Deck 21: Assisting With Assessment

Question 1

Temperature, pulse, respirations, and blood pressure are

A) Basic needs
B) Vital signs
C) Measurements
D) Observations

Answer 1

Vital signs

Question 2

The beat of the heart felt at an artery as a wave of blood passes through the artery is the

A) Pulse
B) Pulse deficit
C) Pulse rate
D) Heartbeat

Answer 2

Pulse

Question 3

Vital signs do the following except

A) Show changes in the person's condition
B) Signal life-threatening events
C) Diagnose illness
D) Tell about responses to treatment

Answer 3

Diagnose illness

Question 4

Body temperature is usually the lowest

A) In the morning
B) In the afternoon
C) In the evening
D) At bedtime

Question 5

The pressure in the arteries when the heart contracts is

A) Blood pressure
B) Pulse deficit
C) Diastolic pressure
D) Systolic pressure

Question 6

Vital signs are immediately reported to the nurse at the following times except

A) If they are within the normal range
B) If there is a change from a previous measurement
C) If they are above the normal range
D) If they are below the normal range

Question 7

A resident needs rehabilitation after hip replacement surgery. You take the person's temperature orally. Which measurement is not within normal range?

A) 98.1° F
B) 99.8° F
C) 98.2° F
D) 98.0° F

Question 8

The amount of heat in the body that is a balance between the amount of heat produced and the amount lost by the body is

A) Fahrenheit
B) Centigrade
C) Celsius
D) Body temperature

Question 9

A systolic blood pressure below 90 mm Hg and a diastolic pressure below 60 mm Hg is

A) Hypertension
B) Hypotension
C) Bradycardia
D) Tachycardia

Question 10

Taking temperatures is delegated to you. The nurse and care plan tell you the following except

A) What thermometer to use
B) What site to use
C) The normal range for the site used
D) When to take temperatures

Question 11

The number of pulses felt in one minute is the

A) Pulse
B) Pulse deficit
C) Pulse rate
D) Heartbeat

Question 12

Body temperature is measured at the following sites except

A) The mouth
B) The tympanic membrane
C) Under the breasts
D) The temporal artery

Question 13

When a person's blood pressure measurements remain above a systolic pressure of 140 mm Hg or a diastolic pressure of 90 mm Hg they are known to have

A) Hypertension
B) Hypotension
C) Bradycardia
D) Tachycardia

Question 14

A rectal thermometer is color-coded in

A) Blue
B) Red
C) Green
D) Yellow

Question 15

The amount of force exerted against the walls of an artery by the blood is the

A) Blood pressure
B) Pulse deficit
C) Diastolic pressure
D) Systolic pressure

Question 16

Body temperature is measured at the following sites except

A) The mouth
B) The axilla
C) The rectum
D) Behind the knee

Question 17

Breathing air into (inhalation) and out of (exhalation) the lungs is

A) Breathing
B) Respiration
C) Respiratory rate
D) Basic need

Question 18

A glass thermometer for rectal temperatures has a

A) Bulb tip
B) Long tip
C) Pear-shaped tip
D) Slender tip

Question 19

The pressure in the arteries when the heart is at rest is the

A) Blood pressure
B) Pulse deficit
C) Diastolic pressure
D) Systolic pressure

Question 20

Unless otherwise ordered, vital signs are taken with the person

A) Sitting or standing
B) Sitting or lying down
C) Lying down only
D) Sitting only

Question 21

The covered probe of the tympanic membrane thermometer is inserted

A) Into the mouth
B) Into the rectum
C) Under the arm
D) Into the ear

Question 22

A mercury-glass thermometer breaks. Which action is incorrect?

A) Tell the nurse at once.
B) Follow agency procedures.
C) Do not let the person touch the mercury.
D) Call the doctor.

Question 23

A person has dementia. Which temperature site promotes the person's comfort and safety?

A) Oral
B) Rectal
C) Axillary
D) Tympanic membrane

Question 24

A resident smokes. The person just had a cigarette. How long do you need to wait before taking the person's temperature orally?

A) 5 to 10 minutes
B) 10 to 15 minutes
C) 15 to 20 minutes
D) You do not need to wait.

Question 25

A person has heart disease. When measuring temperature, you cannot use the

A) Oral site
B) Rectal site
C) Axillary site
D) Tympanic membrane site

Question 26

Each short line of a centigrade thermometer means

A) 0.1 of a degree
B) 0.2 of a degree
C) 0.5 of a degree
D) One degree

Question 27

A person is unconscious. When measuring temperature, you cannot use the

A) Oral site
B) Rectal site
C) Axillary site
D) Tympanic membrane site

Question 28

To measure a temporal artery temperature, which of the following should be done?

A) Insert the device gently into the ear
B) Gently stroke the device across the forehead
C) Place the device behind the knee
D) Gently insert the device between the toes

Question 29

Every other long line of a Fahrenheit thermometer is

A) An even number
B) An odd number
C) A consecutive number
D) A fraction

Question 30

A person has diarrhea. When measuring temperature, you cannot use the

A) Oral site
B) Rectal site
C) Temporal artery site
D) Tympanic membrane site

Question 31

Each short line of a Fahrenheit thermometer means

A) 0.1 of a degree
B) 0.2 of a degree
C) 0.5 of a degree
D) One degree

Question 32

To rinse a glass thermometer, you need to use

A) Warm water
B) Hot water
C) Cold water
D) A disinfectant solution

Question 33

Before inserting a rectal thermometer, do the following

A) Clean it with hot water
B) Lubricate the end of the probe
C) Place it in a probe cover
D) Clean it with a disinfectant

Question 34

A person is receiving oxygen. When measuring temperature, you cannot use the

A) Oral site
B) Rectal site
C) Temporal artery site
D) Tympanic membrane site

Question 35

A person has a naso-gastric tube. When measuring temperature, you cannot use the

A) Oral site
B) Rectal site
C) Axillary site
D) Tympanic membrane site

Question 36

To take a rectal temperature, how is the person positioned?

A) Lying down
B) In semi-Fowler's position
C) In Sims' position
D) In the prone position

Question 37

For an accurate measurement, the axillary site must be

A) Wet
B) Dry
C) Lubricated
D) Cleaned

Question 38

You are taking an oral temperature with a glass thermometer. How long do you leave the thermometer in place?

A) 1 minute
B) 2 minutes
C) 2 to 3 minutes
D) 5 to 10 minutes

Question 39

To read a glass thermometer, you need to hold it

A) At the tip
B) With tissues
C) With gloved hands
D) At the stem

Question 40

Each long line of a centigrade thermometer means

A) One degree
B) Two degrees
C) 0.1 of a degree
D) 0.5 of a degree

Question 41

Respirations usually are counted

A) Right after taking the temperature
B) Right after taking the pulse
C) Right before measuring blood pressure
D) Right after measuring blood pressure

Question 42

Which instrument is used to listen to sounds produced by the body?

A) Thermometer
B) Sphygmomanometer
C) Stethoscope
D) Cuff

Question 43

Which of the following is used to measure blood pressure?

A) Thermometer
B) Sphygmomanometer and stethoscope
C) Your first 2 or 3 fingertips
D) Cuff

Question 44

Before placing the stethoscope on the person, you need to warm the diaphragm

A) In warm water
B) In hot water
C) In your hand
D) Under the person's arm

Question 45

For an adult, which pulse rate is reported to the nurse at once?

A) 66
B) 74
C) 88
D) 104

Question 46

When taking an apical pulse, you need to use

A) Your thumb
B) The middle 3 fingers
C) Your ring and little fingers
D) A stethoscope

Question 47

The healthy adult has

A) 10 to 14 respirations per minute
B) 12 to 18 respirations per minute
C) 12 to 20 respirations per minute
D) 15 to 30 respirations per minute

Question 48

The period of heart muscle contraction is

A) Bradycardia
B) Tachycardia
C) Systole
D) Diastole

Question 49

You measured a resident's blood pressure. His systolic pressure is 144 mm Hg. His diastolic pressure is 78 mm Hg. How do you record these measurements?

A) 78 mm Hg/144 mm Hg
B) 78/144 mm Hg
C) 144 mm Hg/78 mm Hg
D) 144/78 mm Hg

Question 50

You are taking a resident's pulse. The beats are not spaced evenly. When reporting to the nurse, how would you describe the person's pulse?

A) Weak and feeble
B) Strong and full
C) Irregular
D) Thready and bounding

Question 51

When taking a radial pulse, you need to use

A) Your thumb
B) Your first 2 or 3 fingertips
C) Your ring and little fingertips
D) A stethoscope

Question 52

What should you use to wipe the earpieces and diaphragm of the stethoscope before and after use?

A) Soap and water
B) Cold water
C) Hot water
D) Antiseptic wipes

Question 53

Which is the most common site for taking a pulse?

A) The radial site
B) The apical site
C) The carotid site
D) The brachial site

Question 54

An apical pulse is counted for

A) 15 seconds
B) 30 seconds
C) 45 seconds
D) 1 minute

Question 55

You are taking an apical pulse. Which statement is correct?

A) The lub sound is counted as one beat.
B) The dub sound is counted as one beat.
C) The lub-dub is counted as one beat.
D) The pulse deficit is counted.

Question 56

The apical pulse is found

A) On the thumb side of the wrist
B) Just below the right nipple
C) Just below the left nipple
D) At the inner aspect of the elbow

Question 57

A radial pulse is usually counted for

A) 15 seconds
B) 30 seconds
C) 45 seconds
D) 60 seconds

Question 58

You are counting a patient's respirations. Which is incorrect?

A) You need to tell the person what you are doing.
B) Each rise and fall of the chest is counted as 1 respiration.
C) Both sides of the person's chest should rise and fall equally.
D) Respirations are usually counted for 30 seconds.

Question 59

For an adult, which pulse rate is reported to the nurse at once?

A) 50
B) 62
C) 75
D) 98

Question 60

Which pulse site requires the use of a stethoscope?

A) The radial site
B) The carotid site
C) The brachial site
D) The apical site

Question 61

A patient complains of pain. Which will not help you collect information about the person's pain?

A) Ask if the pain is mild, moderate, or severe.
B) Ask the person what factors cause the pain.
C) Check the person's vital signs.
D) Give the person drugs to relieve the pain.

Question 62

A patient has a cast on his left wrist. Which statement is correct?

A) Blood pressure is measured on the left arm.
B) Blood pressure is measured on the right arm.
C) The person decides what arm to use.
D) You use the arm that is easiest to reach.

Question 63

Phantom pain is

A) Felt suddenly
B) Felt in a body part that is no longer there
C) Felt at the site of tissue damage and in nearby areas
D) Discomfort

Question 64

Chronic pain lasts

A) 7 days
B) 30 days
C) Until tissues heal
D) Long after healing occurs

Question 65

A patient has an IV in her left arm. Which is correct?

A) Blood pressure is measured on the right arm.
B) Blood pressure is measured on the left arm.
C) The patient decides what arm to use.
D) You use the arm that is easiest to reach.

Question 66

Which statement about pain is correct?

A) The meaning of pain is the same for everyone.
B) You can see and feel another person's pain.
C) Sore and aching mean the same thing to everyone.
D) If the person complains of pain the person has pain.

Question 67

Acute pain

A) Is felt suddenly
B) Is felt in a body part that is no longer there
C) Is felt at the site of tissue damage and in nearby areas
D) Is constant or occurs on and off

Question 68

You are going to measure a resident's height. Which of the following information do you need from the nurse and the care plan?

A) How to measure height
B) What the person's height should be
C) What scale to use
D) If the person should wear shoes

Question 69

The blood pressure cuff is applied over the

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

Question 70

Which systolic pressure should you report at once?

A) 168
B) 120
C) 116
D) 118

Question 71

You are measuring blood pressure. How far should you inflate the cuff beyond the point where you last felt the person's pulse?

A) 10 mm Hg
B) 20 mm Hg
C) 30 mm Hg
D) 40 mm Hg

Question 72

You cannot hear a person's blood pressure. What should you do?

A) Take it again.
B) Get a different stethoscope.
C) Tell the nurse at once.
D) Record the previous measurement.

Question 73

A resident just finished his daily exercise program. You need to measure the person's blood pressure. How long does he need to rest before the measurement?

A) 5 minutes
B) 5 to 10 minutes
C) 10 to 20 minutes
D) 20 to 30 minutes

Question 74

The blood pressure cuff is applied

A) Over clothing
B) To the bare arm
C) Over the radial artery
D) Under the brachial artery

Question 75

A resident complains of pain. Which will not help you collect information about the person's pain?

A) Ask the person to point to the area of pain.
B) Ask to see the pain.
C) Ask the person when the pain started.
D) Ask the person to describe the pain.

Question 76

Which diastolic pressure should you report at once?

A) 50
B) 62
C) 74
D) 80

Question 77

The diastolic pressure is the

A) First sound you hear
B) Second sound you hear
C) Third sound you hear
D) Last sound you hear

Question 78

Radiating pain is

A) Felt suddenly
B) Felt in a body part that is no longer there
C) Felt at the site of tissue damage and in nearby areas
D) Constant or occurs on and off

Question 79

Intake and output are totaled

A) Every 2 hours
B) Every 4 hours
C) At the end of the shift
D) At least once during an 8-hour shift

Question 80

A patient's coffee cup holds 250 mL. The person did not drink all the coffee. You measure that 75 mL of coffee remain. How much did the person drink?

A) 100 mL
B) 200 mL
C) 175 mL
D) 125 mL