Deck 20: Measuring Vital Signs

Question 1

For which adult client should the nurse make follow-up observations and monitor the vital signs closely? A client whose:
1)Resting morning blood pressure (BP) is 128/78 mm Hg, whereas the afternoon BP is 122/76 mm Hg
2)Oral temperature is 97.9°F (36.6°C) in the morning and 99.8°F (37.7°C) in the evening
3)Heart rate is 76 beats/min before eating and 88 beats/min after eating
4)Respiratory rate is 16 breaths/min when standing and 18 breaths/min when lying down

Answer 1

1

Question 2

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 parameter would the nurse document as a 7/10?
1)Pulse pressure
2)Pain
3)Oxygen saturation
4)Emotional distress

Answer 2

2

Question 3

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 (39.6°C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mm Hg. Which should be the nurse's first intervention at this time?
1)Ask the client whether he has had a warm drink in the last 30 minutes.
2)Notify the primary care provider of the client's temperature.
3)Determine if the client is feeling chilled.
4)Take the temperature by a different route.

Answer 3

1

Question 4

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?
1)Radial
2)Temporal
3)Apical
4)Brachial

Question 5

A 42-year-old female client has a rectal temperature reading of 39.2°C (102.6°F). Her blood pressure has decreased from 124/76 to 118/70 mm Hg since taken 4 hours earlier. Her pulse rate has increased from 68 to 78 beats/min. What is the nurse's best initial action?
1)Document the vital signs, and discontinue the assessment.
2)Contact the provider immediately due to the alarming changes in the vital signs.
3)Obtain a pulmonary artery temperature reading before initiating any type of treatment.
4)Ask the unlicensed assistive personnel (UAP) to obtain another set of vital signs in 4 hours.

Question 6

The nurse is instructing a client how to appropriately dress an infant in cold weather. Which instruction would be most important for the nurse to include?
1)Be sure to put mittens on the infant.
2)Layer the infant's clothing.
3)Place a cap on the infant's head.
4)Put warm booties on the infant.

Question 7

The nurse assesses the following changes in a client's vital signs. Which client situation should be reported to the primary care provider?
1)Decreased blood pressure (BP) after standing up
2)Decreased temperature after a period of diaphoresis
3)Increased heart rate after walking down the hall
4)Increased respiratory rate when the heart rate increases

Question 8

The nurse is teaching a client how to use a portable blood pressure device to monitor the blood pressure at home. Which action is most important for the nurse to take?
1)Ask the client to demonstrate the use of the blood pressure device.
2)Explain the importance of frequent calibration of the device.
3)Give the client a chart to record the blood pressure readings.
4)Provide written instructions of the information taught.

Question 9

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." Which is the best response by the nurse?
1)"The vital signs confirm that your infection is resolved; how do you feel?"
2)"I'll let your healthcare provider know so that you can be discharged."
3)"Your vital signs are stable, but there are other things to monitor."
4)"We still need to keep monitoring your blood pressure for a while."

Question 10

A client's vital signs 4 hours ago were temperature (oral) 101.4 $\degree$ F (38.6 $\degree$ C), heart rate 110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/78 mm Hg. The temperature is now 99.4 $\degree$ F (37.4 $\degree$ C). Based only on the expected relationship between temperature and respiratory rate, which respiratory rate would the nurse expect to find?

A)16
B)18
C)20
D)22

Question 11

The nurse is assessing vital signs for a client after a surgical procedure on the left leg. Intravenous (IV) fluids are infusing. Which action would be most important for the nurse to take?
1)Compare the left pedal pulse with the right pedal pulse.
2)Count the client's respiratory rate for 1 full minute.
3)Take blood pressure in the arm without an IV line.
4)Obtain oral temperature with an electronic thermometer.

Question 12

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?
1)62
2)82
3)112
4)132

Question 13

The nurse enters the client's room and before taking vital signs, the nurse hears a piercing, high-pitched sound coming from the client when breathing. Which best action should the nurse take initially?
1)Document the finding, and continue with the assessment.
2)Ask the client to cough and deep breathe over the next 24 hours.
3)Give the client extra fluids to loosen the secretions of mucus.
4)Assess the client's airway patency.

Question 14

In evaluating a client's blood pressure (BP) for hypertension, it would be most important for the nurse to take which action?
1)Use the same type of manometer each time.
2)Auscultate all five Korotkoff sounds.
3)Measure BP in both arms.
4)Monitor BP for a pattern.

Question 15

Which set of vital signs are all within normal limits for patients at rest?
1)Infant: Temperature (T) 98.8°F (37.1°C) (rectal); heart rate (HR) 160; respiratory rate (RR) 16; blood pressure (BP) 120/54 mm Hg
2)Adolescent: T 98.2°F (37°C) (oral); HR 80; RR 18; BP 108/68 mm Hg
3)Adult: T 99.6°F (37.6°C) (oral); HR 48; RR 22; BP 130/84 mm Hg
4)Older adult: T 98.6°F 37°C) (oral); HR 110; RR 28; BP 170/100 mm Hg

Question 16

A 1-day postoperative client has a temperature of 36.8°C. What is the nurse's next best action?
1)Contact the primary care provider for guidance.
2)Document the temperature, and continue with nursing care.
3)Administer the prescribed antipyretic medication.
4)Instruct the client to drink more fluids.

Question 17

A client's average normal temperature is 98°F (36.7°C). Which temperature would be expected during the night in this healthy, young adult client who does not have a fever, inflammatory process, or underlying health problems?
1)97.2°F (36.2°C)
2)98.0°F (36.7°C)
3)98.6°F (37°C)
4)99.2°F (37.3°C)

Question 18

Which client would probably have a higher than normal respiratory rate? A client who has:
1)Had surgery and is receiving a narcotic analgesic
2)Had surgery and lost a unit of blood intraoperatively
3)Lived at a high altitude and then moved to sea level
4)Been exposed to the cold and is now hypothermic

Question 19

A client's axillary temperature is 100.8°F (38.2°C). The nurse realizes that this is outside the normal range for this client and that axillary temperatures do not reflect the core temperature. What should the nurse do to obtain a good estimate of the core temperature?
1)Add 1°F to 100.8°F to obtain an oral equivalent.
2)Add 2°F to 100.8°F to obtain a rectal equivalent.
3)Obtain a rectal temperature reading.
4)Obtain a tympanic membrane reading.

Question 20

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?
1)Have the client take several deep breaths.
2)Ask the client to take a deep breath and cough.
3)Take the client's blood pressure and apical pulse readings.
4)Count the client's respiratory rate for 1 minute.

Question 21

The nurse is caring for a patient with a history of postural hypotension. The nurse obtains a blood pressure (BP) reading of 130/80 mm Hg with the patient lying and 100/60 mm Hg with the patient standing. What is the highest priority nursing diagnosis for this patient?
1)Risk for falls
2)Risk for fatigue
3)Risk for dizziness
4)Risk for activity intolerance

Question 22

The nurse volunteers to work at the annual summer 20-mile marathon in the community. Which assessment finding will alert the nurse a runner is experiencing heat exhaustion?
1)Slurred speech
2)Impaired judgment
3)Bradycardia
4)Diaphoresis

Question 23

The nurse documents a patient's radial pulse rate as 100 beats/min and regular. One hour later, the nurse rechecks the pulse, and it is irregular at 120 beats/min. What is the most appropriate nursing action?
1)Ask another nurse to check the pulse.
2)Administer fluids while the patient is in bed.
3)Place the patient on a cardiac monitor.
4)Check the pulse in the opposite arm.

Question 24

The nurse administers two blood pressure (BP) medications to a patient and asks the certified nurse assistant (CNA) to obtain a BP reading in 30 minutes. The CNA states, "I just took the BP." What is the most appropriate response by the nurse?
1)"Take it again so that we can be sure nothing else is wrong with the patient."
2)"I need to check the patient's response to the BP medications."
3)"If BP drops too much, I'll need to discontinue one of the medications."
4)"If you just took the BP, then recheck it in 2 hours instead."

Question 25

Which of these steps in taking a blood pressure are correct? Select all that apply.
1)Use a bladder that encircles 40% of the arm.
2)Wrap the cuff snugly around the client's arm.
3)Ask the client to hold the arm at heart level.
4)Have the client sit with feet flat on the floor.
5)Identify client with one identifier.

Question 26

Comparing the changes in vital signs as a person ages, which statements are correct? Select all that apply.
1)Blood pressure decreases, but less than heart rate and respiratory rate.
2)Respiratory rate remains fairly stable throughout a person's life.
3)Blood pressure increases; respiratory rate declines.
4)Men have higher blood pressure than women until after menopause.
5)Body temperature rises slightly as one ages.

Question 27

During a clinic interview, a client states he has been experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement?
1)Ask the client when in the day dizziness occurs.
2)Help the client to assume the Trendelenburg position.
3)Take both heart rate and blood pressure with the client standing.
4)Measure vital signs with the client supine, sitting, and standing.

Question 28

The nurse caring for a postsurgical patient obtains an oral temperature reading of 102°F (38.9°C). The nurse contacts the surgeon, obtains an order, and administers acetaminophen 650 mg orally. Which clinical data should the nurse document? Select all that apply.
1)Oral temperature 102°F (38.9°C)
2)Called the surgeon to obtain the order
3)Administered acetaminophen 650 mg orally
4)Administered aspirin 650 mg orally
5)Rectal temperature 102°F (38.9°C)

Question 29

The nurse provides client education regarding hypertension prevention and management. Which statement indicates the client understands the instructions?
1)"I don't have to worry if my blood pressure (BP) is high once in a while."
2)"I guess I will have to make sure I don't drink too much water."
3)"I can lose some weight to help lower my BP."
4)"I will need to reduce the amount milk and other dairy products I use."

Question 30

The nurse is caring for a patient in a skilled nursing center. What is the likely schedule for measuring the patient's vital signs?
1)Every 4 hours
2)Once per shift
3)Once a week
4)Every 2 hours for 24 hours

Question 31

The nurse on a medical-surgical unit palpates a patient's carotid pulse for 30 seconds and obtains a rate of 80 beats/min. The nurse knows in obtaining a patient's carotid pulse, careful technique must be followed to prevent which response?
1)Increase in heart rate
2)Decrease in heart rate
3)Increase in blood pressure
4)Irregular heart rhythm

Question 32

Which assessment data best supports a report of severe pain in an adult client whose baseline vital signs are within an average normal range?
1)Oral temperature: 100°F (37.8°C)
2)Respiratory rate: 26 breaths/min and shallow
3)Apical heart rate: 56 beats/min
4)Blood pressure: 124/72 mm Hg

Question 33

The nurse is caring for a critically ill patient with a severe midbrain injury involving the hypothalamus. Which vital sign is most critical for the nurse to monitor closely for this patient?
1)Temperature
2)Pulse
3)Respirations
4)Blood pressure

Question 34

The nurse obtains a blood pressure (BP) reading of 160/90 mm Hg from a cardiac patient. What is the first action by the nurse?
1)Obtain BP readings with the client in the lying, sitting, and standing positions.
2)Contact the primary care provider for medication orders.
3)Recheck BP in 30 minutes.
4)Check the patient's BP pattern over the past 3 days.

Question 35

The nurse obtains the following vital signs on an adult patient: temperature (T) 100.6°F (38.1°C); blood pressure (BP) 100/60 mm Hg; heart rate (HR) 110 beats/min; respiratory rate (RR) 36 breaths/min. What is the first action by the nurse?
1)Offer oral fluids.
2)Begin an intravenous (IV) infusion.
3)Obtain a pulse oximetry reading.
4)Administer oxygen.

Question 36

The nurse is obtaining vital signs on a newborn infant and notes respirations at 56 breaths/min. What is the most appropriate action by the nurse?
1)Apply oxygen immediately.
2)Document the finding while continuing the assessment.
3)Contact the obstetrician for orders.
4)Compare the finding with other infants in the nursery.

Question 37

For which patient would it be most important to obtain an apical-radial pulse and calculate the pulse deficit? A patient who:
1)Had abdominal surgery 2 hours ago
2)Suffered a fractured hip yesterday
3)Is dehydrated from vomiting
4)Has a heart or lung disease

Question 38

Which blood pressure reading has a pulse pressure within normal limits? Select all that apply.
1)104/50 mm Hg
2)120/62 mm Hg
3)120/80 mm Hg
4)130/86 mm Hg
5)180/70 mm Hg

Question 39

Which procedure technique has the most effect on the accuracy of an irregular apical pulse count?
1)Counting the rate for 1 full minute
2)Exposing only the left side of the chest
3)Determining why assessment of apical pulse is indicated
4)Using the ring finger to palpate the intercostal spaces

Question 40

Which interventions would be appropriate for a client who has a fever? Select all that apply.
1)Put an ice pack on the client's neck and axillae.
2)Provide the client with several blankets.
3)Offer the client fluids to drink every 1 to 2 hours.
4)Take the temperature using a tympanic thermometer.
5)Place caffeinated drinks by patient's bedside.

Question 41

Which nursing interventions are appropriate for a patient who has been admitted with a diagnosis of Dehydration and has a temperature of 101.5°F (38.6°C)? Select all that apply.
1)Provide oral and/or intravenous (IV) fluids.
2)Take vital signs every 2 hours.
3)Contact the provider for respirations of 18 breaths/min.
4)Keep the patient on a "nothing by mouth" (NPO) diet until defervescence occurs.
5)Increase physical activity level.

Question 42

A 70-year-old homeless man is admitted to the emergency department with heat stroke following 3 days of overexposure to outside temperatures. The nurse is most alert to which signs and symptoms associated with heat stroke? Select all that apply.
1)Temperature of 103.8°F (39.9°C)
2)Throbbing headache
3)Diaphoresis
4)Confusion
5)Red, hot dry skin

Question 43

When assessing the quality of a client's pedal pulses, what is the nurse assessing? Select all that apply.
1)Rhythm of the pulses
2)Strength of the pulses
3)Bilateral equality of pulses
4)Rate compared with apical pulse
5)Intervals between heartbeats