Question 1

A 1-day postoperative client has a temperature of 36.8°C.What is the nurse's next best action?

Accepted Answer

The temperature of 36.8°C is equivalent to 98.2°F.This is a normal temperature for a postoperative patient.To convert Fahrenheit to centigrade,subtract 32 from the temperature,and multiply by 5/9.Because this is a normal temperature,no change in action is needed.The nurse should compare this reading with the previous temperature reading and document the temperature in the medical records.

Question 2

The client has an order for the drug digitalis,which has the effect of decreasing the heart rate.Which site should the nurse use to obtain a pulse rate prior to administering the medication?

Accepted Answer

The nurse should use count the pulse rate for 1 full minute using the apical site.It is the most accurate of any of the peripheral sites.When administering medications that affect the heart rate,an accurate rate is essential.To assess the apical pulse,auscultate and count the number of heartbeats at the apex of the heart.

Question 3

For which of the following adult clients should the nurse make follow-up observations and monitor the vital signs closely? A client whose:

Accepted Answer

Both blood pressures would be classified as prehypertension according to the JNC 7 Express guidelines,so the client would need further observations.Body temperature normally increases during the course of a day.Heart rate increases for several hours after eating.Respiratory depth decreases when lying down,so it would be normal for the rate to increase; both rates are within normal limits.

Question 4

The nurse is instructing a client how to appropriately dress an infant in cold weather.Which of the following instructions would be most important for the nurse to include?

Accepted Answer

All interventions are correct,but because of the many blood vessels close to the skin surface in the head,infants lose approximately one-third of their body heat through the head.Therefore,to prevent heat loss,it is most important to cover the head.

Question 5

The nurse is assessing vital signs for a client after a surgical procedure on the left leg.IV fluids are infusing.It would be most important for the nurse to:

Accepted Answer

For a client having surgery on the leg,the most important data would be whether the circulation has been compromised because of the surgery.This assessment can be made only by comparing one leg with the other.The nurse would,of course,count the respiratory rate for 1 full minute and take the BP in the arm without the IV.Oral temperatures are commonly obtained using electronic thermometers.

Question 6

The nurse hears rhonchi when auscultating a client's lungs.Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds?

Accepted Answer

Rhonchi are caused by secretions in the large airways and may clear with coughing.This is how you differentiate between rhonchi and other adventitious sounds.Deep breathing will not help to clear rhonchi.Taking the blood pressure and apical pulse readings and counting the respiratory rate are not effective for clearing rhonchi,and would not be sufficient for the nurse to identify whether the sounds were,indeed,rhonchi.

Question 7

A client who has been hospitalized for an infection states,"The nursing assistant told me my vital signs are all within normal limits; that means I'm cured." The nurse's best response would be which of the following?

Accepted Answer

Vital signs are one indicator of a client's physiological status,but they are not an absolute indicator of well-being from every aspect.It may be inaccurate to state that the vital signs indicate the infection is resolved; vital signs could stabilize even if the infection remains active.The healthcare provider's decision regarding the client's readiness for discharge is not based exclusively on the vital signs but rather is based on a compilation of other sources of information,primarily the client's clinical status,but also cultures,complete blood counts,and various other laboratory and possibly radiological evidence.Although the nurse will need to continue monitoring the temperature,other clinical signs must also be monitored; therefore,the statement "We still need to keep monitoring your temperature ..." is incomplete and less useful than the statement that begins "Your vital signs are stable,but ..."

Question 8

The nurse is teaching a client how to use a portable blood pressure device to monitor his blood pressure at home.It would be most important for the nurse to:

Accepted Answer

All are important things to include in client education,but self-monitoring of blood pressure is of little value unless it is done using proper technique.Requesting the client demonstrate the procedure would allow the nurse to evaluate the client's technique.

Question 9

A client's vital signs at the beginning of the shift are as follows: oral temperature 99.3°F (37°C),heart rate 82 beats/min,respiratory rate 14 breaths/min,and blood pressure 118/76 mm Hg.Four hours later,the client's oral temperature is 102.3°F (39.1°C).Based on the temperature change,the nurse should anticipate the client's heart rate would be how many beats/min?

Accepted Answer

Heart rate increases about 10 beats/min for each degree Fahrenheit of temperature to meet increased metabolic needs and compensate for peripheral dilation.

Question 10

After obtaining a full set of vital signs,the nurse assesses the client's fifth vital sign as a 7 on a scale of 1 to 10 (or 7/10).Which action by the nurse is most appropriate?

Accepted Answer

Pain is considered to be the "fifth vital sign." A pain rating of 7 out of 10 means the patient is experiencing a significant amount of pain.This can lead to an increase in blood pressure and pulse rate.The nurse's initial focus is on addressing the patient's pain.

Question 11

A client's vital signs 4 hours ago were temperature (oral)101.4°F (38.6°C),heart rate 110 beats/min,respiratory rate 26 breaths/min,and blood pressure 124/78 mm Hg.The temperature is now 99.4°F (37.4°C).Based only on the expected relationship between temperature and respiratory rate,the nurse might best anticipate the client's respiratory rate to be:

Accepted Answer

For every degree Fahrenheit (0.6°C)the temperature falls,the respiratory rate may decrease up to four breaths per minute.The client's temperature has fallen 2 degrees; multiplied by 4,this is 8.It was 26 breaths/minute.26 minus 8 = 18 breaths/min.Keep in mind that this is an estimate and would vary depending on the patient's baseline health,current condition,age,and other factors.

Question 12

A client's axillary temperature is 100.8°F.The nurse realizes this is outside normal range for this client,and that axillary temperatures do not reflect core temperature.What should the nurse do to obtain a good estimate of the core temperature?

Accepted Answer

Rectal temperatures are most reliable and most accurately reflect the core temperature.Body temperatures,from lowest to highest,are axillary,oral,rectal,and tympanic.For oral,axillary,and rectal temperatures,there is a 1°F degree difference between each site and the next higher one.However,mathematical conversions between sites are not reliable and should be used only when a rough estimate is needed-for instance,to decide whether a reading needs to be validated by another site or another thermometer.Tympanic membrane readings are considered by most to be the least accurate and least reliable.

Question 13

At last measurement,the client's vital signs were as follows: oral temperature 98°F (36.7°C),heart rate 76 beats/min,respiratory rate 16 breaths/min,and blood pressure (BP)118/60 mm Hg.Four hours later,the vital signs are as follows: oral temperature 103.2°F (38.5°C),heart rate 76 beats/min,respiratory rate 14 breaths/min,and blood pressure 120/66 mm Hg.Which should the nurse's first intervention be at this time?

Accepted Answer

With a fever,the heart rate and respiratory rate are usually elevated.In this case,they are within normal limits,so the nurse should wonder about the accuracy of the temperature reading and validate it in some way.Because having a hot drink is a common cause of false readings,the nurse should determine whether that has occurred before retaking or otherwise validating the reading.

Question 14

Which of the following sets of vital signs are all within normal limits for patients at rest?

Accepted Answer

All of the adolescent's vital signs are within normal parameters for the age.The infant's temperature is below normal for a rectal reading because the core temperature is approximately 1 degree higher than readings from other sites.The heart rate (HR)for an infant is high,the respiratory rate (RR)is low,and the blood pressure (BP)is high for the age.For the typical adult,the temperature is high,the HR is low,the RR is high,and the BP is elevated for the age.For the older adult,the temperature is high-end normal,the HR is high,the RR is high,and the BP is high for the age.

Question 15

Which one of the following clients would probably have a higher than normal respiratory rate? A client who has:

Accepted Answer

A reduction in hemoglobin from blood loss would increase the respiratory rate.Narcotics and hypothermia slow the respiratory rate.Going from lower altitudes to higher altitudes inhibits oxygen binding,so going to a lower altitude would decrease the respiratory rate or have no effect.Hypothermia decreases the metabolic rate,so the respiratory rate would like decrease.

Question 16

The nurse enters the client's room and before he can take vital signs,he hears a piercing,high-pitched sound coming from the client when he breathes.The nurse's initial next best action is to:

Accepted Answer

These sounds are known as stridor and indicate that the client is in respiratory distress or has an obstructed airway.The nurse's initial action is to assess the patency of the airway.Coughing would help if the problem involved rhonchi.Stridor requires an immediate assessment of the client's airway patency.

Question 17

A 42-year-old client has a rectal temperature reading of 39.2°C (102.6°F).Her blood pressure has decreased from 124/76 to 118/70 since taken 4 hours earlier.Her pulse rate has increased from 68 to 78.The nurse's initial best action is to:

Accepted Answer

The nurse simply needs to continue monitoring the patient's vital signs.The patient's temperature of 102.5°F (39.2°C)is not considered an emergency temperature for an adult.A moderate fever of up to 103°F (39.4°C)is considered a mechanism by which the body fights off infection.The metabolic rate is expected to increase with a fever,which will lead to an increase in the pulse rate.Blood pressure is more likely to decrease with a fever because of peripheral vasodilation.

Question 18

The nurse assesses the following changes in a client's vital signs.Which client situation should be reported to the primary care provider?

Accepted Answer

A decrease in the client's blood pressure when standing indicates orthostatic hypotension,and the cause should be investigated.The changes in vital signs indicated in the other options are normal changes for the situations.

Question 19

A client's average normal temperature is 98°F.Which of the following temperatures would be expected during the night in this healthy,young adult client who does not have a fever,inflammatory process,or underlying health problems?

Accepted Answer

The lowest temperature occurs during sleep (usually at night)when the metabolic rate is lowest.Temperature normally increases throughout the day until it peaks in the early evening.

Question 20

In evaluating a client's blood pressure for hypertension,it would be most important to:

Accepted Answer

Blood pressure fluctuates a great deal during the day and is influenced by age,sex,activity,and many other factors.Any determination of hypertension must be done after two or more BP readings taken on separate occasions.The type of manometer does not greatly influence the reliability of BP readings.Although more accurate,the manual manometer is being replaced by nonmercury-containing devices,such as the aneroid or electronic blood pressure monitors.Only the first and last Korotkoff sounds are necessary to determine a BP reading.The first time BP is assessed for a patient,the nurse should compare the reading in the left and right arm; however,this is not specific to evaluating for hypertension.

Quiz 20: Measuring Vital Signs