Deck 2: Vital Signs

Question 1

The nurse is caring for a newborn with rapid respirations.How would the nurse get an accurate respiratory rate?

A)Remove the client's clothing so the chest movement can be seen.
B)Count respirations for 30 seconds and multiply by two.
C)Place the hand on the client's back to feel the respirations.
D)Use a stethoscope to hear respirations.

Answer 1

Use a stethoscope to hear respirations.

Question 2

The nurse assesses the client in respiratory distress and notes that the client has see-saw respirations with the chest and abdomen alternately rising,blue discoloration of the fingertips,and noisy difficult respirations.How would the nurse describe the client's condition when calling the health care provider?

A)Client is tachypneic with costal breathing and cyanosis.
B)Client is bradycardic with diaphragmatic breathing and cyanosis.
C)Client is demonstrating diaphragmatic breathing,and is dyspneic and cyanotic.
D)Client is demonstrating diaphragmatic breathing with audible Korotkoff's sounds.

Answer 2

Client is demonstrating diaphragmatic breathing,and is dyspneic and cyanotic.

Question 3

In order to get an accurate reading,which technique would the nurse use to measure the client's respirations?

A)Stare intently at the client's chest.
B)Place a hand on the client's chest to feel the thoracic cavity move.
C)Maintain the fingers on the radial pulse.
D)Watch the nose flare with each respiration.

Answer 3

Maintain the fingers on the radial pulse.

Question 4

The nurse delegates the measurement of vital signs on three clients to the unlicensed assistive personnel (UAP).The nurse evaluates the UAP's performance and notes that blood pressure is measured on a client by having the client hold the arm hanging over the side of the bed.Which is the priority action by the nurse?

A)Commend the UAP for following the proper procedure.
B)Inform the charge nurse that the UAP does not know how to measure blood pressures.
C)Yell at the UAP and tell her she is incompetent.
D)Instruct the UAP that blood pressure should be measured with the artery at or above the level of the heart,and demonstrate correct technique.

Question 5

When the nurse delegates measurement of vital signs to an unlicensed assistive personnel (UAP),which are the nurse's responsibilities?

A)Assessment of vital sign readings obtained by the unlicensed assistive personnel
B)Assessment of the UAP's skills in measuring vital signs
C)Determination that the vital signs were obtained correctly
D)Follow up on vital sign measurements that are abnormal or unexpected
E)Observe the UAP as she measures vital signs

Question 6

The nurse is caring for a client who had bilateral mastectomies.Where would the nurse measure the client's blood pressure to obtain the most accurate reading?

A)Either upper arm using the brachial artery
B)Either forearm using the radial artery
C)In the lower leg using the posterior tibial artery
D)In the thigh using the popliteal artery

Question 7

Which task could not be delegated by the nurse to the unlicensed assistive personnel (UAP)?

A)Monitor client's vital signs and oxygen saturation every 4 hours.
B)Measure client's blood pressure and report to the nurse after administration of routine daily antihypertensive medication.
C)Monitor vital signs of client who complained of chest pain,requiring three doses of nitroglycerin to resolve,earlier in the shift.
D)Measure vital signs on client who had a stroke 3 years ago and is admitted for urinary tract infection.

Question 8

The nurse is caring for a client requiring continuous pulse oximetry readings.How often would the nurse alter the probe site?

A)Every 2 hours
B)Every 4 hours if the probe is an adhesive wraparound sensor
C)Every 4 hours if the probe is a spring-loaded sensor
D)Every 2 hours if the probe is an adhesive wraparound sensor

Question 9

Which term is used to describe the first sound heard by the nurse when measuring the client's blood pressure?

A)Diastolic
B)Systolic
C)Korotkoff's sound phase 4
D)Korotkoff's sound phase 5

Question 10

The nurse is caring for a client with a history of arrhythmia resulting in an irregular pulse.How long would the nurse count the pulse to get the most accurate reading?

A)15 seconds and multiply by 4
B)30 seconds and multiply by 2
C)1 minute
D)2 minutes

Question 11

The client has an elevated temperature.Which statement is the most clinically appropriate for the nurse to use when documenting this finding in the medical record?

A)The client is fever.
B)The client is febrile.
C)The client is hyperpyrexia.
D)The client is hyperthermia.

Question 12

When might it be inappropriate for the nurse to assess a client's vital signs?

A)When a client has a change in health status
B)Upon admitting the client to the facility
C)Before and after the client ambulates
D)When a terminal client with a do-not-resuscitate order has a change in condition

Question 13

The nurse working night shift recognizes the value of allowing clients to sleep uninterrupted whenever possible.Which client would the nurse wake to assess vital signs?

A)Postoperative client who had surgery 5 days ago and will be discharged in the morning
B)Client who has been afebrile for 3 days on antibiotics
C)Client who required medication earlier in the day for chest pain
D)A client who required the insertion of an indwelling catheter this evening secondary to urine retention related to an enlarged prostate

Question 14

The nurse is informed during shift report that the assigned client has a wide pulse pressure,is hypertensive,and has a pulse deficit.When the nurse enters the client's room,which assessments would the nurse perform in order to confirm this report?

A)Blood pressure and apical pulse assessments
B)Blood pressure and radial pulse assessment
C)Blood pressure and respiratory rate assessment
D)Blood pressure and radial-apical pulse assessment

Question 15

The nurse is caring for several clients.Rank the order in which the nurse would assess vital signs for these clients.

A)Client who is returning from the operating room after abdominal surgery Response
B)Client who will walk the hallway for the first time Response
C)Client who was febrile and required an antipyretic medication 1 hour ago Response
D)Client who is to be discharged this morning

Question 16

In order to obtain an accurate oxygen saturation reading,on which location will the nurse place the probe?

A)On a spot that the client cannot move
B)On the client's nondominant hand
C)On the client's dominant hand
D)On a site that is well perfused and warm on the client

Question 17

The nurse is measuring the client's radial pulse.How does the nurse properly perform this procedure?

A)Place two fingers on the medial side of the inner wrist gently on the surface of the skin.
B)Place the thumb on the lateral side of the wrist and apply gentle pressure.
C)Place two fingers on the lateral side of the inner wrist and apply gentle pressure.
D)Place the thumb on the medial side of the wrist gently.

Question 18

Prior to assessing the adult client's temperature rectally,which action by the nurse is the most appropriate?

A)Lubricate the tip of the thermometer.
B)Obtain a health care provider's order.
C)Position the client in the Trendelenburg position.
D)Position the client in the Fowler's position.

Question 19

The nurse working in the emergency department admits a 2-month-old infant whose mother reports had a temperature of 104.2^°F axillary.Which route would the nurse use to measure the infant's temperature?

A)Tympanically
B)Orally
C)Axillary
D)Rectally

Question 20

Where would the nurse measure temperature if the client was confused and disoriented following rectal surgery?

A)Rectally
B)Orally
C)Axillary
D)Either orally or tympanically

Question 21

Which factors could influence oral temperature measurement?

A)Smoking
B)Eating or drinking
C)Exercise
D)Perfusion
E)Time of day

Question 22

Which factors could influence oxygen saturation measurement?

A)Hemoglobin
B)Hematocrit
C)Carbon dioxide poisoning
D)Activity
E)Circulation

Question 23

What is a normal oxygen saturation reading?

Question 24

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?

A)Apply oxygen
B)Call the health care provider
C)Call the rapid response team
D)Move the pulse oximetry sensor to the ear or nose

Question 25

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

A)Reduction in temperature,increase in heart rate,decrease in respiratory rate,and increase in blood pressure
B)Reduction in oxygen saturation,decreased heart and respiratory rate,and decreased blood pressure
C)Reduced heart and respiratory rate and increased blood pressure
D)Decreased temperature,reduced heart and respiratory rate,and increased blood pressure

Question 26

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

A)The fingers
B)The toes
C)The ear
D)The thumb

Question 27

Which factors could influence blood pressure measurement?

A)Age
B)Height
C)Sex
D)Race
E)Obesity

Question 28

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

Question 29

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

Question 30

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?

A)98.6^°F;88;16;134/88
B)98.2^°F;60;12;92/64
C)100.8^°F;102;18;136/84
D)98.7^°F;96;14;156/102

Question 31

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

A)22-year-old man with temperature of 100.2^°F oral
B)74-year-old woman with temperature of 100.8^°F oral
C)Newborn temperature of 99.6^°F axillary
D)Middle-aged adult with temperature of 99.2^°F oral

Question 32

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

A)Postoperative client who had abdominal surgery has vital signs of 99.8^°F oral;120;10;108/56.
B)Pulse oximeter probe on the finger of a client diagnosed with hypotension reads 72%.
C)Client who successfully walked the entire hallway after 2 weeks of bed rest has vital signs of 98.8^°F oral;108;22;140/88.
D)Client with no significant medical history who has recently been selected to be a member of the U.S.Olympic swimming team has vital signs of 98.6^°F oral;52;12;98/52.

Question 33

Which factors could influence respiratory rate measurement?

A)Age
B)Exercise
C)Fever
D)Medications
E)Rapid heart rate

Question 34

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?

A)Pulse rate
B)Respiratory rate
C)Diastolic blood pressure
D)Systolic blood pressure
E)Oxygen saturation

Question 35

Which factors could influence pulse measurement?

A)Activity
B)Temperature
C)Stress
D)Antibiotic medications
E)Hydration

Question 36

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?

A)Call the health care provider STAT to examine the client.
B)Apply oxygen and sit the client up.
C)Assess the client.
D)Document the client's status,and place the chart so that the primary care provider is aware the client is ready to be seen.

Question 37

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?

A)Stimulate the infant.
B)Encourage infant-maternal bonding.
C)Dry the infant.
D)Administer oxygen.

Question 38

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

Question 39

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

Question 40

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

A)An obese young adult client admitted for a fractured femur requiring traction
B)A middle-aged adult client with hypertension admitted for removal of a tumor that might be cancerous
C)A febrile elderly client with diabetes admitted for treatment of cellulitis
D)An adolescent client admitted with an anxiety disorder

Question 41

When is it inappropriate to measure vital signs?

A)Before and after a procedure
B)On admission to the hospital
C)When client is in pain
D)When the client is resting

Question 42

When observing the unlicensed assistive personnel (UAP)checking pedal pulses,the nurse identifies which technique as appropriate?

A)Palpating the inner aspect of the biceps muscle of the arm
B)Palpating the femoral artery as it passes alongside the inguinal ligament
C)Palpating the pulse from the middle of the ankle to the space between the big and second toe
D)Palpating the client's chest

Question 43

Which client could safely have a temperature taken via the oral route?

A)A client who is confused and disoriented secondary to a diagnosis of Alzheimer disease
B)A client who had maxillofacial surgery
C)An adult client with an elevated temperature of 102.4^°F
D)A client with a diagnosis of Bell palsy

Question 44

Which adult vital signs would the nurse need to report immediately?

A)99.2°F;100;20;138/88
B)100.2°F;88;18;128/72
C)97.4°F;96;28;142/82
D)98°F;64;14;88/60

Question 45

The nurse is assessing the client's peripheral pulse,and is not able to palpate a pedal pulse.The client's foot is pink and warm.Which action by the nurse is the most appropriate?

A)Apply a warm soak to the foot.
B)Notify the health care provider that the client has lost circulation to the foot.
C)Elevate the foot.
D)Auscultate the pulse using an ultrasound Doppler.

Question 46

The nurse is able to demonstrate proper placement of the stethoscope when assessing the apical pulse by placing the bell at which location?

A)The brachial site
B)The apex of the heart
C)The carotid site
D)The radial site

Question 47

The nurse is caring for a postoperative client who returned from surgery a few hours ago.The client is currently demonstrating shallow,slow breathing,with audible adventitious sounds.Which is the most likely cause for the client's clinical manifestations?

A)Low blood sugar
B)Pneumonia
C)Asthma
D)Deep narcotic sedation

Question 48

The nurse is preparing to assess vital signs for clients currently assigned.For which client would measuring temperature via the rectal route be contraindicated?

A)A comatose client with an oral endotracheal tube in place
B)An adolescent client who has had recent maxillofacial surgery
C)A toddler with previous temperature reading of 104.2^°F axillary
D)A client with a fever who is in a chronic vegetative state

Question 49

The nurse is caring for a client admitted with pneumonia requiring oxygen administration.Which are the priority assessments to document for this client?

A)Pulses in all extremities
B)Respirations and oxygen saturation
C)Blood pressure and temperature
D)Pulse rate and blood pressure

Question 50

The nurse working at a community health center is caring for a client who required bilateral amputation of both arms.How would the nurse measure pulse rate?

A)By palpating the temporal pulse
B)By palpating the carotid pulse
C)By palpating the brachial pulse
D)By palpating the femoral pulse

Question 51

The nurse observes the unlicensed assistive personnel (UAP)obtaining vital signs.Which would indicate a safe temperature measurement procedure?

A)Taking an oral temperature on a 2-year-old child
B)Taking a rectal temperature on a client who had a hemorrhoidectomy earlier this morning
C)Taking an axillary temperature on a confused client who was combative earlier in the day
D)Taking a tympanic temperature on a client with a large amount of cerumen in the ear

Question 52

The nurse is assessing the client's peripheral pulses.What would the nurse assess for?

A)Bilaterality
B)Regularity
C)Strength
D)Rate
E)Arrhythmia

Question 53

Which statement should the nurse )when discussing what is included when taking vital signs?

A)"You are taking my temperature."
B)"You will be listening to my heart."
C)"You will be measuring what I have eaten."
D)"You will be taking my blood pressure."
E)"You will be listening to my stomach."

Question 54

Which respiratory finding would indicate the need for further assessment by the nurse?

A)Regular
B)Quiet
C)Deep
D)Rate of 12-20 per minute

Question 55

The nurse is caring for a client with vital signs 97.2^°F;112;48;104/86;and oxygen saturation is 76%.Place the nursing actions in order of their priority for this client.

A)Assess the client.Response
B)Reduce client anxiety.Response
C)Notify the health care provider.Response
D)Obtain assistance from another nurse or member of the team.Response
E)Administer oxygen.

Question 56

The nurse is assisting with resuscitative efforts on an infant who is experiencing cardiac arrest.Where would the nurse measure pulse rate?

A)Apical site
B)Radial site
C)Brachial site
D)Posterior tibial site

Question 57

Which is the appropriate site to use when taking an infant's temperature?

A)Axillae
B)Temporal artery
C)Tympanic membrane
D)Oral cavity

Question 58

The most accurate pulse rate is obtained at which pulse site?

A)Radial
B)Apical
C)Brachial
D)Carotid

Question 59

The nurse is caring for a client experiencing dyspnea.Which symptoms would the nurse anticipate this client to have?

A)Rapid respirations
B)Reduced oxygen saturation
C)Noisy breath sounds
D)Deep breathing
E)Shallow breathing

Question 60

The nurse admits a client with a medical diagnosis of peripheral artery disease complaining of severe pain in the right leg.Which is the nurse's priority assessment?

A)Assessing the client's femoral pulses bilaterally
B)Obtaining a thorough nursing history
C)Assessing the client's radial and brachial pulses bilaterally
D)Assessing the femoral,popliteal,posterior tibial,and pedal pulses bilaterally