chapter 20 Flashcards
If the body is overheating, it will compensate with:
A - Vasodilation
B - Vasoconstriction
A
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
B
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
A
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
A
When a patient’s temperature increases, the pulse rate also increases. This finding would be:
A - Normal
B- Abnormal
A
While palpating Ms. Smith’s pulse, you find a rate of 116 beats/min. This finding is considered _______.
A- Tachycardia
B - Bradycardia
A
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
B
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
A
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
A
When a patient’s blood pressure decreases, his pulse increases. This finding would be:
A - Normal
B - Abnormal
A
Which blood pressure Korotkoff sound represents the systolic reading?
A - 1st Sound
B - 5th Sound
A
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
A
B
D
E
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
D
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
A
C
E
_____________ pressure is peak blood pressure against arterial walls.
A - Brachial
B - Mean
C - Systolic
D - Radial
E - Diastolic
C
What information is needed when assessing the respiratory vital signs? Select all that apply.
A - Rate
B - Depth
C - Rhythm
D - Effort
E - Quality
A
B
C
D
Which factors impact a client’s normal body temperature? Select all that apply.
A - Age
B - Gender
C - Exercise
D - Environment
E - Recent intake
A
B
C
D
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
B
C
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
D
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)
A
D
E
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.
C
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.
C
Which gases are primarily exchanged during respiration? Select all that apply.
A - Oxygen
B - Chloride
C - Nitrogen
D - Hydrogen
E - Carbon dioxide
A
E
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
B
D
E
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).
B
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.
C
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
D
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
B
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
A
C
D
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
C
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
B
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
B
A client has a respiratory rate of 8 breaths per minute. What is this rate called?
A - Apnea
B - Hypoxia
C - Tachypnea
D - Bradypnea
D
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
D
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
A
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
B
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
C
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.
D
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
D
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
B
C
D
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
B
C
F
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
D
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.
A
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
A
