Question 1

A nurse is taking vital signs of an adult patient whose oxygen saturation is 96%. The patient's temperature is 102° F, blood pressure is 130/86, pulse is 100 beats/min, and respiratory rate is 26 breaths/min. Which factor may be contributing to the elevated respiratory rate?

A) The patient's temperature
B) The patient's oxygen saturation
C) The patient's pulse rate
D) The patient's blood pressure

The patient's temperature

Accepted Answer

Fever is a factor that may increase respiratory rate, and this patient's temperature is 102° F. The patient's oxygen saturation is a measure of the oxygen carried by hemoglobin and it is within expected limits-above 90%. The patient's pulse rate may be due to the high temperature, but a pulse of 100 does not contribute to an elevated respiratory rate in this case. The patient's blood pressure is higher than normal, but does not contribute to an elevated respiratory rate in this case.

Question 2

A nurse notices that the patient has gained 11 lb. If this increase in weight is related to fluid retention, the patient is retaining approximately how many liters of fluid?&#10;A) 1 L&#10;B) 5 L&#10;C) 11 L&#10;D) 24 L

Accepted Answer

Every kilogram (kg) equals a liter of fluid. Thus, 11 lb ÷ 2.2 = 5 L.

Question 3

Which of these respiratory rates are within normal limits?&#10;A) 16-month-old; 42&#10;B) 6-year-old; 20&#10;C) 14-year-old; 26&#10;D) 40-year-old; 10

Accepted Answer

A school-age child's respiratory rate ranges from 18 to 26. A toddler's respiratory rate ranges from 24 to 40. An adolescent's respiratory rate ranges from 12 to 16. An adult's respiratory rate ranges from 12 to 20.

Question 4

The nurse suspects an irregularity in the rhythm of the patient's radial pulse. What is the most appropriate action for this nurse to take at this time?&#10;A) Document this rhythm as normal for the patient.&#10;B) Use a Doppler to check the brachial pulse.&#10;C) Count the patient's apical pulse for a full minute.&#10;D) Count the radial pulse again for 15 seconds and multiply by 4.

Accepted Answer

When an irregular pulse is palpated, the nurse counts the number of pulsations for a full minute. An irregular rhythm is not a normal finding. The pulsation between each beat should be the same or regular. A Doppler is not indicated in this case; it is used when the pulse cannot be palpated. Counting the radial pulse again for 15 seconds and multiplying by 4 may reconfirm the initial findings, but does not provide additional data for the nurse on this patient.

Question 5

Which action by the nurse results in the patient's blood pressure measurement being falsely high? (Select all that apply.)&#10;A) Using a blood pressure cuff that is too narrow for the patient's upper arm&#10;B) Deflating the blood pressure cuff too rapidly&#10;C) Wrapping the blood pressure cuff too loosely&#10;D) Reinflating the blood pressure cuff before it completely deflates&#10;E) Positioning the patients arm above the level of the heart

Accepted Answer

Using a blood pressure cuff that is too narrow for the patient's upper arm, wrapping the cuff too loosely, reinflating the cuff before it completely deflates, and positioning the patients arm above the level of the heart all result in readings that are falsely high. Deflating the blood pressure cuff too rapidly causes the blood pressure reading to be falsely low.

Question 6

Which method of temperature measurement does a nurse choose when assessing school-aged children in a wellness clinic? (Select all that apply.)&#10;A) Axillary temperature&#10;B) Rectal temperature&#10;C) Temporal artery temperature&#10;D) Oral temperature&#10;E) Tympanic membrane temperature

Accepted Answer

Axillary, temporal artery, oral, and tympanic membrane temperatures are appropriate for children. A rectal temperature is sometimes appropriate for young infants, but not routinely; and is used for other ages if other routes are not available or if the child is unable to cooperate, is unconscious, is agitated, or is prone to seizures. Rectal temperature measurement is considered safe and accurate for adults only. A rectal temperature is sometimes appropriate for young infants, but not routinely; and is used for other ages if other routes are not available or if the child is unable to cooperate, is unconscious, is agitated, or is prone to seizures.

Question 7

A temperature of 99.8&#176; F taken in the axilla is equivalent to which temperature value taken orally?&#10;A) 100.8&#176; F&#10;B) 99.8&#176; F&#10;C) 98.8&#176; F&#10;D) 97.8&#176; F

Accepted Answer

Normal temperature readings from the axilla are about 1° F below the normal oral temperature.

Question 8

Which statement is correct regarding taking or interpreting axillary temperatures?&#10;A) Axillary temperatures should not be used in patients less than 2 years of age.&#10;B) Readings may be less accurate.&#10;C) The thermometer is left in place for no more than 3 minutes.&#10;D) The thermometer is placed in the axilla with the shoulder abducted.

Accepted Answer

Multiple studies have shown temperature measurements at the axillary site are less accurate compared with alternative sites. The axilla is a common site for temperature measurement on infants and children. The thermometer is left in place until the audible signal occurs and the temperature appears on the screen. Place the probe in the middle of the axilla, with the arm held against the body (adducted).

Question 9

Which body system does the nurse assess primarily by inspection?&#10;A) Respiratory&#10;B) Gastrointestinal&#10;C) Skin&#10;D) Cardiovascular

Accepted Answer

Skin is assessed primarily using inspection, but also palpation. The respiratory system is assessed primarily using auscultation, but also percussion and inspection when observing pale or cyanotic skin from hypoxia. The gastrointestinal system is assessed primarily by auscultation and palpation, but also with inspection when looking at the contour of the abdomen. The cardiovascular system is assessed primarily with auscultation and palpation, but also by inspection when looking at the color of extremities for evidence of perfusion or edema.

Question 10

According to research findings, which site is preferred for measuring blood pressure when the nurse is unable to use the patient's upper arms?&#10;A) Ankle&#10;B) Thigh&#10;C) Calf&#10;D) Wrist

Accepted Answer

A study comparing accuracy among sites recommended the ankle as an alternative site for blood pressure measurement. The thigh is an alternative site, but the ankle is the preferred site. A study comparing accuracy among sites recommended the ankle site in preference to the calf as an alternative site for blood pressure measurement if the upper arm is unavailable. Approaches to measuring blood pressure using the wrist and finger sites have been developed, but these lack acceptable accuracy and cost efficiency to be recommended for clinical practice.

Question 11

The nurse taking a patient's blood pressure recognizes that several factors may cause an increased blood pressure reading. Which factors below can increase blood pressure? (Select all that apply.)&#10;A) The patient rates pain at a level of 7 on a scale of 0 to 10.&#10;B) The cuff was reinflated before being completely deflated.&#10;C) The patient drank cold milk just before the reading.&#10;D) The time of day is late afternoon.&#10;E) The cuff is too wide for the extremity.

Accepted Answer

The answer of The nurse taking a patient's blood pressure...

Question 12

Which action by the nurse results in the patient's blood pressure measurement being falsely low? (Select all that apply.)&#10;A) Using a blood pressure cuff that is too wide for the patients arm&#10;B) Not inflating the blood pressure cuff enough&#10;C) Positioning the patient's arm above the level of the heart&#10;D) Wrapping the cuff too loosely around the arm&#10;E) Deflating the cuff too rapidly

Accepted Answer

The answer of Which action by the nurse results in...

Question 13

A patient's blood pressure has been averaging 120/72 when using the upper arms. Today, the nurse uses this patient's thigh to measure the blood pressure. What is the expected systolic pressure using the thigh that is equivalent to a systolic pressure of 120?

A) A systolic reading of 110 mm Hg
B) A systolic reading of 120 mm Hg
C) A systolic reading of 140 mm Hg
D) A systolic reading of 170 mm Hg

Accepted Answer

The answer of A patient's blood pressure has been averaging...

Question 14

A female patient admitted with fluid retention has been in diuretic therapy to remove fluid. She weighed 187 lb on admission. Today she weighs 179 lb. Since admission, this patient has lost _____ L from fluid loss.

Accepted Answer

The answer of A female patient admitted with fluid retention...

Question 15

Which method of temperature measurement indirectly reflects inner core temperature? (Select all that apply.)&#10;A) Axillary temperature&#10;B) Oral temperature&#10;C) Tympanic temperature&#10;D) Rectal temperature&#10;E) Temporal artery temperature

Accepted Answer

The answer of Which method of temperature measurement indirectly reflects...

Question 16

Nurses understand that a patient's diastolic pressure represents which physiologic function?&#10;A) The pressure needed to open the aortic and pulmonic valves&#10;B) The pressure in blood vessels when the ventricles contract&#10;C) The pressure of the blood returning to the heart from the venous system&#10;D) The pressure in blood vessels when the ventricles are relaxed

Accepted Answer

The answer of Nurses understand that a patient's diastolic pressure...

Question 17

The temperature of a patient is measured every 6 hours at 6 AM, 12 PM, 6 PM, and 12 AM. Which temperature reading is expected to be low due to a normal variation?&#10;A) The measurement at 6 AM&#10;B) The measurement at 12 PM&#10;C) The measurement at 6 PM&#10;D) The measurement at 12 AM

Accepted Answer

The answer of The temperature of a patient is measured...

Question 18

A patient is sitting slightly forward bracing his arms on his knees in a tripod position. This position is associated with which symptom?&#10;A) Abdominal pain&#10;B) Spinal deformity&#10;C) Back pain&#10;D) Breathing difficulty

Accepted Answer

The answer of A patient is sitting slightly forward bracing...

Deck 4: General Inspection and Measurement of Vital Signs