Vital Signs

Question 1

A nurse is caring for a client who has hypotension. Which of the following factors should the nurse identify as a contributing factor to the client’s condition?

a) Decrease in contractility.
b) Increase in blood viscosity.
c) Decrease in respiratory rate.
d) Increase in preload.

Answer 1

a) Decrease in contractility.

Contractility is the ability of the heart muscle to contract effectively.

Question 2

What is Cardiac output?

Answer 2

Cardiac output is the amount of blood flow through the heart in 1 minute

Question 3

For which of the following clients should the nurse obtain a rectal temperature?

a) a toddler who has diarrhea.
b) A client who is 1 day postoperative following a hemorrhoidectomy and receiving pain medications via PCA pump.
c) An infant who is receiving IV fluids.
d) A client who is diaphoretic and frequently chewing ice to relieve dry mouth.

Answer 3

d) Diaphoretic client.

Diaphoresis will make it difficult to obtain accurate temp via tympanic membrane or temporal artery. Ice cubes will make oral temp inaccurate.

Question 4

Newborn expected pulse

Answer 4

110 - 160/min

Question 5

Infant expected pulse

Answer 5

90 - 160/min

Question 6

Toddler expected pulse

Answer 6

80 - 140/min

Question 7

Preschooler expected pulse

Answer 7

70 -120/min

Question 8

School-age expected pulse

Answer 8

60 - 110/min

Question 9

Adolescent expected pulse

Answer 9

50 - 100/min

Question 10

Adult expected pulse

Answer 10

60 -100/min

Question 11

Newborn RR

Answer 11

30 - 60/min

Question 12

Infant RR

Answer 12

25 - 30/min

Question 13

Toddler RR

Answer 13

25 - 30/min

Question 14

Preschooler RR

Answer 14

20 -25/min

Question 15

School-age RR

Answer 15

20 - 25/min

Question 16

Adolescent RR

Answer 16

16 - 20/min

Question 17

Adult RR

Answer 17

12 - 20/min

Question 18

Newborn average BP

Answer 18

65/40

Question 19

Toddler average BP

Answer 19

90/45

Question 20

Preschooler average BP

Answer 20

95/55

Question 21

School-age average BP

Answer 21

105/60

Question 22

Adolescent & Adult average BP

Answer 22

Less than 120/80

Question 23

Body temperature range

Answer 23

36’C - 38’C

96.8’F - 100.4’F

Question 24

8 pulse points

Answer 24

Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Dorsalis pedis

Question 25

O2 Saturation range

Answer 25

95-100%

Question 26

5 sites for measuring Temp

Answer 26

Oral
Tympanic membrane
Temporal artery
Axillary
Rectal

Question 27

4 Manifestations of Bradypnea

Answer 27

Dizziness
Fatigue
Confusion
Impaired coordination

Question 28

Percentage of adult arm BP cuff should encircle

Answer 28

80%

Question 29

Length of time to avoid taking oral temp after client has warm drink

Answer 29

10 - 30 min

Question 30

Expected capillary refill time

Answer 30

Less than 2 seconds

Question 31

Documentation of Respiration (4)

Answer 31

Rate, rhythm & depth

Manifestations of respiratory alterations.

Abnormal respiratory sounds.

Type of oxygen therapy.

Question 32

Documentation of Pulse (4)

Answer 32

Rate, rhythm and strength

Site used.

Manifestations of pulse alterations.

Pulse deficit

Question 33

Acceptable pulse deficit.

Answer 33

2

Question 34

Documentation of BP (3)

Answer 34

Reading

Site used

Manifestations of BP alterations.

Question 35

Documentation of Temp (3)

Answer 35

Reading

Route used

Manifestations of temp alterations

Question 36

Documentation of O2 saturation (4)

Answer 36

Reading

Site

Manifestations of abnormal O2 Saturation

Type of O2 therapy.

Question 37

Taking adult tympanic temp

Answer 37

Pull pinna up and back

Question 38

Taking child tympanic temp

Answer 38

Pull pinna down and back