Deck 30: Vital Signs

Question 1

While the nurse is assessing the patient's respirations,it is important for the patient to do what?

A)Be aware of the procedure being done.
B)Not know that respirations are being assessed.
C)Understand that respirations are estimated to save time.
D)Not be touched until the entire process is finished.

Answer 1

Not know that respirations are being assessed.

Question 2

How does the posterior hypothalamus help control temperature?

A)By causing vasoconstriction.
B)By shunting blood to the skin and extremities.
C)By increasing sweat production.
D)By causing vasodilation.

Answer 2

By causing vasoconstriction.

Question 3

The nurse is caring for a patient who has an elevated temperature.What should the nurse know?

A)Fever and hyperthermia are the same thing.
B)Hyperthermia occurs when the body cannot reduce heat loss.
C)Hyperthermia is an upward shift in the set point.
D)Hyperthermia occurs when the body cannot reduce heat production.

Answer 3

Hyperthermia occurs when the body cannot reduce heat production.

Question 4

The nurse is caring for an infant and is measuring vital signs.The best site for the nurse to obtain the infant's pulse would be which artery?

A)Radial.
B)Brachial.
C)Femoral.
D)Popliteal.

Question 5

The thickness or viscosity of the blood affects the ease with which blood flows through small vessels.Examining what value might help determine the amount of blood viscosity?

A)Hematocrit.
B)Cardiac output.
C)Arterial size.
D)Blood volume.

Question 6

The nurse working the night shift on a surgical unit is making rounds at 0400 hours.She notices that the patient's temperature is 36°C (96.8°F),whereas at 1600 hours the preceding day,it was 37°C (98.6°F).What should the nurse do?

A)Call the physician immediately to report a possible infection.
B)Realize that this is a normal temperature variation.
C)Provide another blanket to conserve body temperature.
D)Provide medication to lower the temperature further.

Question 7

The patient has a temperature of 40.7°C (105.2°F).The nurse is attempting to lower his temperature by providing tepid sponge baths and placing cool compresses in strategic body locations.The nurse is attempting to lower the patient's temperature through the use of which of the following?

A)Radiation.
B)Conduction.
C)Convection.
D)Evaporation.

Question 8

The nurse is caring for a patient who has a temperature reading of 38°C (100.4°F).His last two temperature readings were 37°C (98.6°F)and 36°C (96.8°F).The nurse should

A)Call the physician and anticipate an order to treat the fever.
B)Assume that the patient has an infection and order blood cultures.
C)Wait an hour and recheck the patient's temperature.
D)Be aware that temperatures this high are harmful and affect patient safety.

Question 9

The patient is being admitted to the emergency department with complaints of shortness of breath.The patient has had chronic lung disease for many years but still smokes.What should the nurse do?

A)Administer high levels of oxygen.
B)Use oxygen cautiously in this patient.
C)Place a paper bag over the patient's face to allow rebreathing of carbon dioxide.
D)Administer CO₂ via mask.

Question 10

The patient requires routine temperature assessment but is confused and easily agitated and has a history of seizures.The nurse's best option would be to take his temperature

A)Orally.
B)Tympanically.
C)Rectally.
D)By the axillary method.

Question 11

The patient needs temperatures measured every two hours.Which of the following cannot be delegated to an unregulated care provider?

A)Selecting appropriate route and device.
B)Obtaining temperature measurement at ordered frequency.
C)Being aware of the usual values for the patient.
D)Assessing changes in body temperature.

Question 12

The patient's blood pressure is 140/60.How would the nurse would record the pulse pressure?

A)As 140.
B)As 60.
C)As 80.
D)As 200.

Question 13

When heat loss mechanisms of the body are unable to keep pace with excess heat production,the result is known as

A)Pyrexia.
B)The plateau phase.
C)The set point.
D)Becoming afebrile.

Question 14

Which statement is true of the ovulation phase?

A)Progesterone levels are below normal.
B)Body temperature is below baseline levels.
C)Body temperature is at previous baseline levels or higher.
D)Intense body heat and sweating occur.

Question 15

The nurse needs to measure the radial pulse in a patient.For accuracy,what must the nurse do?

A)Place the tips of the nurse's first two fingers over the groove along the thumb side of the patient's wrist.
B)Place the thumb over the groove along the thumb side of the patient's wrist.
C)Apply a very light touch so that the pulse is not obliterated.
D)Apply very strong pressure to detect the pulse.

Question 16

The patient is being admitted to the emergency department after a motor vehicle accident.His jaw is broken,and he has several broken teeth.He is ashen,and his skin is cool and diaphoretic.To obtain an accurate temperature,the nurse uses which of the following routes?

A)Oral.
B)Axillary.
C)Rectal.
D)Temporal.

Question 17

The patient is found to be unresponsive and not breathing.To determine the presence of central blood circulation and circulation of blood to the brain,the nurse checks which pulse?

A)Radial.
B)Brachial.
C)Posterior tibial.
D)Carotid.

Question 18

Of the following mechanisms of heat loss by the body,identify the mechanism that transfers heat away by using air movement?

A)Radiation.
B)Conduction.
C)Convection.
D)Evaporation.

Question 19

When focusing on temperature regulation of newborns and infants,what should the nurse know?

A)Temperatures are basically the same for infants and older persons.
B)Infants have well-developed temperature-regulating mechanisms.
C)The normal temperature range gradually increases as the person ages.
D)Newborns need to wear a cap to prevent heat loss.

Question 20

The patient is restless and has a temperature of 39°C (102.2°F).What is one of the first things the nurse should do?

A)Place the patient on oxygen.
B)Restrict fluid intake.
C)Increase patient activity.
D)Increase patient's metabolic rate.

Question 21

The physician's order reads "Lopressor (metoprolol)50 mg PO daily.Do not give if blood pressure is less than 100 mm Hg systolic." The patient's blood pressure is 92/66.The nurse does not give the medication;what else does the nurse do?

A)Does not tell the patient what the blood pressure is.
B)Documents only what the blood pressure was.
C)Documents that the medication was not given owing to low blood pressure.
D)Does not need to inform the health care provider that the medication was withheld.

Question 22

When temperature assessment is required,which of the following cannot be delegated to an unregulated care provider?

A)Temperature measurement.
B)Assessment of changes in body temperature.
C)Selection of appropriate route and device.
D)Consideration of factors that falsely raise temperature.

Question 23

Of the following values,which value would be considered as a high normal reading?

A)98/50 in a 7-year-old child.
B)115/70 in an infant.
C)135/85 in an older person.
D)120/80 in a middle-aged adult.

Question 24

The patient is admitted with shortness of breath and chest discomfort.Which of the following laboratory values could account for the patient's symptoms?

A)Hemoglobin level of 80 g/L.
B)Hematocrit level of 45%.
C)Red blood cell count of 5.0 million/mm3.
D)Pulse oximetry value of 90%.

Question 25

When assessing the temperature of newborns and children,the nurse decides to utilize a temporal artery thermometer.Why is this preferable to methods used for adults?

A)It is accurate even when the forehead is covered with hair.
B)It is not affected by skin moisture.
C)It reflects rapid changes in radiant temperature.
D)There is no risk of injury to patient or nurse.

Question 26

The patient was found unresponsive in her apartment and is being brought to the emergency department.She has arm,hand,and leg edema;her temperature is 35.3°C (95.6°F);and her hands are cold secondary to her history of peripheral vascular disease.It is reported that she has a latex allergy.To quickly measure the patient's oxygen saturation,what should the nurse do?

A)Attach a finger probe to the patient's index finger.
B)Place a nonadhesive sensor on the patient's ear lobe.
C)Attach a disposable adhesive sensor to the bridge of the patient's nose.
D)Place the sensor on the same arm that the electronic blood pressure cuff is on.

Question 27

The nurse is caring for a newborn in the hospital nursery.She notices that the infant is breathing rapidly but is pink,warm,and dry.The nurse knows that the normal respiratory rate for a newborn is how many breaths per minute?

A)30 to 60.
B)25 to 32.
C)16 to 19.
D)12 to 20.

Question 28

When taking the pulse of an infant,the nurse notices that the rate is 145 beats/min and the rhythm is regular.The nurse realizes that this rate is which of the following?

A)Normal for an infant.
B)The proper rate for a toddler.
C)Too slow for an infant.
D)The same as that of a normal adult.

Question 29

The nurse is caring for an elderly patient and notes that his temperature is 36°C (96.8°F).This patient is in which condition?

A)Suffering from hypothermia.
B)Expressing a normal temperature.
C)Hyperthermic relative to his age.
D)Demonstrating the increased metabolism that accompanies aging.

Question 30

After measuring the patient's temperature,the nurse documents the value and the route used to obtain the reading.Why is this done?

A)Temperatures are the same regardless of the route used.
B)Temperatures vary depending on the route used.
C)Temperatures are cooler when taken rectally than when taken orally.
D)Axillary temperatures are higher than oral temperatures.

Question 31

The nurse is caring for a patient who has a pulse rate of 44.His blood pressure is within normal limits.In trying to determine the cause of the patient's low heart rate,what would the nurse suspect?

A)That the patient has a fever.
B)Possible hemorrhage or bleeding.
C)That the patient is taking calcium channel blockers or digitalis medications.
D)Chronic obstructive pulmonary disease (COPD).

Question 32

The unregulated care provider is measuring vital signs and reports that a patient's blood pressure is abnormally low.What should the nurse do?

A)Have the unregulated care provider retake the blood pressure.
B)Ignore the report and have it rechecked at the next scheduled time.
C)Retake the blood pressure herself and assess the patient's condition.
D)Have the unregulated care provider assess the patient's other vital signs.

Question 33

A nurse is caring for a patient who smokes and drinks caffeine.Which point is important for the nurse to understand before she assesses the patient's blood pressure (BP)?

A)Neither caffeine nor smoking affects blood pressure.
B)She needs to insist that the patient stop smoking for at least 3 hours.
C)The nurse should have the patient perform mild exercises.
D)Caffeine and smoking can cause false BP elevations.

Question 34

While attempting to obtain oxygen saturation readings on a toddler,what should the nurse do?

A)Place the sensor on the earlobe.
B)Place the sensor on the bridge of the nose.
C)Determine whether the toddler has a tape allergy.
D)Ignore any variation between the oximeter pulse rate and the patient's apical pulse rate.

Question 35

Of the following patients,which one is the best candidate to have his temperature measured orally?

A)A 27-year-old postoperative patient with an elevated temperature.
B)A teenage boy who has just returned from outside "for a smoke."
C)An 87-year-old confused male suspected of hypothermia.
D)A 20-year-old male with a history of epilepsy.

Question 36

The nurse is preparing to assess the blood pressure of a 3-year-old.How should the nurse proceed?

A)Choose the cuff that says "Child" instead of "Infant."
B)Obtain the reading before the child has a chance to "settle down."
C)Use the diaphragm portion of the stethoscope to detect Korotkoff sounds.
D)Explain to the child what the procedure will be.

Question 37

Which artery is the most appropriate for assessing the pulse of a small child?

A)Radial.
B)Femoral.
C)Brachial.
D)Ulnar.

Question 38

The nurse is caring for a patient who complains of feeling light-headed and "woozy." The nurse checks the patient's pulse and finds that it is irregular.The patient's blood pressure is 100/72.It was 113/80 an hour earlier.What should the nurse do?

A)Call the physician immediately.
B)Perform an apical/radial pulse assessment.
C)Apply more pressure to the radial artery to assess the pulse.
D)Use own thumb to detect the patient's pulse.

Question 39

What is one benefit of using a stationary automatic blood pressure device?

A)It fits over clothing.
B)It is extremely reliable.
C)It is the method of choice for irregular heart rhythms.
D)It is more reliable when pressure is less than 90 mm Hg systolic.

Question 40

The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension.The patient is instructed to measure his blood pressure three times a day and to keep a record of the readings.The nurse recommends that the patient purchase a portable electronic blood pressure device.What other instruction should the nurse give the patient?

A)The patient can apply the cuff in any manner he chooses because the machine is designed to be used by nonprofessionals.
B)The patient must not adjust his medication dosages without consulting the health care provider.
C)The cuff can be placed over clothing if necessary.
D)The machine is accurate when blood pressures are low.

Question 41

When the nurse records the patient's respiratory status,what must be recorded? (Select all that apply. )

A)Respiratory rate.
B)Character of respirations.
C)Amount of oxygen therapy.
D)Only normal findings.
E)Only in the graphic section.

Question 42

The patient has new-onset restlessness and confusion.His pulse rate is elevated,as is his respiratory rate.His oxygen saturation,however,is 94% according to the portable pulse oximeter.The nurse ignores the oximeter reading and calls the physician to obtain an order for measuring arterial blood gases (ABGs).The nurse does this because many things can cause inaccurate pulse oximetry readings,including which of the following? (Select all that apply. )

A)Oxygen saturations (SaO₂)higher than 70%.
B)Carbon monoxide inhalation.
C)Nail polish.
D)Hypothermia at the assessment site.
E)Intravascular dyes.

Question 43

The nurse is assessing the patient and his family for probable familial causes of the patient's hypertension.The nurse begins by analyzing the patient's personal history,as well as family history and current lifestyle situation.Which of the following issues would be considered risk factors? (Select all that apply. )

A)Obesity.
B)Cigarette smoking.
C)Recent weight loss.
D)Heavy alcohol consumption.
E)Low blood cholesterol levels.

Question 44

Of the following sites,which are used for obtaining a core temperature? (Select all that apply. )

A)Oral.
B)Rectal.
C)Tympanic.
D)Axillary.
E)Pulmonary artery.

Question 45

The patient is being encouraged to purchase a portable automatic blood pressure device so he can monitor his own blood pressure at home.What are some of the benefits of self-monitoring? (Select all that apply. )

A)Blood pressures can be obtained if pulse rates become irregular.
B)Patients can provide information about patterns to health care providers.
C)Patients can actively participate in their treatment.
D)Self-monitoring helps with compliance and treatment.
E)The risk of obtaining an inaccurate reading is decreased.