abdomen

Answer 2

Relax and gently place the patient's hand over the upper abdomen

Question 3

The patient is returning from a cardiac catheterization.The puncture site is in the right femoral artery.The patient is having vital signs assessed every 15 minutes.Along with vital signs,the nurse assesses the pedal pulses of the right and left feet.A major concern would be if:

A) Both pedal pulses were bounding
B) The femoral artery could be palpated
C) The right pedal pulse was weaker than the left
D) The radial artery pulse was 88

Answer 3

The right pedal pulse was weaker than the left

Question 4

The patient is a 1-year-old male infant who is admitted with possible sepsis.The patient is irritable and agitates easily.To assess the patient's temperature,the nurse should:

A) Take an oral temperature before doing anything else
B) Take an axillary temperature using the upper axilla
C) Place the child in the Sims' position for a rectal temperature
D) Take a rectal temperature as the last vital sign

Question 5

When inserting a rectal thermometer,the nurse encounters resistance.The nurse should:

A) Apply mild pressure to advance
B) Ask the patient to take deep breaths
C) Remove the thermometer immediately
D) Remove the thermometer and reinsert it gently

Question 6

The nurse should report an assessment of:

A) 14 respirations per minute for an adult patient
B) 16 respirations per minute for an 8-year-old patient
C) 25 respirations per minute for a toddler
D) 38 respirations per minute for a newborn

Question 7

When evaluating the radial pulse measurement technique of the nursing assistant,the nurse identifies appropriate technique when the assistant:

A) Has the patient's arm elevated
B) Positions the patient supine or sitting
C) Applies significant pressure to the pulse site
D) Counts the pulse for 15 seconds and multiplies by 4

Question 8

A person's core temperature is considered the most accurate since it is:

A) Reflective of the surrounding environment
B) The same for everyone
C) Controlled by the hypothalamus
D) Independent of external influences

Question 9

To conduct an assessment of a possible pulse deficit:

A) A nurse measures the pulse after the patient exercises
B) Two nurses check the same pulse on opposite sides of the body
C) Two nurses assess the apical and radial pulses and determine the difference
D) The current pulse is compared with previous pulse measurements for differences

Question 10

The nurse notices that the patient has an irregular pulse.She assesses the patient for a pulse deficit and finds it to be significant.The nurse should:

A) Do nothing and check the patient later to see if the pulse deficit remains
B) Assess blood pressure and neurological status
C) Refuse to answer patient questions related to why two nurses are needed
D) Have nursing assistive personnel take only apical pulses

Question 11

The patient is admitted with abdominal pain but also has a history of chronic obstructive pulmonary disease (COPD).His temperature is 37º C with a pulse rate of 88 beats per minute,a respiratory rate of 26,and a blood pressure of 144/92.His O₂ saturation,however,is 87%.The nurse should:

A) Contact the physician immediately
B) Continue to monitor the patient
C) Call for stat arterial blood gases (ABGs)
D) Realize that this is a normal saturation

Question 12

The nurse is about to take vital signs on a newborn patient in the nursery.She should:

A) Assess respiratory rate after taking a rectal temperature
B) Observe the child's chest while the child is sleeping
C) Call the physician if the rate is over 40
D) Expect that the child will have short periods of apnea

Question 13

An appropriate procedure for the measurement of an adult's temperature with a tympanic membrane sensor is:

A) Pulling the ear pinna down and back
B) Moving into the ear in a figure-eight pattern
C) Fitting the probe loosely into the ear canal
D) Pointing the probe toward the mouth and chin

Question 14

The nurse is caring for an infant in the NICU.While taking vital signs,the nurse finds that the baby's heart rate is 195.The nurse calls the physician,knowing that the normal heart rate should be:

A) 60 to 100 beats per minute
B) 100 to 160 beats per minute
C) 90 to 140 beats per minute
D) 220 or higher

Question 15

When evaluating the patient's temperature levels,the nurse expects the patient's temperature to be lower:

A) In the morning
B) After exercising
C) During periods of stress
D) During the postoperative period

Question 16

The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette.The patient has just returned from his "cigarette break." The nurse is about to take the patient's radial pulse and should:

A) Wait about 15 minutes before taking his pulse
B) Use her thumb to detect the pulse and get an accurate count
C) Press hard to detect the pulse and get an accurate count
D) Take his pulse for 15 seconds and multiply by four

Question 17

The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette.The patient has just returned from his "cigarette break." The nurse is about to take the patient's temperature orally and should:

A) Wait about 15 minutes before taking his temperature
B) Give him oral fluids to rinse the nicotine away before taking his temperature
C) Give him a stick of chewing gum to chew, then take his temperature
D) Take his oral temperature and record the findings

Question 18

The gold standard for assessing a patient's core temperature is:

A) The pulmonary artery thermometer
B) The oral temperature
C) The tympanic membrane temperature
D) The temporal artery temperature

Question 19

The nurse takes the patient's temperature using a tympanic electronic thermometer.The temperature reading is 36.5º C (97.7º F).The nurse knows that this correlates to:

A) 37.0º C (98.6º F) rectally
B) 37.0º C (98.6º F) orally
C) 36.0º C (97.7º F) axillary
D) 36.0º C (97.7º F) orally

Question 20

The patient is brought to the Emergency Department complaining of severe shortness of breath.She is cyanotic and her extremities are cold.In an attempt to quickly assess the patient's respiratory status,the nurse should:

A) Remove the patient's nail polish to get a pulse oximetry reading
B) Use a forehead probe to get a pulse oximetry reading
C) Use a finger probe to get a pulse oximetry reading
D) Check the color of the patient's nail polish before attempting a reading

Question 21

The patient has been sleeping and has been lying on his right side.The nurse is ready to take his temperature using a tympanic thermometer.She needs to insert the thermometer into his ___________ear.

Question 22

During the normal cardiac cycle,blood pressure reaches a peak,followed by a trough in the cycle.The peak is known as:

A) Pulse pressure
B) Systole
C) Diastole
D) Korotkoff phase

Question 23

When the benefits of the different types of blood pressure monitoring devices are compared,which of the following patients would be the best candidate for noninvasive electronic blood pressure measurement?

A) A 49-year-old postsurgical patient with no history of heart disease on q 15-minute vital signs
B) A 22-year-old patient undergoing active grand mal seizures
C) A 68-year-old patient with diagnosed peripheral vascular disease
D) A 54-year-old patient with chronic atrial fibrillation

Question 24

When heat loss mechanisms are unable to keep pace with heat production,____________ is the result.

Question 25

Which of the following processes are involved in respiration? (Select all that apply.)

A) Ventilation
B) Diffusion
C) Oximetry
D) Perfusion

Question 26

The patient is admitted in a near comatose state with a blood glucose level of 750.His respiratory rate is 42 breaths per minute,and his respiratory pattern is deep and regular.This type of breathing is known as:

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

Question 27

The patient is an 86-year-old woman who is being admitted for dehydration and pneumonia.The patient is lying in bed but tells the nurse that she needs to go to the bathroom.The nurse tells the patient that she will stay with her and will help her get there.The patient states,"That's OK.I can make it on my own." The nurse should:

A) Help the patient to the bathroom and stay with her
B) Allow the patient to get up on her own and go to the bathroom
C) Allow the patient to go to the bathroom and call for help if needed
D) Insert a Foley catheter

Question 28

The site used to auscultate blood pressure is the:

A) Radial
B) Ulnar
C) Brachial
D) Temporal

Question 29

___________,a subjective symptom,also is referred to as a vital sign,along with the physiological signs.

Question 30

The nurse is about to take a patient's blood pressure.Which of the following conditions would cause the nurse to obtain a falsely high reading? (Select all that apply.)

A) Bladder cuff too narrow
B) Bladder cuff too wide
C) Patient's arm below the level of the heart
D) Inflating the cuff too slowly

Question 31

During his initial screening,the patient's blood pressure was noted to be elevated.Two months after the first assessment,he was noted to have a blood pressure of 150/92 and 166/96 at different times during the visit.It is now a month and a half later,and the nurse is concerned because the patient's initial blood pressure on this visit was 154/94.She is preparing to take a second blood pressure,understanding that another reading in this range could lead to a diagnosis of:

A) Hypotension
B) Prehypertension
C) Hypertension
D) Orthostatic hypotension

Question 32

A disadvantage of the disposable sensor pad for pulse oximetry is:

A) It is less restrictive
B) It contains latex
C) It is less expensive to use
D) It is available in different sizes

Question 33

The nurse chooses a sphygmomanometer that has a circular gauge and a needle that registers the millimeter calibrations.This type of device is known as a(n):

A) Mercury manometer
B) Electronic manometer
C) Aneroid manometer
D) Direct (invasive) manometer

Question 34

The nurse is working on the general surgical unit and is caring for a patient who has a right total mastectomy.To take the patient's vital signs and to accurately assess the patient's blood pressure,it will be necessary to:

A) Place the blood pressure cuff on the left upper arm
B) Place the blood pressure cuff on the right upper arm
C) Place the blood pressure cuff on the right lower arm
D) Use direct (invasive) blood pressure measurement

Question 35

The patient was found in an alley on a cold winter night and is admitted with hypothermia from environmental exposure.She is elderly and is having difficulty breathing.Her breath sounds are diminished,and the tip of her nose is cyanotic.The nurse wants to assess the oxygen level in the patient's blood.She decides to use the pulse oximeter.The best way to apply this to this patient would be:

A) With a finger probe
B) With an earlobe sensor
C) With a forehead reflectance sensor
D) With a toe sensor

Question 36

The patient is complaining of a severe headache.The nurse takes the patient's blood pressure and finds it to be 240/110.The pulse pressure then is:

A) 110
B) 240
C) 130
D) 350

Question 37

The nurse is caring for a 2-year-old child who is admitted with croup and crying.To take the child's vital signs,the nurse should:

A) Place the pediatric blood pressure cuff on the left arm
B) Place the blood pressure cuff on the right thigh
C) Skip the blood pressure measurement
D) Place the blood pressure cuff on the left thigh

Question 38

The nurse is preparing to take the patient's temperature.Which of the following may cause the temperature to fluctuate? (Select all that apply.)

A) Age
B) Stress
C) Hormones
D) Medications
E) None of above

Question 39

The nurse is taking a rectal temperature on an adult patient.She expects to insert the thermometer __________ inches.

Question 40

The nurse is about to teach the patient about risk factors for hypertension.Which of the following are risk factors for hypertension? (Select all that apply.)

A) Obesity
B) Cigarette smoking
C) High blood cholesterol
D) Renal disease
E) None of above

Question 41

_________ is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction.

Question 42

___________ is the sound of the tricuspid and mitral valves closing at the end of ventricular filling.

Question 43

An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a ____________.

Question 44

An irregular heartbeat,often found in children,that speeds up with inspiration and slows down with expiration is known as a sinus ___________.

Question 45

The percent to which hemoglobin is filled with oxygen is known as _________________.

Question 46

_____________ occurs when the systolic blood pressure falls to 90 mm Hg or below.

Question 47

To take a manual blood pressure,the nurse places the cuff of the _____________ around the patient's upper arm.

Question 48

When the proper size blood pressure cuff is determined,the width of the cuff should be ________% of the circumference of the limb being assessed.

Question 49

After applying the sphygmomanometer to the patient's upper arm,the nurse inflates the cuff to the proper level,and then,using a stethoscope,listens for the __________________ sounds.