Chapter 30 Vital Signs

Question 1

A 52 yr old woman sis admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 yrs and recently lost over 10lbs. Her vital signs on admission are: HR 112, BP 138/82, RR 22, temp 98.2, and O2 94 %. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy?

1. Temp 98.6
2. Radial pulse 112
3. RR 24
4. O2 96%

Answer 1

4. O2 96%

Question 2

A 55 yr old female patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a leg laceration on her forehead. An IV line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. Which sites do you instruct the nursing assistant to use for obtaining the pts blood pressure and temp?

1. Right antecubital and tympanic membrane
2. Right popliteal and rectal
3. Left antecubital and oral
4. Left popilteal and temporal artery

Answer 2

1. Right antecubital and tympanic membrane

Question 3

The nurse observes a nursing student taking a BO on a pt. The nurse notes that the student very slowly deflates the cuff in an attempt to hear the sounds. The patients BP range over the past 24 hrs is 132/64 to 126/72 mm Hg. Which of the following BP readings made by the student is most likely caused by an incorrect technique?

1. 96/40
2. 110/66
3. 130/90
4. 156/82

Answer 3

3. 130/90

Question 4

As you are obtaining oxygen saturation on a 19 yr old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks why her nail polish had to be removed. What is the best response?

1. Nail polish attracts microorganisms and contaminants the finger sensor
2. Nail polish increases oxygen saturation
3. Nail polish interferes with sensor function
4. Nail polish creates excessive heat in sensor probe.

Answer 4

3. Nail polish interferes with sensor function

Question 5

A patient has been hospitalized for the past 48 hrs with a fever of unknown origin. His medical record indicates tympanic temps of 101.6 (0400), 97.9(0800), 98.4 (1200), 99.6(1600), 100.9(2000). How would you describe this pattern of temp measurements?

1. Usual range of circadian rhythm measurements
2. Sustained fever pattern
3. Intermittent fever pattern
4. Resolving fever pattern

Answer 5

3. Intermittent fever pattern

Question 6

A pt presents in the clinic with dizziness and fatigue. The nursing assistant reports a slow but regular radial pulse of 44. What is your priority intervention?

1. Request that the nursing assistant repeat the pulse check
2. Call for a stat ECG
3. Assess the pts apical pulse and evidence of a pulse deficit
4. Prepare to administer cardiac-stimulating medications

Answer 6

3. Assess the pts apical pulse and evidence of pulse deficit

Question 7

Which pt is at highest risk for tachycardia?

1. A healthy basketball player during warmup exercises
2. A pt admitted with hypothermia
3. A pt with a fever of 103
4. A 90 yr old male taking beta blockers

Answer 7

3. A pt with a fever of 103

Question 8

Which of the following patients are at most risk for tachypnea? (Select all that apply)

1. Pt just admitted with four rib fractures
2. Woman who is 9 months pregnant
3. Adult who has consumes alcoholic beverages
4. Adolescent waking from sleep
5. Three-pack-per-day smoker with pneumonia

Answer 8

1. Pt just admitted with four rib fractures
2. Woman who is 9 months pregnant
3. Thee-pack-per-day smoker with pneumonia

Question 9

A pt has been admitted for a cerebrovascular accident (Stroke). She cannot move her right arm,a nod she has a right sided facial droop. She is able to eat with her dentures in place and swallow safely. The nursing assistive personnel (NAP) reports to you that the pt will not keep the oral thermometer prober in her mouth. What direction fo you provide to the NAP?

1. Direct the NAP to hold the thermometer in place with her gloved hand
2. Direct the NAP to switch the thermometer probe to the left sublingal pocket
3. Direct the NAP to obtain a right tympanic temp
4. Direct the NAP to use a temporal artery thermometer from the right to left

Answer 9

4. Direct the NAP to use a temporal artery thermometer from the right to left

Question 10

The NAP reports to you that the blood pressure of the patient in question 11 is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? (Select all that apply)

1. Notify the health care provider immediately
2. Repeat the measurements on both arms using a stethoscope
3. Ask the pt if she has taken her blood pressure medications recently
4. Obtain BP measurements on lower extremities
5. Verify that the correct cuff size was used during measurements
6. Review the pts record for her baseline vital signs
7. Compare right and left radial pulses for strength

Answer 10

2. Repeat the measurements on both arms using a stethoscope

6. Review the pts record for her baseline vital signs

Question 11

The NAP informs toy that the electronic blood pressure machine on the pt who has recently returned from surgery following removing of her gallbladder is flashing a BO of 65/46 and alarming. Place your care activities in priority order.

1. Press the start button on the electronic BP machine to obtain a new reading
2. Obtain a manual blood pressure with a stethoscope
3. Check the pt pulse distal t the blood pressure cuff
4. Assess the pts mental status
5. Remind the pt not to bend her arm with the blood pressure cuff off

Answer 11

4. Assess the pts mental status
5. Press the start button on the electronic BP machine to obtain a new reading
6. Check the pt pulse distal t the blood pressure cuff
7. Obtain a manual blood pressure with a stethoscope
8. Remind the pt not to bend her arm with the blood pressure cuff off

Question 12

A healthy adult pt tells the nurse that he obtained his BP in “one of those quick machines in the mall” and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a BP of 116/76. What would account for the blood pressure of 115/92? (Select all that apply)

1. Cuff too small
2. Arm positioned above heart level
3. Slow inflation of the cuff by the machine
4. Patient did not remove his long sleeved shirt
5. Insufficient time between measurements

Answer 12

1. Cuff too small

5. Insufficient time between measurements

Question 13

A pt is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant reports his admitting vital signs to the nurse. Which measurements should the nurse reassess? (Select all that apply)

1. R Arm BP 118/72
2. Radial pulse rate 72 and irregular
3. Temp 99.3
4. Respiratory rate: 28
5. O2 99%

Answer 13

2. Radial pulse rate 72 and irregular
3. RR 28
4. O2 99%