Deck 15: Vital Signs

Question 1

Upon a patient's admission to the nursing unit,the registered nurse delegated to the nursing assistive personnel to take her vital signs.What is the registered nurse's responsibility regarding delegating this task?

A) This is inappropriate delegation; the nurse should always take the vital signs.
B) Have the NAP repeat the measurement if vital signs appear abnormal.
C) The nurse should review and interpret the vital sign measurements.
D) This task has been delegated so the nurse is not responsible.

Answer 1

The nurse should review and interpret the vital sign measurements.

Question 2

The nursing student is obtaining the patient's vital signs.The patient has gone to the clinic seeking help because she is having chest pain.Which of the following vital signs are most important to obtain?

A) Temperature, pulse, respirations
B) Temperature, pulse, respirations, oxygen saturation
C) Temperature, pulse, respirations, blood pressure, oxygen saturation
D) Temperature, pulse, respirations, blood pressure, oxygen saturation, pain

Answer 2

Temperature, pulse, respirations, blood pressure, oxygen saturation, pain

Question 3

The nurse is having difficulty hearing his patient's apical pulse with his stethoscope.Which of the following would best maximize the sound quality of what is heard through the stethoscope?

A) Positioning the diaphragm very lightly on the area to which he is listening
B) Placing the stethoscope chest piece directly on the patient's skin
C) Make sure that the earpieces fit loosely in the ear canals
D) Use a stethoscope with the longest tubing available

Answer 3

Placing the stethoscope chest piece directly on the patient's skin

Question 4

A senior nursing student is doing her community clinical rotation.When visiting a young family to whom she has been assigned,the mother of a 3-year-old child states that her daughter does not feel well.The nursing student feels her skin,which is warm.She asks the mother if she has taken her temperature to which the mother replies,"Yes,I used the same thermometer that was my great-grandmother's; it has been used by my family for years.Her oral temperature was 102.3° F." The most important action for the nursing student to perform is to do which of the following?

A) Teach that temporal artery thermometers are more accurate than others.
B) Tell the mother that hospitals still use mercury thermometers.
C) Ask to see the thermometer.
D) Recommend a chemical thermometer for greater accuracy.

Question 5

A 15-year-old girl was taken to a small rural hospital by her mother.The family had been camping,and it had become very cold during the night.The mother had difficulty waking her daughter in the morning,and she was shivering uncontrollably.The patient is still unconscious.Which of the following interventions should the admitting nurse do first?

A) Have the patient drink hot liquids.
B) Wrap the girl in warm blankets.
C) Uncover the head to allow the head to warm.
D) Place heating pads on the bottom of the feet.

Question 6

A 38-year-old postoperative patient is suddenly unresponsive but is still breathing.The nurse will use which site to assess the patient's pulse?

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

Question 7

The nurse is taking the pulse of an adult patient and finds that the patient's heart rate is 48.He knows that this is considered:

A) tachycardia.
B) bradycardia.
C) a normal heart rate for an infant.
D) a normal heart rate for an adult.

Question 8

A man has been admitted to the hospital with lethargy.He was placed on the telemetry unit and is being continuously monitored.He is due to receive his dose of digoxin.The nurse knows that the medication is to be held if the pulse rate is less than 60 beats per minute.The nurse will use which site to assess the patient's pulse?

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

Question 9

A 45-year-old mother of three children is at the doctor's office and her blood pressure 152/92.This is the first time that she has ever shown an elevated reading.She is concerned that she has hypertension.The nurse's best response would be:

A) "A single reading may not mean anything. We will take it again at your next visit."
B) "It looks like you have high blood pressure now. We'll check it again in 3 months."
C) "Fortunately, hypertension isn't related to other diseases and is easily treated."
D) "You may have hypertension, but there is little else that can be done except medicines."

Question 10

A 36-year-old African-American patient has been admitted to the hospital with diabetic ketoacidosis.The nurse who is admitting him notes that his blood pressure is 164/98.Which of the following should the nurse do next?

A) Call the health care provider because the patient's values differ from the standard range.
B) Immediately call the health care provider and request antihypertensive medication.
C) Ask the patient what his blood pressure normally measures for comparison.
D) Do nothing; this is within a normal range for a patient with diabetic ketoacidosis.

Question 11

A nurse is working on a medical unit in an acute care hospital.One of the patients she is caring for has a fever of 100.6° F.Which of the following is the best reason why the patient should not receive an antipyretic at this time?

A) A temperature of 100.3° F is within the normal range.
B) Shivering is a more effective way to dissipate heat energy.
C) Corticosteroids are safer to use than antipyretics.
D) Mild fevers are an important defense mechanism of the body.

Question 12

A nurse notices that a patient has an irregular pulse.The nurse should do which of the following?

A) Count the number of "lub-dubs" occurring in 30 seconds.
B) Assess how often the dysrhythmia is occurring.
C) Assess the radial pulse for a pulse deficit.
D) Chart the abnormally low heart rate as tachycardia.

Question 13

The patient has just returned to the postsurgical unit after undergoing surgery to remove a lung tumor.During one of the postoperative vital sign checks,the nurse notes that the patient's systolic blood pressure had dropped by 30 points.In addition to the drop in systolic blood pressure,the patient's skin is pale and "clammy." The nurse should do which of the following?

A) Report the findings to the health care provider immediately.
B) Understand that the patient's arteries are constricting, causing pallor.
C) Wait to see if the blood pressure increases in 30 minutes.
D) Nothing; this is a normal occurrence following a thoracic surgery.

Question 14

A 26-year-old man was helping a friend replace a roof on his backyard shed after work on a hot July afternoon.His friend brought him to the hospital after the patient complained of severe muscle cramps and became confused.Which of the following should the admitting nurse do first when assessing the patient?

A) Place the patient in a tub of iced water.
B) Take the patient's temperature.
C) Remove fans to prevent premature chilling.
D) Apply a hyperthermia blanket to lower temperature slowly.

Question 15

The young mother of an 8-month-old patient brought her daughter to the clinic after taking the little girl's temperature rectally and obtaining a reading of 100.4° F.The mother was concerned that her daughter might be ill.Which of the following is the best response?

A) "Children usually run lower rather than higher temperatures when ill."
B) "Because of her age, it is probably a bacterial infection."
C) "Rectal temperatures are higher than temperatures obtained orally."
D) "When taking multiple temperatures, the sites should be rotated."

Question 16

A 5-year-old child was admitted for a diagnosis of meningitis with a fever of 104.5° F and nuchal rigidity.She responded to antipyretics that were ordered.In addition,the patient's mother was asked to help reduce the fever by limiting the number of blankets covering the patient.After interventions,the child's temperature is 100.5° F.The nurse recognized that the mother has an understanding of the patient's condition when she states which of the following?

A) "The high temperature is useful in fighting bacteria and viruses as long as it's not too high."
B) "You need to get her temperature down quickly. She's so uncomfortable."
C) "Her fever is dropping because she is shivering. She must be cold."
D) "She probably picked up a bacteria. That's what kids do. That's why they get infected."

Question 17

A 6-year-old was taken to the hospital after having a seizure at home.The patient's mother tells the nurse that she has been ill for the past week and has had a fever with nausea and vomiting.The patient's mother believes that the seizure was caused by a fever of 99.5° F,which the patient had during the course of her illness.What is the nurse's best response?

A) "With a temperature that high, we can only hope that there is no permanent damage."
B) "Fevers in this range are part of the body's natural defense system"
C) "Febrile seizures are common in children Nancy's age."
D) "The child will need antibiotics. Does she have any allergies?"

Question 18

A nursing assistant asks the nurse why she needs to bathe a febrile patient.The best response is that this intervention increases heat loss through which of the following?

A) Convection
B) Radiation
C) Conduction
D) Evaporation

Question 19

A 6-year-old child was taken to the after-hours pediatric clinic with a fever and a rash.She had been seen by her pediatrician earlier in the day and had been given a prescription for an antibiotic.Later that evening she developed a fever and a rash on her abdomen.The nurse who assesses the child in the clinic suspected the symptoms are associated with which of the following?

A) Dehydration
B) An allergic response to the prescribed medication
C) Febrile seizures
D) Fever of unknown origin (FUO)

Question 20

A 56-year-old grandmother has been admitted to the hospital with a fever of 103.2° F after caring for her 5-year-old granddaughter who also developed a fever.The health care provider has ordered blood cultures,antibiotics,antipyretics,a clear liquid diet,and a chest radiograph.Which of the orders should the nurse do first?

A) Administer antibiotic.
B) Administer antipyretic.
C) Draw blood cultures.
D) Apply water cooled blankets.

Question 21

When patients with normal blood pressure experience a drop in blood pressure upon rising to an upright position and have symptoms of light-headedness or dizziness,the condition is known as:

A) hypertension.
B) hypotension.
C) orthostatic hypotension.
D) the pulse pressure.

Question 22

What is the difference between systolic and diastolic pressure?

A) Diastolic pressure
B) Pulse pressure
C) Hypertension
D) Systolic pressure

Question 23

A nurse is ready to take the temperature of an adult patient rectally.The nurse's realizes that rectal temperatures are which of the following?

A) Preferable to oral temperatures
B) Safer than oral temperatures if the patient has neutropenia
C) The best way to obtain temperatures in newborns
D) That readings can be influenced by impacted stool

Question 24

One of the ways the body increases heat production is through:

A) convection.
B) radiation.
C) shivering.
D) evaporation.

Question 25

A patient is obese.At the bedside is a standard-size blood pressure cuff.The nurse realizes that the use of this cuff will provide which of the following?

A) Accurate readings as long as it is 20% of the circumference of the midpoint of the limb.
B) Indistinct readings if the bladder encircles 80% of the adult's arm.
C) A falsely low reading if the cuff is wrapped too loosely around the arm.
D) Inaccurate readings and needs to be replaced with a larger cuff.

Question 26

The mechanical movement of gases into and out of the lungs is known as:

A) respiration.
B) ventilation.
C) perfusion.
D) eupnea.

Question 27

The movement of oxygen and carbon dioxide between the alveoli and the red blood cells is known as:

A) diffusion.
B) perfusion.
C) respiration.
D) eupnea.

Question 28

When the fever "breaks," the temperature returns to an acceptable range and the patient becomes:

A) febrile.
B) afebrile.
C) fever of unknown origin (FUO).
D) pyrexic.

Question 29

An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates:

A) dysrhythmia.
B) tachycardia.
C) bradycardia.
D) a pulse deficit.

Question 30

The patient's temperature has reached 103.4° F.The nurse prepares to draw a blood culture before giving the patient an antipyretic medication.What is the best reason to draw a blood culture before giving an antipyretic medication?

A) The causative organism is most prevalent during a spike in temperature.
B) Elevated temperatures slow metabolic rate and improve blood oxygenation.
C) Increased blood flow leads to moist mucous membranes making blood draws easier.
D) Venous distention is greater because of fluid retention secondary to hyperthermia.

Question 31

A woman has been hospitalized with pneumonia.She has had oxygen on via nasal cannula at a rate of 2 L per minute.A nursing student is taking her vital signs.She notes that her respirations are labored and the rate is 32 respirations per minute.The nursing student recognizes this as which of the following?

A) Normal.
B) Tachypnea.
C) Bradypnea.
D) Apnea.

Question 32

What term refers to a fever whose cause cannot be determined?

A) Febrile
B) Afebrile
C) Fever of unknown origin (FUO)
D) Pyrexic

Question 33

A nurse delegates the task of obtaining vital signs to a nursing assistant.The nurse reminds the nursing assistant that blood pressure:

A) will be lower if the cuff is too wide.
B) is not affected by cuff length.
C) should be taken slowly for more accuracy.
D) should be taken with the arm above heart level.

Question 34

An elevated body temperature related to the body's inability to promote heat loss or reduce heat production is known as:

A) hyperthermia.
B) heat stroke.
C) hypothermia.
D) fever of unknown origin.

Question 35

When the ventricles relax,the blood remaining in the arteries exerts a minimum or:

A) diastolic pressure.
B) pulse pressure.
C) hypertension.
D) systolic pressure.

Question 36

A systolic blood pressure (BP)less than 90 mm Hg or a diastolic BP less than 60 mm Hg is known as:

A) hypertension.
B) hypotension.
C) orthostatic hypotension.
D) postural hypotension.

Question 37

Under high pressure,the left ventricle ejects blood into the aorta; the peak pressure is known as:

A) diastolic pressure.
B) pulse pressure.
C) hypertension.
D) systolic pressure.

Question 38

Medications that reduce fever by interfering with the hypothalamic response include:

A) salicylates.
B) acetaminophen.
C) ibuprofen.
D) corticosteroids.

Question 39

To determine the patient's actual temperature,the nurse is aware that:

A) the patient's core temperature is not affected by environmental temperature
B) surface temperatures are the most stable
C) circadian rhythms keep the body temperature stable throughout the day.
D) gender and age have no effect on body temperature.

Question 40

A regular interval interrupted by an early beat,late beat,or missed beat indicates an abnormal rhythm or:

A) dysrhythmia.
B) tachycardia.
C) bradycardia.
D) a pulse deficit.

Question 41

Core temperatures are obtained via which of the following? (Select all that apply.)

A) Axillae
B) Rectal
C) Oral
D) Pulmonary artery
E) Urinary bladder

Question 42

Two common abnormalities in heart rate are:

A) dysrhythmia.
B) apical pulse.
C) tachycardia.
D) bradycardia.
E) pulse deficit.

Question 43

The nurse is obtaining an oxygen saturation reading from a female patient who was brought in after collapsing at a party.Factors that may lead to inaccurate SpO? readings include which of the following? (Select all that apply.)

A) Using a pulsatile area to attach the probe
B) The patient wearing fingernail polish
C) Measuring the level intermittently
D) The patient being anemic
E) Measuring the level continuously

Question 44

The nurse has assessed the need to check the patient for orthostatic hypotension.Conditions that would cause the nurse to be concerned about this would be which of the following? (Select all that apply.)

A) Dehydration
B) Obesity
C) Recent blood loss
D) Cigarette smoking
E) Prolonged bed rest

Question 45

Any injury to the hypothalamus impairs heat loss mechanisms.Educate patients at risk for hyperthermia to do which of the following? (Select all that apply.)

A) Avoid strenuous exercise in hot, humid weather.
B) Avoid exercising in areas with poor ventilation.
C) Drink clear fluids before and after exercising, not during.
D) Wear light, loose-fitting clothing.
E) Do not visit hot climates.

Question 46

While being tested for orthostatic hypotension,the patient stands up and begins to feel light-headed and feels faint.The nurse should do which of the following? (Select all that apply.)

A) Have the patient lie down.
B) Report findings to the health care provider.
C) Have the nursing assistive personnel (NAP) check orthostatic blood pressure.
D) Instruct the patient not to get out of bed without assistance.
E) Take the BP in each arm and use the arm with the lowest systolic reading.

Question 47

What term refers to the distribution of red blood cells to and from the pulmonary capillaries?

A) Diffusion
B) Perfusion
C) Respiration
D) Eupnea

Question 48

Blood pressure depends on the interrelationships of which of the following? (Select all that apply.)

A) Cardiac output
B) Peripheral vascular resistance
C) Blood volume
D) Blood viscosity
E) Pulse pressure

Question 49

The body's tissues and cells function efficiently within a relatively narrow temperature range,from 36° to 38° C (96.8° to 100.4° F).Factors that cause fluctuations in body temperature include which of the following? (Select all that apply.)

A) The body's core temperature
B) Age
C) Time of day
D) Circadian rhythm
E) physical activity

Question 50

A registered nurse is caring for a patient who was admitted to the hospital after being involved in a motor vehicle accident.The patient has undergone two surgeries and now has a health care-acquired infection.Multiple medications were ordered.Which of the following would be appropriate for the nurse to administer to reduce the fever without masking signs of infection? (Select all that apply.)

A) Acetaminophen
B) Corticosteroid
C) Ibuprofen
D) Indomethacin
E) Salicylates