Deck 10: Vital Signs

Question 1

The types of thermometers used in hospitals have changed according to a dictate from The American Hospital Association.The type eliminated is the ---------------thermometer.

Answer 1

mercury

Question 2

The rationale for positioning the probe of the electronic thermometer in the sublingual pocket at the base of the tongue is that the

A)Client can more easily close his or her mouth and thus an accurate temperature is obtained.
B)Teeth do not rest on the probe,which can lead to an inaccurate temperature reading.
C)Larger blood vessel in the pocket more accurately reflects the core temperature.
D)Blood supply is limited in that area,so it does not cause a false temperature reading.

Answer 2

Larger blood vessel in the pocket more accurately reflects the core temperature.

Question 3

You receive an order to monitor pedal pulses every hour on a client with peripheral vascular disease.Your first assessment reveals a strong pedal pulse on the right and an apparent absence of a pulse on the left side.Your next intervention would be to

A)Obtain a Doppler stethoscope and auscultate for blood flow.
B)Take the client's blood pressure to determine if client is hypotensive.
C)Warm the client's extremity and assess in 15 minutes.
D)Assess for the presence of a posterior tibial and popliteal pulse.

Answer 3

Assess for the presence of a posterior tibial and popliteal pulse.

Question 4

Conductive gel is applied to the client's skin before using Doppler ultrasound to facilitate the movement of the ultrasound beam.To assist with this process,the nurse must ensure that

A)The old gel is removed before applying new gel.
B)An airtight seal is maintained between the probe and skin.
C)The Doppler machine is turned to the OFF position until it is placed on the skin.
D)The gel is liberally spread over a 2 cm × 2 cm area on the client's skin.

Question 5

Although not considered a cardinal sign,JCAHO suggests that _____________ now be included as the 5th vital sign.

Question 6

Heart rates vary in individuals.Which statement most accurately describes the variance in heart rate?

A)Older clients have a slightly higher heart rate.
B)Men have slightly higher pulse rates than women.
C)Children's heart rates usually beat 120 times per minute.
D)Normal heart rate is from 80 to 100 beats per minute.

Question 7

The usual ratio of pulse to respirations is

A)3:1.
B)4:1.
C)5:1.
D)6:1.

Question 8

The most accepted method of obtaining an apical-radial pulse is

A)One nurse counts the pulse for 1 minute,first at the brachial site and then at the apical site.
B)One nurse counts the pulse for 1 minute at the brachial and apical sites simultaneously.
C)Two nurses count the pulse for 1 minute simultaneously,one counts at the apical site and one at the radial site,using one watch.
D)Two nurses count the pulse for 1 minute,first one nurse counts at the apical site and then one at the radial site,each using his or her own watch.

Question 9

The appropriate method for obtaining an apical pulse is,using the

A)Bell of the stethoscope,listen at the second intercostal space,right side of sternum.
B)Bell of the stethoscope,listen at the fifth intercostal space,left sternal border.
C)Diaphragm of the stethoscope,listen at the second intercostal space,left sternal border.
D)Diaphragm of the stethoscope,listen at the fifth intercostal space,midclavicular line.

Question 10

When taking an oral temperature,the client states he just had a cup of coffee.You should wait _____ minutes before taking the temperature.

A)5-10
B)10-15
C)15-20
D)10-20

Question 11

The most accurate method for taking an adult client's rectal temperature is to insert the thermometer _____ inches and hold in place _____ minutes.

A)
B)1-2,2-3
C)
D)

Question 12

There are many factors that may alter vital signs.Which one of the following factors is the most common?

A)Pain
B)Stress
C)Age
D)Exercise

Question 13

The bladder of the blood pressure cuff should be what circumference percentage of the limb?

A)40%
B)50%
C)60%
D)70%

Question 14

When checking the nurses' notes prior to caring for a client who has had vascular surgery,you observe that the charting of the peripheral pulses states the client has a 2+ pedal pulse.What is your interpretation of this statement?

Question 15

While taking a radial pulse,you assess that it is irregular with a rate of 72.Your prep sheet indicates the pulse has been regular since admission.Your first nursing action is to

A)Notify the team leader immediately.
B)Take the radial pulse again in 15 minutes.
C)Document the findings and leave a note for the physician.
D)Take an apical pulse for 1 full minute.

Question 16

You have been obtaining the client's vital signs every hour according to the usual procedures.You have just taken the radial pulse rate,and it now appears to be irregular.What is your next nursing action?

Question 17

Circulatory control mechanisms include the baroreceptor reflex.Which of the following statements is correct in relation to the reflex?

A)An increased blood pressure increases the reflex action and produces vasoconstriction.
B)Baroreceptors transmit signals that stimulate the vasomotor center to produce vasodilation when the blood pressure increases.
C)Decreased blood pressure leads to inhibition of baroreceptor stimulation.
D)Increased blood pressure and heart rate result from baroreceptor stimulation of the vasomotor center.

Question 18

The normal range for an oral temperature is

A)96°-105°F.
B)97°-99.5°F.
C)98.6°-99.6°F.
D)97.6°-98.6°F.

Question 19

A client who requires that peripheral pulses be monitored using the Doppler can be assigned to a(n)__________ for this task.

A)CNA/UAP
B)RN
C)RN or LVN/LPT
D)All of the above

Question 20

If the client's arm is positioned below the level of the heart when taking the blood pressure,the reading will be

A)Lower than normal.
B)No different from if above the level of the heart.
C)Higher than normal.
D)Altered if the client has peripheral vascular disease only.

Question 21

When using the stethoscope for taking a blood pressure reading,the nurse needs to remember

A)The bell detects high-pitched sounds best.
B)The diaphragm detects low-pitched sounds best.
C)Korotkoff sounds are best heard by the portion of the stethoscope that detects low-frequency sounds.
D)Either bell or diaphragm can be used as frequency sounds are not detected with blood pressure readings.

Question 22

The term used for a pulse that diminishes in amplitude with inspiration as a result of more blood remaining in the lungs is

A)Pulses paradoxus.
B)Pulses alternans.
C)Pulse deficit.
D)Bigeminal pulse.

Question 23

The blood pressure cuff is wrapped snugly and smoothly around the upper arm

A)
Inch above the antecubital space.
B)1 inch above the antecubital space.
C)1 inch down from the axilla.
D)2 inches down from the axilla.

Question 24

The pressure in the blood pressure cuff is deflated

A)Quickly at 5 points or 5 mm Hg/second.
B)Slowly at 2 points or 2 mm Hg/second.
C)Gradually at 2 to 4 points or 2 to 4 mm Hg/second.
D)At a rate that does not exceed 5 points or 5 mm Hg/second.