chapter 20

Question 1

If the body is overheating, it will compensate with:
A - Vasodilation
B - Vasoconstriction

Answer 1

A

Question 2

Mr. Lu is admitted with an abdominal pain. His oral temperature is 100.4°F (38°C), pulse is 88 beats/min, respirations are 18 breaths/min, and blood pressure is 118/78 mm Hg. These findings are:
A - Normal
B- Abnormal

Answer 2

B

Question 3

Ms. Martin vomited 200 mL of stomach contents after breakfast. Her vital signs include tympanic temperature, 97.6°F (36.4°C); pulse, 99 beats/min; respirations, 16 breaths/min; and blood pressure, 104/67 mm Hg. These findings are:
A - Normal
B - Abnormal

Answer 3

A

Question 4

Ms. Hernandez has a temperature of 102.5°F. Antipyretic medication is ordered for a temperature higher than 39°C. Can the nurse safely administer the medication?
A - Yes
B - No

Answer 4

A

Question 5

When a patient’s temperature increases, the pulse rate also increases. This finding would be:
A - Normal
B- Abnormal

Answer 5

A

Question 6

While palpating Ms. Smith’s pulse, you find a rate of 116 beats/min. This finding is considered _______.
A- Tachycardia
B - Bradycardia

Answer 6

A

Question 7

While assessing Mr. Brown’s respiratory rate, you also observe that his chest expands fully on inspiration. His respiratory depth would be considered:
A - Shallow
B - Deep

Answer 7

B

Question 8

At the beginning of a visit, the nurse assesses Mr. Broda’s blood pressure and finds it is 116/76 mm Hg. During the visit, Mr. Broda receives some disturbing news about a diagnostic test. If his blood pressure was reassessed at that time, you would expect it to:
A - Rise
B - Fall

Answer 8

A

Question 9

Ms. Weakly presents to the emergency department with difficulty breathing. Her respiratory rate is 28 breaths/min and her pulse is 110 beats/min. Given the situation, this finding is:
A - Normal
B - Abnormal

Answer 9

A

Question 10

When a patient’s blood pressure decreases, his pulse increases. This finding would be:
A - Normal
B - Abnormal

Answer 10

A

Question 11

Which blood pressure Korotkoff sound represents the systolic reading?
A - 1st Sound
B - 5th Sound

Answer 11

A

Question 12

What are the primary vital signs of the nursing assessment? Select all that apply.

A - Blood pressure
B - Pulse
C - Pulse oximetry
D - Respiratory rate
E - Temperature

Answer 12

A
B
D
E

Question 13

While palpating Mrs. Wong’s pulse, you find a rate of 40 beats/min. This finding is _________.

A - Tachypnea
B - Tachycardia
C - Bradypnea
D - Bradycardia

Answer 13

D

Question 14

The nurse performs a vital sign assessment and obtains the following results: Temperature, 101.3°F (38.5°C); pulse, 110 beats/min; respiratory rate, 28 breaths/minute; blood pressure, 107/66 mm Hg. Which findings are abnormal? Select all that apply.

A - Respiratory rate
B - Systolic blood pressure
C - Temperature
D - Diastolic blood pressure
E - Pulse

Answer 14

A
C
E

Question 15

_____________ pressure is peak blood pressure against arterial walls.

A - Brachial
B - Mean
C - Systolic
D - Radial
E - Diastolic

Answer 15

C

Question 16

What information is needed when assessing the respiratory vital signs? Select all that apply.

A - Rate
B - Depth
C - Rhythm
D - Effort
E - Quality

Answer 16

A
B
C
D

Question 17

Which factors impact a client’s normal body temperature? Select all that apply.

A - Age
B - Gender
C - Exercise
D - Environment
E - Recent intake

Answer 17

A
B
C
D

Question 18

Which physiological processes occur when the hypothalamus is stimulated due to a client being warm? Select all that apply.

A - Epinephrine release
B - Peripheral vasodilation
C - Perspiration
D - Piloerection
E - Shunting of blood away from the periphery

Answer 18

B
C

Question 19

Which disorder can cause an increase in the basal metabolic rate (BMR) and thus raises body temperature?

A - Hypertension
B - Hyperlipidemia
C - Hypothyroidism
D - Hyperthyroidism

Answer 19

D

Question 20

In which clients would the nurse find elevated pulse rates? Select all that apply.

A - A 3-month-old infant
B - A client with hypothyroidism
C - A client taking digoxin (Lanoxin)
D - A client with a temperature of 101.0°F
E - A client with chronic obstructive pulmonary disease (COPD)

Answer 20

A
D
E

Question 21

The nurse is assessing a client with congestive heart failure and notes 3+ bilateral pitting pedal edema. The nurse is unable to palpate the pedal pulses. What would be the best intervention?

A - Document that the pedal pulses cannot be obtained.
B - Ask another nurse to verify the lack of pedal pulses.
C - Obtain a portable Doppler and check for pedal pulses.
D - Notify the primary health-care provider of a lack of pedal pulses.

Answer 21

C

Question 22

The nurse is working at a health fair providing blood pressure and pulse screenings. The nurse finds a young adult client has an apical pulse of 44 bpm. What would be the nurse’s first action?

A - Call 911 and notify emergency medical services (EMS).
B - Have the client drink some water, then recheck the apical pulse.
C - Ask the client if he or she is an athlete or runs every day.
D - Instruct the client to make an appointment to see his or her health-care provider.

Answer 22

C

Question 23

Which gases are primarily exchanged during respiration? Select all that apply.

A - Oxygen
B - Chloride
C - Nitrogen
D - Hydrogen
E - Carbon dioxide

Answer 23

A
E

Question 24

Which factors affect respiration? Select all that apply.

A - Decreased serum potassium levels
B - Level of carbon dioxide tension in the blood
C - Changes in pressure within the thoracic cavity
D - Central chemoreceptors in the medulla and pons
E - Peripheral chemoreceptors located in the carotid and aortic bodies

Answer 24

B
D
E

Question 25

A client visits an urgent care center while on vacation in Colorado. The client reports difficulty breathing since arriving. Which factor most likely explains the client’s dyspnea? A - The client is experiencing a sickle cell crisis. B - The high altitudes prevent oxygen from binding to hemoglobin. C - The client has consumed large amounts of caffeinated coffee. D - The client has underlying chronic obstructive pulmonary disease (COPD).

Answer 25

B

Question 26

What should the nurse do when obtaining a client’s orthostatic blood pressure (BP)? A - Take the standing BP first. B - Perform these readings prior to the client eating. C - Wait 1 to 3 minutes in between each reading. D - Document the lowest BP reading.

Answer 26

C

Question 27

Which is the best term for the nurse to include in his or her assessment documentation to note that a client is unable to lie flat without becoming short of breath? A - Wheezes B - Crackles C - Dyspnea D - Orthopnea

Answer 27

D

Question 28

A nurse has asked the unlicensed assistant personnel (UAP) to take vital signs on six clients. Which traditional measurements do vital signs include? A - Pulse, respiratory rate, and temperature B - Temperature, pulse, respirations, and blood pressure C - Blood pressure, pulse, and temperature D - Respirations, pulse, and temperature

Answer 28

B

Question 29

At what times should a client’s vital signs be measured and documented? Select all that apply. A - On admission to a hospital or clinic visit B - At the end of a shift C - After certain medications have been administered D - Whenever the client’s condition changes E - Before and after surgery or certain procedures F - At discharge

Answer 29

A C D

Question 30

In addition to the four major vital signs, the Joint Commission added a fifth vital sign. What is the fifth vital sign? A - Oxygen saturation B - Smoking status C - Pain D - Emotional distress

Answer 30

C

Question 31

A nurse is auscultating lung sounds on a client with asthma. The nurse would expect to hear which abnormal lung sounds in this client? A - Low-pitched, continuous gurgling sounds caused by secretions in the large airways B - High-pitched, continuous musical sounds, usually heard on expiration, which are caused by narrowing of the airways C - A piercing, high-pitched sound that is caused by an obstructed airway and is most common in infants D - Discontinuous popping sounds usually heard on inspiration and caused by fluid in the alveoli

Answer 31

B

Question 32

A nurse is learning about the processes of heat exchange between the body and the environment. What is this process that accounts for almost 50% of body heat loss called? A - Convection B - Radiation C - Evaporation D - Conduction

Answer 32

B

Question 33

A client has a respiratory rate of 8 breaths per minute. What is this rate called? A - Apnea B - Hypoxia C - Tachypnea D - Bradypnea

Answer 33

D

Question 34

A UAP has been assigned to take vital signs on four clients. Which temperature should be reported immediately to the nurse? A - An oral temperature of 96.5°F for a client who is 88 years old B - A rectal temperature of 99.9°F for a client who is 26 years old C - An axillary temperature of 98.1°F for a client who is 30 years old D - An oral temperature of 104.9°F for a client who is 40 years old

Answer 34

D

Question 35

A client with peripheral vascular disease has weak pedal pulses and the right foot is cool and pale. Which nursing diagnosis has the highest priority? A - Ineffective tissue perfusion B - Risk for impaired skin integrity C - Risk for decreased cardiac output D - Risk for deficient fluid volume

Answer 35

A

Question 36

A nurse is calculating the pulse pressure for a client who has a blood pressure of 150/80. What is the pulse pressure? A - 230 mm Hg B - 70 mm Hg C - 1.875 mm Hg D - 140 mm Hg

Answer 36

B

Question 37

When taking a manual blood pressure, the nurse listens for Korotkoff sounds. What numbers of Korotkoff sounds produce the systolic and diastolic numbers? A - First and third B - First and fourth C - First and fifth D - First and second

Answer 37

C

Question 38

What is the correct technique for palpating the carotid pulses? A - Quickly palpate each carotid pulse so as to not make the client nervous. B - Have the client hold his or her breath during palpation. C - Gently palpate both carotid pulses at the same time. D - Gently palpate one carotid pulse at a time.

Answer 38

D

Question 39

Pulse oximetry is a noninvasive method to assess a client’s oxygen level in what part of the blood? A - Hematocrit B - Platelets C - White blood cells D - Hemoglobin

Answer 39

D

Question 40

A nurse can delegate assessment of vital signs to a UAP for which clients? Select all that apply. A - Client who is 1 hour post-appendectomy B - Client who will be discharged to home the next day C - Client who is 4 hours post laparoscopic cholecystectomy D - Client with diverticulitis and taking prednisone E - Client who has a pain level of 9 on a scale of 0 to 10

Answer 40

B C D

Question 41

Which are modifiable risk factors for preventing hypertension? Select all that apply. A - Age B - Smoking C - Salt and alcohol intake D - Sex E - Ethnicity F - Stress

Answer 41

B C F

Question 42

A nurse is reviewing the blood pressure log for a 57-year-old African American client. The average blood pressure for this client is 156/88. Which stage of blood pressure is this? A - Normal B - Prehypertension C - Stage 1 hypertension D - Stage 2 high blood pressure

Answer 42

D

Question 43

A home care nurse is teaching a client and his wife about taking digoxin. What is the most important teaching intervention? A - Call the primary care provider if the pulse is less than 60. B - Call the primary care provider if the client has difficulty voiding. C - Call the primary care provider if the client loses his or her appetite. D - Call the primary care provider if the client develops constipation.

Answer 43

A

Question 44

A nurse has received shift reports on several clients. Which client should the nurse see first? A - A client with heart failure with a respiratory rate of 42 breaths per minute B - A newly admitted client with fine wheezes in the upper lobes C - A client with diabetes who has a pulse of 68 D - A client being discharged in one hour

Answer 44

A