Deck 46: Vital Signs

Question 1

Which physiological functions will the nurse assess when monitoring a client's vital signs? Select all that apply.

A) Respirations
B) Temperature
C) Pulse rate
D) Blood pressure
E) Weight

Answer 1

Respirations
Temperature
Pulse rate
Blood pressure

Question 2

Which precaution should a nurse take when assessing the body temperature of a client orally?

A) Postpone the assessment if the client has recently drank a cold or hot liquid.
B) Ensure that the client is resting during the measurement.
C) Ensure that the client is not wearing any constrictive clothing.
D) Record the temperature to the even six tenths of a degree.

Answer 2

Postpone the assessment if the client has recently drank a cold or hot liquid.

Question 3

Which statement made by the nurse would indicate that the rectal temperature is contraindicated?

A) "The client hasn't had a bowel movement in 48 hours."
B) "There was a small amount of stool on the thermometer when it was removed."
C) "The client has been experiencing dyspnea."
D) "The client has had diarrhea three times this morning."

Answer 3

"The client has had diarrhea three times this morning."

Question 4

What is the normal temperature range for an axillary temperature?

A) 35.5°C to 37.5°C (95.9°F to 99.5°F)
B) 36.6°C to 38°C (97.9°F to 100.4°F)
C) 34.7°C to 37.3°C (94.5°F to 99.1°F)
D) 35.8°C to 38°C (96.4°F to 100.4°F)

Question 5

What is the normal temperature range for a rectal temperature?

A) 35.5°C to 37.5°C (95.9°F to 99.5°F)
B) 36.6°C to 38°C (97.9°F to 100.4°F)
C) 34.7°C to 37.3°C (94.5°F to 99.1°F)
D) 35.8°C to 38°C (96.4°F to 100.4°F)

Question 6

Which statement accurately describes an intermittent fever?

A) A temperature that alternates between a fever and a normal or subnormal reading
B) A temperature that rises several degrees above normal and returns to normal or near normal
C) A temperature that stays elevated for days or hours
D) A sudden drop from fever to within a normal temperature range

Question 7

What is considered a fever by the oral route?

A) 35.5°C to 37.5°C (95.9°F to 99.5°F)
B) 36.6°C to 38°C (97.9°F to 100.4°F)
C) 34.7°C to 37.3°C (94.5°F to 99.1°F)
D) 37.5°C to 39.4°C (100°F to 103°F)

Question 8

Which type of thermometer should the nurse use when monitoring the temperature of a client placed on contact precautions?

A) Temporal artery
B) Rectal
C) Disposable single use
D) Tympanic

Question 9

Which type of thermometer would provide the nurse with the quickest and most noninvasive method for obtaining the client's temperature?

A) Temporal artery
B) Rectal
C) Disposable single use
D) Tympanic

Question 10

What pulse should the nurse use to assess the heart rate of an 18-month-old child?

A) Radial pulse
B) Apical pulse
C) Pedal pulse
D) Carotid pulse

Question 11

What is the most important consideration for the nurse when assessing a client's carotid pulse?

A) Avoid reaching across the client's neck to count the pulse.
B) Count the pulse beats for 30 seconds.
C) Use the index finger to check the pulse.
D) Assess both carotid pulses simultaneously.

Question 12

The client is suspected of having a pulse deficit. Which apical-radial (A-R) measure needs to be re-taken by the nurse?

A) Apical 72 Radial 82
B) Apical 82 Radial 60
C) Apical 96 Radial 90
D) Apical 104 Radial 100

Question 13

What respiratory rate best reflects tachypnea?

A) 8 to 10 breaths per minute
B) 12 to 18 breaths per minute
C) 20 to 24 breaths per minute
D) 25 to 35 breaths per minute

Question 14

When assessing the respiration of a client, a nurse observes a hissing, crowing sound. What is the most likely cause of this sound?

A) Spasms and edema of the bronchi
B) Air passing through secretions present in the air passages
C) Obstruction near the glottis
D) Air passageway being partially blocked

Question 15

When measuring the blood pressure (BP) of a client with vascular disease, the nurse obtains readings of greater than a 10-point difference between both arms. This is an indication of which condition?

A) Circulatory problem
B) Arterial occlusion in one arm
C) Hemorrhage or shock
D) Orthostatic hypotension

Question 16

A nurse is required to document an adult client's blood pressure. Which nursing intervention will help ensure that the systolic reading is not underestimated?

A) Assist the client to a comfortable position before assessing the pressure.
B) Center the cuff's bladder above the site where the brachial pulse is palpated.
C) Check that the aneroid manometer is vertical and at eye level.
D) Inflate the cuff to a pressure 30 mm Hg above the point where the pulse disappears.

Question 17

Which vital sign indicates an abnormal finding for a healthy adult?

A) Blood pressure 118/74
B) Oral temperature 37°C/98.6°F
C) Pulse 66 beats per minute
D) Respiration rate 21 breaths per minute

Question 18

What event is characteristic of phase II Korotkoff's sounds?

A) The first tapping sound heard
B) The auscultatory gap detected
C) Sounds associated with a child's diastolic pressure
D) The last sound heard before the period of continuous silence

Question 19

What does a pulse oximetry reading of 96% indicate about the composition of a client's blood?

A) Percentage of carbon dioxide in the hemoglobin
B) Percentage of oxygen saturation in the hemoglobin
C) Percentage of potassium saturation in the blood
D) Percentage of sodium in the blood

Question 20

What factors determine the pressure within the heart's ventricles as they contract and rest? Select all that apply.

A) Amount of red blood cells in the blood
B) Rate of heartbeat
C) Blood vessel condition
D) Blood volume
E) Force of heartbeat

Question 21

The nurse obtaining a pulse oximetry reading on a client can place the pulse oximetry sensor on what anatomical positions of the body? Select all that apply.

A) Finger
B) Toe
C) Forehead
D) Earlobe
E) Wrist

Question 22

What classifications of medication commonly cause orthostatic hypotension? Select all that apply.

A) Antipsychotics
B) Antibiotics
C) Antilipidemia
D) Antiseizure
E) Antifungal