Deck 77: Vital Signs

Question 1

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.The nurse should

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.

Answer 1

B
Because low levels of arterial O₂ provide the stimulus that allows the patient to breathe,administration of high oxygen levels will be fatal for patients with chronic lung disease.Oxygen must be used cautiously in these types of patients.Patients with chronic lung disease have ongoing hypercarbia (elevated CO₂ levels)and do not need to have CO₂ administered or "rebreathed."

Question 2

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

Answer 2

C
Waiting an hour and rechecking the patient's temperature would be the most appropriate action in this case.A fever usually is not harmful if it stays below 102.2° F (39° C),and a single temperature reading does not always indicate a fever.In addition to physical signs and symptoms of infection,a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time.Mild temperature elevations enhance the body's immune system by stimulating white blood cell production.Usually,staff nurses do not order blood cultures,and nurses should base actions on knowledge,not on assumptions.

Question 3

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

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

Answer 3

A
The hematocrit,or the percentage of red blood cells in the blood,determines blood viscosity.Blood pressure also depends on the cardiac output or volume pumped by the heart,but cardiac output does not affect viscosity.Arterial size helps to modify blood pressure.The smaller lumen of a vessel increases vascular resistance but does not affect viscosity.Blood volume also affects blood pressure,but it does not directly affect viscosity.

Question 4

The patient has a temperature of 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

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

Question 5

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 6

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

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.

Question 7

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 8

The nurse is caring for an infant and is obtaining the patient's vital signs.The best site for the nurse to obtain the infant's pulse would be the _____ artery.

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

Question 9

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 10

The patient is being admitted to the emergency department following 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 11

The nurse needs to obtain a radial pulse from a patient.To obtain the correct measure,what must the nurse do?

A) Place the tips of the 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 12

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 the patient's _____ pulse.

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

Question 13

The posterior hypothalamus helps control temperature by

A) Causing vasoconstriction.
B) Shunting blood to the skin and extremities.
C) Increasing sweat production.
D) Causing vasodilation.

Question 14

The patient requires temperatures to be taken every two hours.Which of the following cannot be delegated to nursing assistive personnel?

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 15

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 16

The nurse is working the night shift on a surgical unit and is making 4 AM rounds.She notices that the patient's temperature is 96.8° F (36° C),whereas at 4 PM the preceding day,it was 98.6° F (37° C).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 17

When focusing on temperature regulation of newborns and infants,the nurse understands that

A) Temperatures are basically the same for infants and older adults.
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 18

The patient is restless with a temperature of 102.2° F (39° C).One of the first things the nurse should do is

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

Question 19

The patient's blood pressure is 140/60.The nurse realizes that this equates to a pulse pressure of

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

Question 20

The nurse is caring for a patient who has an elevated temperature.The nurse understands that

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.

Question 21

Of the following values,which value would be considered prehypertension?

A) 98/50 in a 7-year-old child
B) 115/70 in an infant
C) 140/90 in an older adult
D) 120/80 in a middle-aged adult

Question 22

The physician 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 and

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 held.

Question 23

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,the nurse would suspect

A) That the patient would have a fever.
B) Possible hemorrhage or bleeding.
C) Calcium channel blockers or digitalis medications.
D) Chronic obstructive pulmonary disease (COPD).

Question 24

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 25

The nurse is caring for an elderly patient and notes that his temperature is 96.8° F (36° C).She understands that this patient is

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

Question 26

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

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

Question 27

The nurse is caring for a newborn infant 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 _____ breaths per minute.

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

Question 28

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 his thumb to detect the patient's pulse.

Question 29

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 his rate is

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 30

When temperature assessment is required,which of the following cannot be delegated to nursing assistive personnel?

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 31

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 8.0
B) Hematocrit level of 45%
C) Red blood cell count of 5.0 million/mm3
D) Pulse oximetry of 90%

Question 32

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 33

After taking 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 34

The incidence of hypertension is greater in which of the following?

A) Non-Hispanic Caucasians
B) African Americans
C) Asian Americans
D) Native Americans

Question 35

One benefit of using a stationary automatic blood pressure device is that the cuff

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

Question 36

The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension.The patient is instructed to take 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.The nurse also instructs the patient that the

A) Patient can apply the cuff in any manner he chooses because the machine is designed to be used by nonprofessionals.
B) Machine requires frequent calibration to ensure accuracy.
C) Cuff can be placed over clothing if necessary.
D) Machine is accurate when blood pressures are low.

Question 37

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?

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 38

Of the following patients,which one is the best candidate to have his temperature taken 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 39

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 40

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 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 41

When recording the patient's respiratory status,what must be recorded?

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 nursing assistive person is taking vital signs and reports that a patient's blood pressure is abnormally low.The nurse should

A) Have the nursing assistive person 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 nursing assistive person assess the patient's other vital signs.

Question 43

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 this?

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.

Question 44

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 an arterial blood gas (ABG).The nurse does this because many things can cause inaccurate pulse oximetry readings,including which of the following?

A) O₂ saturations (SaO₂) >70%
B) Carbon monoxide inhalation
C) Nail polish
D) Hypothermia at the assessment site
E) Intravascular dyes

Question 45

Of the following sites,which are used for obtaining a core temperature?

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

Question 46

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?

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