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Vital Signs - Ch. 12 > Study Guide Ch. 12 > Flashcards

Study Guide Ch. 12 Flashcards

1
Q
  1. bradycardia
A

b. Normal finding for well-conditioned athlete

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2
Q
  1. dyspnea
A

e. Laboring with difficulty to get enough oxygen

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3
Q
  1. hyperthermia
A

g. Above-normal body temperature

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4
Q
  1. bradypnea
A

f. Slow respiratory rate, fewer than 10 per minute

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5
Q
  1. systolic
A

c. Represents the ventricles contracting, forcing blood into the aorta and the pulmonary arteries

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6
Q
  1. tachypnea
A

d. Expected respiratory pattern while exercising

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7
Q
  1. dysrythmia
A

a. Irregularity in the normal rhythm of the heart

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8
Q
  1. hypothermia
A

j. Oral temperature of 93.2F (34C)

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9
Q
  1. tachycardia
A

h. Expected heart rate if very frightened or angry

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10
Q
  1. hypertension
A

i. The silent killer

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11
Q
  1. The nurse if taking blood pressures (BPs) at a community health fair and screening people for risk factors for hypertension. Which person has the most risk factors for developing hypertension?

A. 23-year-old athletic Asian American woman with a BP of 120/80 Hg and a family history of hypertension.
B. 32-year-old African American mother of two children with a BP of 134/70 Hg who exercises regularly
C. 66-year-old thin Jewish American male with a BP of 124/80 mm Hg; he regularly drinks alcohol and has a sedentary lifestyle.
D. 45-year-old African American man with a BP of 130/80 mm Hg who smokes, is overweight , and eats a vegetarian diet.

A

D. 45-year-old African American man with a BP of 130/80 mm Hg who smokes, is overweight , and eats a vegetarian diet.

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12
Q
  1. The unlicensed assistive personnel (UAP) just reported patients’ vital signs to the nurse. For which patient is an increased pulse an expected finding?

A. Patient received antihypertensive medications 4 hours ago.
B. Patient needs scheduled routine medication for hypothyroidism.
C. Patient who has a fever had a dose of antipyretic medication 6 hours ago.
D. Patient’s medication are being managed by the cardiac rehabilitation team.

A

C. Patient who has a fever had a dose of antipyretic medication 6 hours ago.

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13
Q
  1. The nurse needs to get an apical pulse on an older woman who has large, pendulous breasts. What would the nurse do first?

A. Lift the left breast and place the bell or diaphragm at the fifth intercoastal space.
B. Lift the breast and place palm of hand over the point of maximal impulse
C. Use the bell of the stethoscope to make a tight seal against the lateral chest wall.
D. Obtain the ultrasonic Doppler and position it where breast tissue is most flattened.

A

A. Lift the left breast and place the bell or diaphragm at the fifth intercoastal space.

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14
Q
  1. The nurse observes that the patient has an elevated temperature. What questions would the nurse ask to collect data about a systemic infection? Select all that apply.

A. “Do you feel thirsty?”
B. “Do you have a headache?”
C. “Are you having trouble resting or getting comfortable?”
D. “Would you like some medication to reduce your fever?”
E. “Have you experienced any chills?”

A

A. “Do you feel thirsty?”
B. “Do you have a headache?”
C. “Are you having trouble resting or getting comfortable?”
E. “Have you experienced any chills?”

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15
Q
  1. The UAP reports to the nurse that the “pulse oximeter might be broken” because some of the patients had low readings. What would the nurse do first?

A. Instruct the UAP to go back and retake the readings on any patient who had a low value.
B. Ask the UAP if the patients who has a low readings were having any problems breathing.
C. Examine and troubleshoot the pulse oximeter and test it on several healthy staff members.
D. Assess the patients who has low readings and determine if extraneous factors are present.

A

D. Assess the patients who has low readings and determine if extraneous factors are present.

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16
Q
  1. The nurse hears in report that the patient has peripheral arterial disease that affects his lower extremities. What would the nurse expect to find during assessment?

A. Popliteal pulses are full and bounding and there is some mild edema in the posterior calf.
B. Dorsalis pedis and posterior tibial pulses are weak, and toes are cooler than upper leg.
C. Patient reports severe pain with loss of sensation and decreased strength and movement in legs.
D. Brachial and radial pulses are weak compared to dorsalis pedis and posterior tibial pulses.

A

B. Dorsalis pedis and posterior tibial pulses are weak, and toes are cooler than upper leg.

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17
Q
  1. The nurse notes that a patient occasionally sighs during the morning assessment. What is the clinical significance of occasional sighing?

A. The patient had trouble breathing during the night and sighing is related to lower blood oxygen levels.
B. This is a behavior that many people demonstrate when they are bored and frustrated.
C. The patient has a chronic lung disease and deep breathing is characteristic of the disorder.
D. Occasional sighing is considered normal and allows all alveoli to be aerated.

A

D. Occasional sighing is considered normal and allows all alveoli to be aerated.

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18
Q
  1. An experienced UAP reports that the patient is alert and asking for breakfast. Vital signs have been completed and recorded as follows: axillary temperature of 100.6* F, Pulse of 80 beats/ min, respirations 16/ min, BP 120/70 mm Hg. What is the nurse’s first action.

A. Instruct the UAP to obtain a breakfast try for the patient.
B. Ask the UAP to repeat the temperature using the oral or tympanic method.
C. Direct the UAP to repeat all of the vital signs and observe technique.
D. Ask the UAP to explain the choice of axillary method to measure the temperature.

A

D. Ask the UAP to explain the choice of axillary method to measure the temperature.

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19
Q
  1. A new nurse has taken a job on a medical surgical unit. According to the shift report, the four assigned patients are stable and should have a predictable clinical stay. Based on the report, how often foes the nurse plan to take the vital signs?

A. Every hour until the nurse verifies for self that the patients are stable.
B. Before and after administrating any oral or intravenous medications.
C. According to facility policy for frequency unless status changes.
D. At the beginning and end of the shift, unless the health care provider (HCP) orders otherwise.

A

C. According to facility policy for frequency unless status changes.

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20
Q
  1. The nursing student takes a BP on a patient who has been in a coma for several months. The student reports to the nurse that the BP seems too low. What would the nurse do first?

A. Direct the student to retake the BP on the opposite extremity.
B. Go with the student and assess the patient for other sign/ symptoms.
C. Instruct the student to check the chart to see what is baseline for the patient.
D. Remind the student that a prolonged coma will cause changes in vital signs.

A

B. Go with the student and assess the patient for other sign/ symptoms.

21
Q
  1. A patient who is brought to the emergency department was discovered lying in an alley. He is cold and wet and demonstrates slurred speech. His temperature is 94* F. How does his condition affect his pulse rate?

A. Tachycardia is likely fir to the stress of cold exposure.
B. Since his is conscious, there should be no effects on pulse.
C. A decreased heart rate reflects lowered metabolism.
D. Palpating pulses will be impossible because of vasoconstriction.

A

C. A decreased heart rate reflects lowered metabolism.

22
Q
  1. The UAP takes vital signs at 3:00am and reports to the nurse that the patient’s temperature is 97.6* F (36.4C). The nurse sees that the patient’s temperature at 6:00pm was 99.6 F (37.5* C) and at 11:00pm was 98.2* F (36.8* C). What would the nurse do?

A. Thank the UAP and explain that lower temperatures occur between 1am and 4am.
B. Repeat the temperature, but use a different method than what the UAP used.
C. Tell the UAP to document the temperature and not to worry about it.
D. Ask the UAP to get the patient a warm blanket and increase the room temperature.

A

A. Thank the UAP and explain that lower temperatures occur between 1am and 4am.

23
Q
  1. Two nurses simultaneously assess to determine if a patient has a pulse deficit. One nurse counts the apical pulse at 105 beats/ min. The other nurse take the radial pulse and counts 96 beats/ min. What is the pulse deficit?
    __________
A

The pulse deficit is 9

24
Q
  1. When assessing the apical pulse how does the nurse count the pulse rate?
    A. Counts for 20 seconds and multiplies by 3.
    B. Counts for 60 seconds and does not multiply.
    C. Counts for 30 seconds and multiplies by 2.
    D. Counts for 15 seconds and multiplies by 4.
A

B. Counts for 60 seconds and does not multiply.

25
Q
  1. The nurse is supervising a first-year nursing student who is checking the patient’s peripheral pulses. The nurse would intervene if the student preformed which action?
    A. Palpated all of the pulses, including carotids and femorals bilaterally.
    B. Positioned the patient in the prone position to asses the popliteal artery.
    C. Palpated the point of maximal impulse and assessed the apical pulse for 60 seconds.
    D. Palpated the radial pulse with the pads of the index and third fingers.
A

A. Palpated all of the pulses, including carotids and femorals bilaterally.

26
Q
  1. Which factor/ condition is most likely to increase the patient’s respiratory rate?
    A. Opioid medication
    B. Acute pain
    C. Hypothermia
    D. Brainstem injury
A

B. Acute pain

27
Q
  1. The nurse counts respirations immediately following measurements of the radial pulse while the fingers are still in place over the artery. What is the best rationale for this technique?
    A. Rapport has been established so the patient is likely to be less anxious.
    B. Therapeutic touch of the nurse’s fingers on the patient’s wrist is soothing.
    C. Patients may voluntarily alter respiratory rate if they know they are being monitored.
    D. Counting respirations immediately after pulse check is an efficient timesaver.
A

C. Patients may voluntarily alter respiratory rate if they know they are being monitored.

28
Q
  1. A nursing student is preparing to take the BP on a patient who has excessive adipose tissue on the upper arm. If the student uses a normal sized cuff, what is likely to occur?
    A. The BP will be falsely elevated.
    B. The patient will be uncomfortable during the procedure.
    C. The systolic pressure will be artificially lower.
    D. The BP is likely to be very close to baseline.
A

A. The BP will be falsely elevated.

29
Q
  1. The nurse receives the end- of-shift reports from the off-going nurse. Based on the vital sign information for the assigned adult patients, which patient would the nurse check on first?
    A. BP 120/80, P 68, R16
    B. BP 110/74, P 72, R14
    C. BP 130/90, P 80, R18
    D. BP 120/90, P 62, R9
A

D. BP 120/90, P 62, R9

30
Q
  1. The nurses sees in the patient’s documentation that the patient has a radial pulse of 4+. What assessment would the nurse plan to make for this patient?
    A. Doppler assessment of pulses for hands and feet.
    B. Observe for pallor or cyanosis in the hands.
    C. Assess BP for hypertension
    D. Assess apical and radial pulse for a pulse deficit.
A

C. Assess BP for hypertension

31
Q
  1. The patient’s pulse oximetry reading appears to be lower than expected. The patient is breathing easily, the lungs are clear, the oxygen is delivered as ordered, and the patient reports, “feeling fine.” What would the nurse do first?
    A. Check the position of the pulse oximeter.
    B. Feel the patient’s fingers for coolness or warmth.
    C. Apply the pulse oximeter to own finger to test function.
    D. Ask the patient if he has any circulation problems.
A

A. Check the position of the pulse oximeter.

32
Q
  1. The nurse needs to take the temperature of a baby who was brought to the clinic for his 6-month well-baby visit. Which method of measuring the temperature is the best choice for this patient?
    A. Oral
    B. Axillary
    C. Rectal
    D. Temporal arterial
A

D. Temporal arterial

33
Q
  1. The nurse received a new stethoscope as a graduation present. What will he/she do to care for and appropriately use the stethoscope?
    A. Drape the stethoscope around the neck to have it readily available.
    B. Clean the tubing with alcohol swabs after every patient contact.
    C. Remove the earpieces regularly and clean off cerumen, dust, and oils.
    D. Frequently rub the tubing between the palms to keep it soft.
A

C. Remove the earpieces regularly and clean off cerumen, dust, and oils.

34
Q
  1. The nurse is caring for a patient who is several days postoperative for major abdominal surgery. The UAP reports that the pulse is 120 beats/ min. The nurse rechecks the pulse and gets 122 beats/ min. What will the nurse assess for? Select all that apply.
    A. Pain
    B. Infection
    C. Anxiety
    D. Hemorrhage
    E. Substance abuse
    F. Hypothermia
A

A. Pain
B. Infection
C. Anxiety
D. Hemorrhage
E. Substance abuse

35
Q
  1. The patient has a sudden deterioration in condition with confusion; diaphoresis; pallor; and cold, clammy skin. Which peripheral pulse site is the best to quickly determine the pulse rate?
    A. Radial
    B. Femoral
    C. Carotid
    D. Brachial
A

C. Carotid

36
Q
  1. The nurse hears in report that the patient has bilateral dorsalis pedis pulses 3+. How does the nurse use this information in planning care?
    A. Allots time to check circulation and sensation on both feet every 2 hours.
    B. Plans to follow up and ensure that the HCP is aware of the finding.
    C. Instructs UAP to do range-of-motion exercises to hand every 3 hours.
    D. Plans to do routine change-of-shift assessment and observe as needed.
A

D. Plans to do routine change-of-shift assessment and observe as needed.

37
Q
  1. The UAP tells the nurse that the patient has a respiratory rate of 40/ min and “is having trouble breathing.” What additional signs or symptoms is the nurse most likely to observe? Select all that apply.
    A. Pursed-lip breathing
    B. Flared nostrils
    C. Epistaxis
    D. Costal retractions
    E. Fatigue
    F. Shortness of breath
A

A. Pursed-lip breathing
B. Flared nostrils
D. Costal retractions
E. Fatigue
F. Shortness of breath

38
Q
  1. The nurse checks the patient’s BP and obtains a reading of 160/90 mm Hg. What is the pulse pressure?
    __________
A

The pulse pressure is 70

39
Q
  1. The nurse hears in report that the patient has an auscultatory gap. The nurse plans to adapt the technique for measuring which vital sign?
    A. Temperature
    B. Pulse
    C. Respiratory rate
    D. BP
A

D. BP

40
Q
  1. The patient states she has a history of an eating disorder and does not want her weight taken while being admitted to the hospital for treatment of pyelonephritis. How would the nurse best handle this request?
    A. Review the chart for the most recent weight from a past admission and enter it with a notation of the reason.
    B. Discuss the history of the eating disorder with the patient to understand why she would avoid a weight now.
    C. Offer to have the patient stand backwards on the scale so as not to see the weight when taken.
    D. Explain that weight is an important part of the data collected upon admission.
A

C. Offer to have the patient stand backwards on the scale so as not to see the weight when taken.

41
Q
  1. The student nurse is checking BPs at the community health fair. Which situations would require the nurse to review BP measurement techniques with the student? Select all that apply.
    A. The patient is seated in a comfortable chair.
    B. The patient’s arm is extended on his lap.
    C. The student is quietly conversing with the patient during the process.
    D. The cuff size if 80% of the circumference of the upper arm.
    E. The patient’s feet are flat on the ground.
    F. The patient’s hand is palm down.
A

B. The patient’s arm is extended on his lap.
C. The student is quietly conversing with the patient during the process.
D. The cuff size if 80% of the circumference of the upper arm.
F. The patient’s hand is palm down.

42
Q
  1. The nurse is checking orthostatic BP and a patient. Which of these steps would be done first?
    A. Obtain a standing BP.
    B. Obtain a supine BP.
    C. Obtain a left lateral BP.
    D. Obtain a sitting BP.
A

B. Obtain a supine BP.

43
Q
  1. Convert the following temperature readings.
    a. 37C =_____F
    b. 101.2F =_____C
    c. 39.2C =_____F
    d. 97.8F =_____C
A

a. 98.6
b. 38.4
c. 102.6
d. 36.5

44
Q
  1. Convert weight in pounds to the equivalent in kilograms.
    a. 44 lbs =_____kg
    b. 210 lbs=_____kg
A

a. 20
b. 95.45

45
Q
  1. Convert weight in kilograms to the equivalent in pounds.
    a. 6 kg =_____lbs
    b. 16 kg=_____lbs
A

a. 13
b. 35

46
Q
  1. Convert height in feet and inches to the equivalent in centimeters.
    a. 5 ft 9 in =_____cm
    b. 2 ft 3 in =_____cm
A

a. 175
b. 69

47
Q
  1. Fluid balance may be assessed by weighing the patient. If the patient weights 2 kg less today than yesterday, how much fluid was lost?_____ mL
A

2,000 mL was lost

48
Q
A

Vital Signs - Ch. 12 (5 decks)

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