Deck 19: Vital Signs

Question 1

A nurse works on a postoperative care unit and sees many patients who have orthopedic surgery. One patient complains of significantly more pain than the other postoperative patients usually do. What action by the nurse is best?

A) Explain to the patient that so much pain is not reasonable.
B) Ask the patient to rate and describe the pain.
C) Give the patient pain medications as prescribed.
D) Call the provider and request an extra dose of pain medication.

Answer 1

Ask the patient to rate and describe the pain.

Question 2

A nurse performs orthostatic blood pressure readings on a patient with the following results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best?

A) Instruct the patient not to get up without help.
B) Document the findings and continue to monitor.
C) Reassure the patient that these findings are normal.
D) Reassess the blood pressures in 1 hour.

Answer 2

Instruct the patient not to get up without help.

Question 3

The nursing faculty member is observing a student taking a patient's carotid pulse. What action by the student requires intervention by the faculty member?

A) Counts pulse for 30 seconds and multiplies by two.
B) Performs hand hygiene prior to patient contact.
C) Compares pulses in both carotid arteries at the same time.
D) Assesses pulse on one side then assesses the other side.

Answer 3

Compares pulses in both carotid arteries at the same time.

Question 4

The nurse is caring for a woman who had a right-sided mastectomy 2 years ago. What action by the nurse is most appropriate?

A) Place a sign above the bed: "No blood pressures on the right arm."
B) Place a sign above the bed: "No continuous blood pressures on the right arm."
C) Place a sign above the bed: "Blood pressures in legs only."
D) No specific action is needed for this situation.

Question 5

The nurse assesses a patient's pulse and finds it hard to obliterate with palpation. What action by the nurse is best?

A) Assess the patient for fluid volume overload.
B) Assess the patient for fluid volume deficit.
C) Assess the patient's apical heart rate.
D) Assess the patient's pulse deficit.

Question 6

A patient returned from a procedure and has vital sign measurements ordered every hour. The patient's blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg. What action by the nurse is most appropriate?

A) Take the vital signs again in another hour.
B) Document the findings in the patient's chart.
C) Have another nurse recheck the vital signs.
D) Plan to take the vital signs more often.

Question 7

A nurse notes a patient has abnormal vital signs. What action by the nurse is best?

A) Document the findings.
B) Notify the provider.
C) Compare with prior readings.
D) Retake the vital signs.

Question 8

A patient's blood pressure is 142/76 mm Hg. What does the nurse chart as the pulse pressure?

A) 28
B) 42
C) 58
D) 66

Question 9

A nurse is going to take a patient's oral temperature. The patient has been drinking coffee. What action by the nurse is best?

A) Have the patient drink room temperature water.
B) Return in 30 minutes to take the patient's temperature.
C) Take the patient's temperature rectally instead.
D) Document that temperature is unable to be obtained.

Question 10

The student nurse is assessing a patient's pulses. What action by the student requires the nurse to intervene?

A) Assessing apical pulse between the fifth and sixth intercostal spaces
B) Assessing the doralis pedis pulse by palpating behind the patient's knee
C) Assessing the radial pulse on the patient's wrist
D) Assessing the brachial pulse on the patient's inner elbow

Question 11

A nursing student is caring for a patient with metabolic acidosis. The student asks the registered nurse why the patient's respiratory rate is so high. What response by the nurse is best?

A) "The patient's metabolic rate is increased from being ill."
B) "The lungs are trying to rid the body of extra carbon dioxide."
C) "The patient is trying to reduce his temperature through panting."
D) "Patients who are acutely ill often have abnormal vital signs."

Question 12

A nurse observes a student taking an adult patient's tympanic temperature. What action by the student requires the nurse to intervene?

A) Student washes hands prior to patient contact
B) Student pulls the pinna of the patient's ear down and back
C) Student explains the procedure to the patient
D) Student pulls the pinna of the patient's ear up and back

Question 13

A nurse is caring for a patient who has orthopnea. What action by the nurse is most appropriate?

A) Encourage deep breathing and coughing.
B) Medicate the patient for pain as needed.
C) Keep the head of the bed elevated.
D) Monitor the length of time the patient doesn't breathe.

Question 14

The nurse is delegating taking vital signs to an unlicensed assistive personnel (UAP). What instructions does the nurse provide the UAP? (Select all that apply.)

A) "Let me know if Mr. Smith's blood pressure is low."
B) "Take Mrs. Jones' blood pressure every 15 minutes."
C) "Call me if Ms. Walsh's systolic blood pressure drops to under 100 mm Hg."
D) "Do you want me to demonstrate using the electronic blood pressure cuff?"
E) "I'll take Mr. Derby's blood pressure since he is not stable."

Question 15

The nursing student learns that the purpose of measuring vital signs includes which rationale? (Select all that apply.)

A) Monitor body systems functioning.
B) Identify early signs of problems.
C) Evaluate effectiveness of interventions.
D) Determine if a cure has been obtained.
E) Provide a baseline to compare against.

Question 16

A nurse is caring for a patient who has a high temperature. The nurse plans to help the patient regain a normal temperature through conduction. What technique does the nurse use?

A) Placing a cooling fan in the patient's room
B) Putting ice packs in the patient's axillae
C) Spraying the patient with a fine mist of water
D) Turning the temperature down in the room

Question 17

A nurse assesses a patient's radial pulse rate to be 110 beats/min and regular. What action by the nurse is best?

A) Assess the patient for causes of tachycardia.
B) Take an apical heart rate and compare the two.
C) Document the findings in the patient's chart.
D) Notify the patient's health care provider.

Question 18

A nurse is told in the hand-off report that a patient is afebrile. What assessment finding correlates with this statement?

A) Blood pressure 152/98 mm Hg
B) Temperature 98.4° F (36.8° C)
C) Pulse 82 beats/min
D) Respirations 16 breaths/min

Question 19

The nurse receives a handoff report on four patients. Which patient should the nurse assess first?

A) Pain rating 4/10 after pain medication
B) Blood pressure 102/62 mm Hg
C) Pulse 42 beats/min
D) Respiratory rate 18 breaths/min

Question 20

The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The pulse oximeter does not provide a good reading. What action by the nurse is best?

A) Move the oximeter probe to another finger.
B) Assess the fingers for good circulation.
C) Document that the reading cannot be obtained.
D) Remove any fingernail polish present on the fingernail.

Question 21

Which parameters does the nurse include when assessing pain? (Select all that apply.)

A) Facial expression
B) Muscle spasms
C) Shallow respirations
D) Immobility
E) Temperature

Question 22

A nurse is teaching a patient and the patient's family about self-care measures for hypertension. Which topics does the nurse include? (Select all that apply.)

A) Increase exercise on most days
B) Maintain a normal body weight
C) Abstain from any alcohol
D) Reduce dietary sodium to 2.4 g/day
E) Follow the DASH diet

Question 23

A nurse is caring for an unconscious patient. What objective assessments does the nurse use to help evaluate pain in this patient? (Select all that apply.)

A) Agitation
B) Restlessness
C) Sighing
D) Vital signs
E) Shivering

Question 24

The nurse assessing respirations understands that problems in what organs can directly affect the process of respiration? (Select all that apply.)

A) Brain
B) Lungs
C) Heart
D) Liver
E) Skeletal muscle

Question 25

The nurse understands that which factors can increase blood pressure? (Select all that apply.)

A) Head injury
B) Decreased fluid volume
C) Increasing age
D) Recent food intake
E) Pain