Question 1

A nurse is caring for a group of patients. Which patient will the nurse see first?

Accepted Answer

When a blood pressure drops in a postoperative patient, bleeding may be occurring and lead to shock. The nurse should assess this patient first. Pain will cause the blood pressure to elevate so this is an expected finding, and while it does need to be assessed, it is not the first one to assess. A teenager who has returned from smoking will have to wait at least 20 minutes before a temperature can be taken, so this is not the first one to see. A patient with hypothermia is expected to have a temperature below normal, so this is not the first one to see.

Question 2

A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient's blood pressure (BP)?

Accepted Answer

Smoking results in vasoconstriction, a narrowing of blood vessels. BP rises when a person smokes and returns to baseline about 15-20 minutes after stopping smoking. Caffeine increases BP for up to 3 hours. Be sure that patient has not ingested caffeine or smoked 20 to 30 minutes before BP measurement.

Question 3

After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action?

Accepted Answer

Temperatures obtained vary depending on the site used. Rectal temperatures are usually 0.5° C (0.9° F) higher than oral temperatures, and axillary temperatures are usually 0.5° C (0.9° F) lower than oral temperatures. There are core temperature readings and body surface readings.

Question 4

When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding?

Accepted Answer

138/62 is the correct reading. The fifth sound marks the disappearance of sound. In adolescents and adults the fifth sound corresponds with the diastolic pressure. The fourth sound becomes muffled and low pitched as the cuff is further deflated. At this point the cuff pressure has fallen below the pressure within the vessel walls; this sound is the diastolic pressure in infants and children. 68 is the pulse pressure of 138/70; 76 is the pulse pressure for 138/62.

Question 5

The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient's low heart rate?

Accepted Answer

Negative chronotropic drugs such as digitalis, beta-adrenergic agents, and calcium channel blockers can slow down pulse rate. Fever, bleeding, hemorrhage, and COPD all increase the body's need for oxygen, leading to an increased heart rate.

Question 6

When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding?

Accepted Answer

The normal rate for an infant is 120 to 160 beats/min. The rate obtained (145 beats/min) is within the normal range for an infant. The normal rate for a toddler is between 90 and 140 beats/min; 145 is too high for a toddler.

Question 7

The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed?

Accepted Answer

The child's cooperation is increased when you or the parent have prepared the child for the unusual sensation of the BP cuff. Most children understand the analogy of a "tight hug on your arm." Different arm sizes require careful and appropriate cuff size selection. Do not choose a cuff based on the name of the cuff. An "Infant" cuff is too small for some infants. Readings are difficult to obtain in restless or anxious infants and children. Allow at least 15 minutes for children to recover from recent activities and become less apprehensive. Korotkoff sounds are difficult to hear in children because of low frequency and amplitude. A pediatric stethoscope bell is often helpful.

Question 8

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 blood pressure 3 times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient?

Accepted Answer

Electronic devices are easier to manipulate but require frequent recalibration-more than once a year. Because of their sensitivity, improper cuff placement or movement of the arm causes electronic devices to give incorrect readings. The portable home devices include the aneroid sphygmomanometer and electronic digital readout devices that do not require the use of a stethoscope. The cuff will need to be applied correctly, and the patient's arm needs to be still during the reading.

Question 9

The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address?

Accepted Answer

The incidence of hypertension is greater in diabetic patients, older adults, and African-Americans. The incidence of hypertension (high BP) is higher in African-Americans than in European Americans.

Question 10

The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient's symptoms?

Accepted Answer

The concentration of hemoglobin reflects the patient's capacity to carry oxygen, which if low can lead to shortness of breath and chest discomfort. Normal hemoglobin levels range from 14 to 18 g/100 mL in males and from 12 to 16 g/100 mL in females. Hemoglobin of 8.0 is low and indicates a decreased ability to deliver oxygen to meet bodily needs. All other values in the selection are considered normal.

Question 11

The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to praise the NAP?

Accepted Answer

The nurse will praise the NAP when obtaining the pulse from the brachial site. The brachial or apical pulse is the best site for assessing an infant's or a young child's pulse because other peripheral pulses are deep and difficult to palpate accurately.

Question 12

The nurse is caring for a patient who reports 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?

Accepted Answer

If the pulse is irregular, do an apical/radial pulse assessment to detect a pulse deficit. If pulse count differs by more than 2, a pulse deficit exists, which sometimes indicates alterations in cardiac output. The nurse needs to gather as much information as possible before calling the health care provider. The radial pulse is more accurately assessed with moderate pressure. Too much pressure occludes the pulse and impairs blood flow. Arterial blood gases is a laboratory test that measures blood pH and oxygenation status. Arterial blood gases would be appropriate if respirations were abnormal or if pulse oximetry results were severely low.

Question 13

The nurse is caring for an older-adult patient and notes that the temperature is 96.8° F (36° C). How will the nurse interpret this finding?

Accepted Answer

The average body temperature of older adults is approximately 35° to 36.1° C (95° to 97° F). This is not hypothermia or hyperthermia. Older adults have poor vasomotor control, reduced amounts of subcutaneous tissue, reduced sweat gland activity, and reduced metabolism. The end result is lowered body temperature.

Question 14

When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse's action?

Accepted Answer

The temporal artery thermometer is especially beneficial when used in premature infants, newborns, and children because there is no risk of injury to the patient or nurse. Temporal artery temperature is a reliable noninvasive measure of core temperature. However, it is inaccurate with head covering or hair on the forehead and is affected by skin moisture such as diaphoresis, or sweating. It provides very rapid measurement and reflects rapid changes in core temperature, not radiant temperature.

Question 15

The patient was found unresponsive in an apartment and is being brought to the emergency department. The patient has arm, hand, and leg edema, temperature is 95.6° F, and hands are cold secondary to a history of peripheral vascular disease. It is reported that the patient has a latex allergy. What should the nurse do to quickly measure the patient's oxygen saturation?

Accepted Answer

A nonadhesive sensor is best for latex allergy, and the earlobe site is the best choice for this patient with peripheral vascular disease and edema. Select forehead, ear or bridge of nose if an adult patient has a history of peripheral vascular disease. Do not attach probe to finger, ear, forehead, or bridge of nose if area is edematous or skin integrity is compromised. Do not use disposable adhesive probes if the patient has latex allergy. Do not attach probe to fingers that are hypothermic. Do not place the sensor on the same extremity as the electronic blood pressure cuff because blood flow to the finger will be temporarily interrupted when the cuff inflates.

Question 16

The health care provider prescription reads "Metoprolol (Lopressor) 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. Which action should the nurse take?

Accepted Answer

The nurse must document any interventions initiated as a result of vital sign measurement such as holding an antihypertensive drug. The nurse should inform the patient of the blood pressure value and the need for periodic reassessment of the blood pressure. Documenting the blood pressure only is not sufficient. Any intervention must be documented as well. Abnormal findings must be reported to the nurse in charge or to the health care provider.

Question 17

The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn?

Accepted Answer

The acceptable respiratory rate range for a newborn is 30 to 60 breaths/min. An infant (6 months) is expected to have a rate between 30 and 50 breaths/min. A toddler's respiratory range is 25 to 32 breaths/min. A child should breathe 20 to 30 times a minute. An adolescent should breathe 16 to 20 times a minute. An adult should breathe 12 to 20 times a minute.

Question 18

A nurse is caring for a group of patients. Which patient will the nurse see first?

Accepted Answer

A calm adolescent should have the following findings: P-60-90 and R-16-20. Since both findings are elevated, the nurse should see this patient first. An infant should have the following findings: P-120-160 and R-30-50; however, since the infant is crying these values will be elevated and this is normal. A toddler should have the following findings: P-90-140 and R-25-32; however, since the toddler is sleeping these values can be slightly decreased and this is normal. An adult should have the following findings: P-60-100 and R-12-20; however, since the adult is exercising these values will be elevated and this is normal.

Question 19

The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take?

Accepted Answer

The nurse should determine whether the patient has latex allergy because disposable adhesive probes should not be used on patients with latex allergies. Earlobe and bridge of the nose sensors should not be used on infants and toddlers because of skin fragility. Oximeter pulse rate and the patient's apical pulse rate should be the same. Any difference requires re-evaluation of oximeter sensor probe placement and reassessment of pulse rates.

Question 20

A nurse reviews blood pressures of several patients. Which finding will the nurse report as prehypertension?

Accepted Answer

An adult's blood pressure tends to rise with advancing age. The optimal blood pressure for a healthy, middle-aged adult is less than 120/80. Values of 120 to 139/80 to 89 mm Hg are considered prehypertension. Blood pressure greater than 140/90 is defined as hypertension. Blood pressure of 98/50 is normal for a child, whereas 115/70 can be normal for an infant.

Quiz 30: Vital Signs

A nurse is caring for a group of patients. Which patient will the nurse see first?

A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient's blood pressure (BP) ?

After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action?

When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding?

The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient's low heart rate?

When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding?

The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed?

The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address?

The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient's symptoms?

The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to praise the NAP?

The nurse is caring for a patient who reports 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?

The nurse is caring for an older-adult patient and notes that the temperature is 96.8° F (36° C) . How will the nurse interpret this finding?

When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse's action?

The health care provider prescription reads "Metoprolol (Lopressor) 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. Which action should the nurse take?

The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn?

A nurse is caring for a group of patients. Which patient will the nurse see first?

The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take?

A nurse reviews blood pressures of several patients. Which finding will the nurse report as prehypertension?