Exam 6: Vital Signs

The nursing assistant reports the following vital signs for four patients just evaluated.Which patient should the nurse see first?

The nurse is assessing a new orientee's knowledge of when to take vital signs.The following statement indicates a need for more education.

A patient has an electronic blood pressure cuff that inflates every 15 minutes for a reading.Which activity by the nursing student would require the nurse to intervene?

A patient has a severe upper respiratory and ear infection and has been experiencing diarrhea.Assessment of the temperature would be most accurate if the nurse checked the temperature using which site?

The nurse is preparing to obtain a rectal temperature.Nursing care is correct if the nurse inserts the thermometer how far into the rectum of an adult?

The patient's oral temperature is 37.1° C (98.78° F)at 1 PM. Which of the following actions should the nurse take next? (Select all that apply.)

While inserting a rectal thermometer,the nurse encounters resistance.What action should the nurse take?

A patient born without arms needs to have a blood pressure assessment.Which artery should the nurse use to most accurately obtain this measurement?

The patient's oral temperature is 39° C.Which conclusion can the nurse make about the patient on the basis of this information?

The patient is unstable; so the nurse is using an electronic blood pressure device to measure blood pressures every 15 minutes.What should the nurse do to verify the accuracy of the electronic blood pressure measurements?

The patient is morbidly obese and the nurse uses a blood pressure (BP)cuff that is too narrow for the patient's arm.What problem will the nurse encounter because of the cuff used?

The nurse is preparing to obtain a set of vital signs.Which is the most important factor for the nurse to consider when measuring patient vital signs?

The nurse notes that the patient's tympanic temperature is 37.88° C (100.2° F)at 4 PM on the patient's second postoperative day.What should the nurse do initially?

The nurse assesses the patient's respirations and sees that they are abnormally shallow (i.e.,two to three breaths followed by an irregular period of apnea).Documentation by the nurse would be correct if which phrase were used?

The nurse is preparing to assess the apical pulse.At which location should the nurse listen to obtain an accurate apical pulse on an adult patient?

The nurse needs to measure the adult patient's temperature,but the patient has just finished a cup of coffee.Which is the best type of temperature for the nurse to obtain accurate results efficiently?

The nurse is validating the measurement of an infant's pulse by a nursing student.Which method should the nurse use to obtain the most accurate count?

While positioning the patient for a routine blood pressure check,the patient asks the nurse why a support was placed under the arm before the BP cuff was applied.Which response by the nurse is most accurate?

The nurse is teaching a family member how to check a teenager's temperature using a tympanic thermometer.Which step is most important for the nurse to include in order to obtain an accurate reading?

The nurse is preparing to measure the patient's blood pressure with an electronic blood pressure device.Which concept is most important for the nurse to consider?