Question 1

Which factors could influence oral temperature measurement?

Accepted Answer

Smoking can affect oral temperature measurement as it can cause an increase in heat production and inflammation in the oral cavity. Eating or drinking hot or cold substances can also affect temperature readings. Exercise can cause a temporary increase in body temperature. The time of day can also influence temperature readings as body temperature tends to be lower in the morning and higher in the afternoon or evening.

Question 2

Which factors could influence oxygen saturation measurement?

Accepted Answer

The answer of Which factors could influence oxygen saturation measurement?
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Question 3

What is a normal oxygen saturation reading?

Accepted Answer

The answer of What is a normal oxygen saturation reading?...

Question 4

The nurse is caring for a homeless client brought to the emergency department with possible hypothermia.The nurse places the pulse oximeter probe on the client's finger and gets a reading of 38%.The client's respiratory rate is 22 breaths per minute,breath sounds are clear and equal,color is pale pink,and the client denies any history of respiratory distress.Which is the priority action by the nurse?

Accepted Answer

The priority action is to move the pulse oximetry sensor to the ear or nose because the low reading of 38% is likely inaccurate due to the client's hypothermia, which can cause peripheral vasoconstriction and affect the accuracy of readings from extremities.

Question 5

The nurse is reviewing a client's vital signs from birth to age 10.Which changes would the nurse expect to find?

Accepted Answer

C) As children grow from infancy through to age 10, their heart and respiratory rates generally decrease due to the maturation of their cardiovascular and respiratory systems. Their blood pressure increases as a result of growth and development of the vascular system.

Question 6

The nurse is caring for a client diagnosed with cardiogenic shock who requires continuous oxygen saturation monitoring.Where would the nurse place the probe?

Accepted Answer

In cases of cardiogenic shock, peripheral perfusion may be compromised, making the ear a more reliable site for oxygen saturation monitoring compared to the fingers, toes, or thumb.

Question 7

Which factors could influence blood pressure measurement?

Accepted Answer

The answer of Which factors could influence blood pressure measurement?
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Question 8

What is a normal oral temperature range for an adult client? ____ to ____^°F

Accepted Answer

The answer of What is a normal oral temperature range...

Question 9

What is a normal range for an adult's blood pressure reading?
____ to ____ mmHg diastolic
____ to ____ mmHg systolic

Accepted Answer

The answer of What is a normal range for an...

Question 10

The nurse assesses vital signs on four clients.Which client would be the first priority for the nurse to assess based on the vital signs?

Accepted Answer

Client D has a blood pressure of 156/102 mmHg, which indicates hypertension stage 2 and requires immediate assessment and intervention to prevent complications.

Question 11

The nurse is working at a local fair on a warm day in August.Which reading would concern the nurse the most?

Accepted Answer

A temperature of 100.8°F in a 74-year-old woman is concerning as older adults may not mount a typical fever response and their immune system may not function as well as it used to, increasing their risk for infection. The other readings are within normal range or only slightly elevated.

Question 12

Which set of vital signs obtained by the nurse would indicate the need to notify the health care provider?

Accepted Answer

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Question 13

Which factors could influence respiratory rate measurement?

Accepted Answer

Age, exercise, fever, and medications can all influence respiratory rate by affecting the metabolic rate and the body's demand for oxygen.

Question 14

The nurse is caring for a client with a fever of 101.8^°F oral.Which other vital signs would the nurse anticipate would be affected?

Accepted Answer

Fever can increase both pulse rate and respiratory rate, as the body tries to compensate for the increased temperature. There may be slight fluctuations in blood pressure, but it is not typically a significant factor with a low-grade fever like this. Oxygen saturation may be affected if the fever is causing respiratory distress or pneumonia, but it cannot be assumed based solely on the fever measurement.

Question 15

Which factors could influence pulse measurement?

Accepted Answer

Activity, temperature, stress, and hydration can all influence pulse measurement. Increased activity or exercise can result in a higher pulse, while a low body temperature can slow down the pulse. Stress also has a potential impact on pulse measurement, as it can result in an increased heart rate. Similarly, dehydration can cause an increased heart rate as the body is trying to compensate for a lack of fluid volume. However, antibiotic medications are unlikely to have an impact on pulse measurement.

Question 16

The nurse working in an outpatient clinic provides care for a client who arrives a few minutes late for an appointment.The client is diaphoretic with a respiratory rate of 24 breaths per minute.Which is the priority action by the nurse?

Accepted Answer

The priority action is to assess the client. This initial assessment will provide crucial information on the client's condition and guide subsequent interventions. Diaphoresis and an elevated respiratory rate could indicate a variety of conditions, and a thorough assessment is necessary to determine the appropriate next steps.

Question 17

The nurse working in the delivery room assesses a newborn infant delivered vaginally.The infant has a strong cry,is moving all extremities vigorously,and its color is pink.Which action by the nurse is the priority?

Accepted Answer

Drying the infant is the priority action as it helps to prevent hypothermia and promote heat loss. Stimulation and oxygen administration may be indicated in certain situations, but are not necessary in this case as the infant has a strong cry and pink color, indicating good oxygenation. Encouraging infant-maternal bonding is also an important aspect of postpartum care, but not the priority in this immediate assessment of the newborn's physical condition.

Question 18

What is a normal respiratory range for an adult?
____ to ____ breaths per minute

Accepted Answer

The answer of What is a normal respiratory range for...

Question 19

What is a normal pulse range for an adult?
____ to ____ beats per minute

Accepted Answer

The answer of What is a normal pulse range for...

Question 20

Which client would the nurse anticipate to most likely have a higher-than-normal pulse rate?

Accepted Answer

Febrile (feverish) conditions often lead to an increased pulse rate as the body attempts to manage the elevated temperature, especially in elderly clients with other conditions like diabetes, which can further complicate their health status.

Quiz 2: Vital Signs

Which factors could influence oral temperature measurement?

Which factors could influence oxygen saturation measurement?

What is a normal oxygen saturation reading?

The nurse is reviewing a client's vital signs from birth to age 10.Which changes would the nurse expect to find?

The nurse is caring for a client diagnosed with cardiogenic shock who requires continuous oxygen saturation monitoring.Where would the nurse place the probe?

Which factors could influence blood pressure measurement?

What is a normal oral temperature range for an adult client? to ^°F

What is a normal range for an adult's blood pressure reading? to mmHg diastolic to mmHg systolic

The nurse assesses vital signs on four clients.Which client would be the first priority for the nurse to assess based on the vital signs?

The nurse is working at a local fair on a warm day in August.Which reading would concern the nurse the most?

Which set of vital signs obtained by the nurse would indicate the need to notify the health care provider?

Which factors could influence respiratory rate measurement?

The nurse is caring for a client with a fever of 101.8^°F oral.Which other vital signs would the nurse anticipate would be affected?

Which factors could influence pulse measurement?

The nurse working in an outpatient clinic provides care for a client who arrives a few minutes late for an appointment.The client is diaphoretic with a respiratory rate of 24 breaths per minute.Which is the priority action by the nurse?

The nurse working in the delivery room assesses a newborn infant delivered vaginally.The infant has a strong cry,is moving all extremities vigorously,and its color is pink.Which action by the nurse is the priority?

What is a normal respiratory range for an adult? to breaths per minute

What is a normal pulse range for an adult? to beats per minute

Which client would the nurse anticipate to most likely have a higher-than-normal pulse rate?

Quiz 2: Vital Signs

Which factors could influence oral temperature measurement?

Which factors could influence oxygen saturation measurement?

What is a normal oxygen saturation reading?

The nurse is reviewing a client's vital signs from birth to age 10.Which changes would the nurse expect to find?

The nurse is caring for a client diagnosed with cardiogenic shock who requires continuous oxygen saturation monitoring.Where would the nurse place the probe?

Which factors could influence blood pressure measurement?

What is a normal oral temperature range for an adult client? ____ to ____°F

What is a normal range for an adult's blood pressure reading? ____ to ____ mmHg diastolic ____ to ____ mmHg systolic

The nurse assesses vital signs on four clients.Which client would be the first priority for the nurse to assess based on the vital signs?

The nurse is working at a local fair on a warm day in August.Which reading would concern the nurse the most?

Which set of vital signs obtained by the nurse would indicate the need to notify the health care provider?

Which factors could influence respiratory rate measurement?

The nurse is caring for a client with a fever of 101.8°F oral.Which other vital signs would the nurse anticipate would be affected?

Which factors could influence pulse measurement?

The nurse working in an outpatient clinic provides care for a client who arrives a few minutes late for an appointment.The client is diaphoretic with a respiratory rate of 24 breaths per minute.Which is the priority action by the nurse?

The nurse working in the delivery room assesses a newborn infant delivered vaginally.The infant has a strong cry,is moving all extremities vigorously,and its color is pink.Which action by the nurse is the priority?

What is a normal respiratory range for an adult? ____ to ____ breaths per minute

What is a normal pulse range for an adult? ____ to ____ beats per minute

Which client would the nurse anticipate to most likely have a higher-than-normal pulse rate?

What is a normal oral temperature range for an adult client? to ^°F

What is a normal range for an adult's blood pressure reading? to mmHg diastolic to mmHg systolic

The nurse is caring for a client with a fever of 101.8^°F oral.Which other vital signs would the nurse anticipate would be affected?

What is a normal respiratory range for an adult? to breaths per minute

What is a normal pulse range for an adult? to beats per minute