Deck 30: Vital Signs

Question 1

While the nurse is taking the patient's blood pressure,the patient asks if the reading is high.In accordance with the newest guidelines,the nurse informs the patient that which of the following blood pressure measurements is consistent with hypertension?

A) 120/76 mm Hg
B) 140/94 mm Hg
C) 132/78 mm Hg
D) 118/80 mm Hg

Answer 1

B

Question 2

The patient has bilateral casts on the upper extremities,so the nurse will be measuring the blood pressure in the legs.Which of the following does the nurse expect the diastolic pressure to be?

A) 10 to 40 mm Hg higher than in the brachial artery
B) 20 to 30 mm Hg lower than in the brachial artery
C) 50 mm Hg higher than in the brachial artery
D) Essentially the same as in the brachial artery

Answer 2

D

Question 3

A patient complains of pain and asks the nurse for pain medication.The nurse first assesses vital signs and finds them to be as follows: Blood pressure 134/92 mm Hg,pulse 90 beats per minute,and respirations 26 breaths per minute.Which of the following is the nurse's most appropriate action?

A) Assess with a pain scale, and administer the medication.
B) Ask if the patient is anxious.
C) Check the patient's dressing for bleeding.
D) Recheck the patient's vital signs in 30 minutes.

Answer 3

A

Question 4

The nurse is alert to which of the following factors that lowers blood pressure?

A) Anxiety
B) Heavy alcohol consumption
C) Cigarette smoking
D) Diuretic administration

Question 5

An 84-year-old diabetic patient is admitted for insulin regulation.Which of the following sets of blood pressure (mm Hg),pulse (beats per minute),and respiration (breaths per minute)measurements,respectively,is considered to be within the expected limits for a patient of this age?

A) Blood pressure 138/88, pulse 68, respirations 16
B) Blood pressure 94/52, pulse 68, respirations 30
C) Blood pressure 108/80, pulse 112, respirations 15
D) Blood pressure 132/74, pulse 90, respirations 24

Question 6

The patient comes to the emergency department after having been in the sun for an extended period.The nurse also determines that the patient is taking a diuretic.Heatstroke is suspected.For which of the following does the nurse observe?

A) Diaphoresis
B) Confusion
C) Temperature of 36ºC
D) Decreased heart rate

Question 7

The postoperative vital signs of an average-sized adult patient are blood pressure 110/68 mm Hg,pulse 54 beats per minute,respirations 8 breaths per minute.The patient appears pale,seems disoriented,and has minimal urinary output.Which of the following actions should the nurse take?

A) Retake the vital signs in 30 minutes.
B) Continue with care as planned.
C) Administer a stimulant.
D) Notify the physician.

Question 8

The patient has developed pneumonia,and his temperature is 38.5ºC.The patient is shivering and "feels uncomfortable." Which one of the following actions should the nurse take?

A) Apply hot packs to the axilla and groin.
B) Wrap the patient's four extremities.
C) Increase oral fluid consumption.
D) Apply a hypothermia mattress.

Question 9

The nurse obtains the following results after measuring the patient's vital signs: blood pressure 180/100 mm Hg,pulse 82 beats per minute,respiratory rate 16 breaths per minute,and rectal temperature 37.5°C.Which of the following actions should the nurse take?

A) Retake the blood pressure.
B) Retake the temperature.
C) Report all of the findings immediately.
D) Record the findings as within normal limits.

Question 10

The patient appears to be breathing faster than before.Which of the following actions should the nurse take first?

A) Ask the patient if there have been any stressful visitors.
B) Have the patient lie down.
C) Count the rate of respirations.
D) Take the radial pulse.

Question 11

A construction worker is seen in the emergency department with low blood pressure,normal pulse,diaphoresis,and weakness.These are clinical signs of which of the following conditions?

A) Heat exhaustion
B) Heatstroke
C) Heat cramps
D) Hypothermia

Question 12

The nurse has just taken vital signs for the 30-year-old patient.Based on the results,the nurse will report which of the following findings that is out of the expected range for a patient of this age?

A) Temperature 37.4°C
B) Pulse 110 beats per minute
C) Respiration 20 breaths per minute
D) Blood pressure 120/76 mm Hg

Question 13

The student nurse is assessing the vital signs of a 10-year-old patient.What are the expected values for pulse (beats per minute),respirations (breaths per minute),and blood pressure (mm Hg)for a patient of this age?

A) Pulse 140, respirations 50, blood pressure 80/50
B) Pulse 100, respirations 40, blood pressure 90/60
C) Pulse 80, respirations 22, blood pressure 100/60
D) Pulse 60, respirations 12, blood pressure 160/90

Question 14

The registered nurse explains to the registered practical nurse that a false high blood pressure reading may result if the registered practical nurse does which of the following?

A) Wraps the cuff too loosely around the arm
B) Deflates the cuff too quickly
C) Repeats the blood pressure assessment too soon
D) Presses the stethoscope too firmly in the antecubital fossa

Question 15

In teaching a patient at home to assess accurately the auxiliary temperature of an 18-month-old child with a glass thermometer,which of the following instructions should the nurse give the parent?

A) Hold the thermometer at the bulb end.
B) Clean the thermometer in hot water.
C) Leave the thermometer in place for five minutes.
D) Let the child hold the thermometer.

Question 16

Which of the following sites does the nurse know is appropriate for taking a pulse on a 2-year-old child?

A) Radial
B) Apical
C) Femoral
D) Pedal

Question 17

A patient has just gotten out of bed to go to the bathroom.As the nurse enters the room,the patient states,"I feel dizzy." Which of the following actions should the nurse take first?

A) Go for help.
B) Take the patient's blood pressure.
C) Assist the patient to sit or lie down.
D) Tell the patient to take deep breaths.

Question 18

The patient is seen in the emergency department for heat exhaustion as a result of exposure.Which of the following does the nurse anticipate that treatment will include?

A) Replacement of fluid and electrolytes
B) Antibiotic therapy
C) Hypothermia wraps
D) Alcohol baths

Question 19

The nurse is ready to take vital signs on a 6-year-old child.The child has just enjoyed a grape Popsicle.What is the most appropriate action for the nurse?

A) Take the rectal temperature.
B) Take the oral temperature as planned.
C) Have the child rinse out the mouth with warm water.
D) Wait 20 minutes, and take the oral temperature.

Question 20

Which of the following vital signs is said to have a circadian rhythm?

A) Pulse
B) Respiration
C) Temperature
D) Blood pressure

Question 21

A mercury-in-glass thermometer is being used in the extended care facility.While the nurse is taking the patient's temperature,the thermometer falls and breaks on the floor without coming into contact with the nurse or patient.Which of the following should be the nurse's first action?

A) Remove the patient from the area.
B) Remove the patient's clothing.
C) Wash his or her hands, and bathe the patient.
D) Notify the environmental services department.

Question 22

The visiting nurse is evaluating the measurement of the patient's blood pressure by his spouse.The nurse determines that additional teaching is required if the spouse is observed doing which of the following?

A) Deflating the cuff at 2 mm Hg per second
B) Having the patient sit down for the measurement
C) Using the same time each day for the measurement
D) Taking the blood pressure reading after the patient comes back from a walk

Question 23

The nurse is working in the newborn nursery.In planning for temperature measurement,the nurse will obtain the best reading on the infants by using which one of the following?

A) Rectal site
B) Oral site
C) Disposable thermometer strips
D) Axilla site

Question 24

Which of the following breathing alterations describes a low respiratory rate?

A) Apnea
B) Hyperpnea
C) Hypoventilation
D) Kussmaul's respiration

Question 25

What is the ideal site to use to measure oxygen saturation in a patient with tremors?

A) Thumb
B) Earlobe
C) Middle digit
D) Single-use skin probe taped to the abdomen

Question 26

A patient is being monitored with pulse oximetry.Which of the following does the nurse know will influence the values?

A) Placement of the sensor on the arm
B) Patient's diagnosis of peripheral vascular disease
C) Reduced amount of light in the room
D) Increased temperature of the room

Question 27

Which of the following is a normal respiratory rate (breaths per minute)for a toddler?

A) 14
B) 18
C) 22
D) 26

Question 28

What is the normal volume of blood circulating in litres (L),within the vascular system of an adult?

A) 3
B) 4
C) 5
D) 6

Question 29

An individual contacts the emergency room of the local hospital to ask what to do for a skiing partner who appears to be suffering from hypothermia.The victim is alert and able to respond to questions.Which of the following actions does the nurse instruct the individual to have the victim take?

A) Take sips of brandy.
B) Drink warm soup.
C) Drink a cup of very hot coffee.
D) Run the affected extremities under hot water.

Question 30

Which of the following describes the correct placement of a blood pressure cuff on an adult patient?

A) 1.5 cm below the antecubital space
B) Over the elbow
C) 2.5 cm above the popliteal space
D) Over clothes and above the level of the heart