VITAL SIGNS Flashcards
1
Q
The most important factor in measuring blood pressure accurately is:
A
using a cuff of the appropriate size for the patient
2
Q
When assessing a patient’s respiration, it is recommended that the patient:
A
have the head of the bed elevated 45 to 60 degrees.
3
Q
When auscultating a patient’s apical pulse, you listen until you hear the S1 and S2 heart sounds clearly and regularly. S2 is produced when the:
A
semilunar valves close
4
Q
To auscultating a patient’s apical pulse accurately, you position the bell of the diaphragm of your stethoscope over the point of maximal impulse, which is located:
A
at the fifth intercostal space at the left midclavicular line.
5
Q
You are assessing a patient’s vital signs. The patient has a temperature of 102F (39C). Which of the following do you expect to find?
A
An elevated pulse rate
6
Q
The best way to determine the depth of a patient’s respiration is to:
A
observe the degree of chest-wall movement during inspiration and expiration
7
Q
When preparing to measure the vital signs of a patient, you should recognize that which of the following will affect the methods that you will use? (Select all that apply)
A
the patient is 60 pounds overweight, the patient is reporting a stuffy nose, the patient is taking digoxin, the patient had a mastectomy 2 years ago
8
Q
You have assessed a 45 yr old patient’s vital signs. Which of the following assessment values requires immediate attention?
A
a respiratory rate of 30/min
9
Q
You are preparing to use a tympanic thermometer. Which of the following steps has the highest priority in the accurate use of the piece of equipment for measuring body temperature?
A
Gently pulling the pinna back and upward
10
Q
You are measuring a patient’s temperature orally. You place the covered probe:
A
in the posterior lingual pocket lateral to the midline
11
Q
You are assessing the vital signs of a newly admitted patient. To establish an accurate baseline of the patient’s respiration, you:
A
observe the patient’s chest movements while appearing to assess his pulse
12
Q
When taking a patient’s blood pressure, why is it important to notice the pressure on the manometer when you hear the fourth Korotkoff sound or phase?
A
You might not hear a fifth korotkoff sound
13
Q
When taking an adult patient’s temperature rectally, it is important to:
A
insert the probe about an inch and a half into the patient’s anus
14
Q
The difference between a patient’s systolic and diastolic blood pressures is called:
A
the pulse pressure
15
Q
You have assessed a 45-year-old patient’s vital signs. Which of the following assessment values requires immediate attention?
A. An oral temperature of 100° F (37.8° C)
B. A blood pressure of 148/88 mm Hg
C. A respiratory rate of 30/min
D. A radial pulse rate of 45 beats per 30 seconds
A
C. A respiratory rate of 30/min
A respiratory rate of 30/min is above the normal range and indicates a respiratory problem that requires immediate attention. An adult breathing at that rate might be experiencing shortness of breath or dyspnea and, without intervention, this could become a life-threatening situation.
16
Q
The difference between a patient’s systolic and diastolic blood pressure is called
A. The pulse deficit
B. The pulse pressure
C. An auscultatory gap
D. a diurnal variation
A
B. The pulse pressure
The difference between the systolic and diastolic pressures is the pulse pressure; if the patient’s blood pressure is 130/85 mm Hg, the pulse pressure is 45/min. Pulse pressure can be a predictor of heart problems, especially in older adults. For example, an elevated pulse pressure usually reflects stiffness and reduced elasticity of the aorta, most often due to hypertension or atherosclerosis.
17
Q
To auscultate a patient’s apical pulse accurately, you position the bell or the diaphragm of your stethoscope over the point of maximal impulse which is located
A. at the right midclavicular line
B. over the suprasternal notch
C. over the Angle of Louis
D. at the fifth intercostal space at the left midclavicular line
A
D. at the fifth intercostal space at the left midclavicular line
To locate the point of maximal impulse, first locate the angle of Louis - a bony prominence just below the suprasternal notch. Slide your fingers down each side of the angle of Louis to locate the second intercostal space. Gently move your fingers down the left side of the sternum to the fifth intercostal space and laterally to the left midclavicular line. You have found the PMI.
18
Q
When assessing a patient’s respiration, it is recommended that the patient
A. have the head of the bed elevated 45 to 60 degrees
B. take several deep breaths prior to the assessment
C. lie flat in bed with his/her head on a pillow
D. continue to go about his/her usual activities
A
A. have the head of the bed elevated 45 to 60 degrees
This is a comfortable position for most patients and it allows full ventilatory movement. Also, any type of discomfort can increase respiratory rate.
19
Q
The most important factor in measuring blood pressure accurately is
A. obtaining the reading in the early morning
B. using a cuff of the appropriate size for the patient
C. making sure the patient is comfortable and relaxed
D. removing clothing from the arm before applying the cuff
A
B. using a cuff of the appropriate size for the patient
Using the wrong cuff size for the patient will result in an erroneous reading. A cuff that is too small will result in a reading that is falsely high while a cuff that is too big will record a false low. One way to select a cuff is to make sure that the width of the cuff is 40% of the arm circumference where the cuff will be wrapped. The bladder (inside the cuff) should surround 80% of the arm circumference.
20
Q
When auscultating patient’s apical pulse, you listen until you hear the S1 and S2 heart sounds clearly and regularly. S2 is produced when the
A. atria contract vigorously
B. ventricular walls vibrate
C. semilunar valves close
D. mitral valve snaps open
A
C. semilunar valves close
The second heart sound, S2, is generated by the closure of the semilunar vales (the aortic and pulmonic valves) and signals the start of diastole. S2 is the “dub” heard in the normal “lub-dub” sound.
21
Q
You are preparing to use a tympanic thermometer. Which of the following steps has the highest priority in the accurate use of this piece of equipment for measuring body temperature?
A. Replacing the thermometer in its charger
B. Assessing the external ear for redness
C. Gently pulling the pinna back and upward
D. Attaching the disposable probe cover
A
C. Gently pulling the pinna back and upward
This position helps straighten the ear canal and provides optimal access to the tympanic membrane. Good contact with sufficient tympanic membrane is essential for an accurate tympanic temperature measurement.
22
Q
When preparing to measure the vital signs of a patient, you should recognize that which of the following will affect the methods that you will use?
A
-Patient is 60 pounds overweight
It is likely that a patient who is 60 pounds (27.3 kilograms) overweight would have a larger-than-average upper-arm circumference. If so, you would have to use a large blood-pressure cuff (instead of a regular-sized cuff) to assure an accurate blood-pressure reading.
-Patient is reporting a “stuffy” nose
A patient who has nasal congestion might resort to “mouth breathing,” which would alter a temperature measurement obtained orally. This condition would also require that you assess the patient’s respiration for a full 60 seconds.
-Patient is taking digoxin (Lanoxin)
The presence of a cardiovascular problem that warrants pharmacological digoxin therapy would require that you assess the patient’s apical pulse for a full 60 seconds.
-The patient had a mastectomy 2 years ago
Lymphatic drainage might be altered in the affected arm post mastectomy. The application of pressure from the assessment of blood pressure could result in a painful condition called lymphedema.
23
Q
You are assessing the vital signs of a newly admitted patient. To establish an accurate baseline of the patient’s respiration, you
A. instruct the patient to breathe in and to exhale out as he would normally
B. make the patient physically comfortable before beginning the assessment
C. determine if the patient has a history of any chronic respiratory problems
D. observe the patient’s chest movements while appearing to assess his pulse
A
D. observe the patient’s chest movements while appearing to assess his pulse
You are most likely to observe the true respiratory pattern (rate, rhythm, and depth) when the patient is unaware that he is being assessed. When patients know their respiration is being observed, it is common for them to alter their respiratory pattern either voluntarily or involuntarily.
24
Q
The best way to determine the depth of a patient’s respiration is to
A. observe the degree of chest-wall movement during inspiration and expiration
B. count how many breathing cycles you observe per minute
C. notice whether or not expiration takes longer than inspiration
D. measure the precise amount of air the patient takes in and breathes out
A
A. observe the degree of chest-wall movement during inspiration and expiration
You determine the depth of respiration subjectively by evaluating how much chest-wall movement you can observe. The movement is generated by the movements of the diaphragm and intercostal muscles as the patient breathes. With shallow respiration, for example, you will observe very little movement. Deep respiration involves full expansion of the lungs, which is usually quite visible.
25
When taking an adult patient's temperature rectally, it is important to
A. rotate the probe gently if you encounter any resistance
B. insert the probe so that you are aiming at the patient's pelvic area
C. dip the probe about an inch to an inch and a half into a tube of lubricant
D. insert the probe about an inch and a half into the patient's anus
D. insert the probe about an inch and a half into the patient's anus
An insertion depth of 1.5 inches (3.5 centimeters) ensures sufficient exposure of the probe to the blood vessels in the rectal wall. Positioning the probe against the blood vessels enables it to measure heat maximally and accurately.
26
You are measuring a patient's temperature orally. You place the covered probe
A. in the posterior lingual pocket lateral to the midline
B. so that it rests on the lower lingual frenulum
C. centrally on top of the patient's tongue
D. under the tongue just beyond the patient's teeth
A. in the posterior lingual pocket lateral to the midline
The heat produced by superficial blood vessels in the right and the left posterior sublingual pocket is what generates an accurate oral temperature reading. Inserting the probe "sideways" into the back of the area under the tongue on the left or the right will access this area.
27
You are assessing a patient's vital signs. The patient has a temp. of 102 degrees F. Which of the following do you expect to find?
A. An elevated pulse rate
B. A decreased blood pressure
C. An elevated blood pressure
D. A decreased pulse rate
A. an elevated pulse rate
A fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate.
28
When taking a patient's blood pressure, why is it important to notice the pressure on the manometer when you hear the fourth Korotkoff sound or phase?
A. It corresponds to the patient's systolic pressure
B. You need it to record the second diastolic pressure
C. It is the loudest of the Korotkoff sounds
D. You might not hear a fifth Korotkoff sound
D. You might not hear a fifth Korotkoff sound
Most clinicians consider the fifth Korotkoff sound, which is actually the disappearance of sound, an adult patient's diastolic blood pressure. However, with some patients, there is no distinct fifth sound. You hear sounds all the way to 0 mm Hg. For these patients, you would record the fourth Korotkoff sound as the diastolic blood pressure.
29
A nurse is planning care for a client who is experiencing tachycardia. Which of the following interventions should the nurse plan to make?
a) instruct the client to increase exercise
b) instruct the client to consume no more than four caffeinated beverages per day
c) encourage the client to practice relaxation techniques each day
d) encourage the client to engage in pattern paced breathing by panting
c) encourage the client to practice relaxation techniques each day
30
A nurse is teaching a group of AP about techniques used to obtain BP. For which of the following clients should the nurse to instruct the AP to obtain an electronic BP measurement?
a) a client who has a BP lower than the expected reference range
b) a school-age client
c) a client recovering from extensive abdominal surgery
d) a client who has stabilized BP measurements
d) a client who has stabilized BP measurements
31
A nurse is observing an AP obtain vital signs from an adult client. Which of the following actions by the AP requires follow up by the nurse?
a) the AP pulls the pinna up and back when obtaining a tympanic temperature
b) the AP informs the client when they are counting the respirations
c) the AP gently presses down with the pads of two or three fingers over the radial pulse site
d) the AP selects a blood pressure cuff that is 40% the circumference of the client's arm
b) the AP informs the client when they are counting the respirations
32
A charge nurse in a clinic is preparing an in-service about blood pressure measurements for a group of staff members. Which of the following should the nurse include?
a) A client diagnosed with an elevated BP when the measurement is greater than 130/80 mm Hg
b) A client us experiencing a hypertensive crisis when their BP is greater than 150/90 mm Hg
c) A client who has a BP of 128/86 mm Hg has stage I hypertension
d) A client who has a blood pressure of 162/102 mm Hg has stage II hypertension
d) A client who has a blood pressure of 162/102 mm Hg has stage II hypertension
33
A charge nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct?
a) pulse 52/min
b) RR 24
c) SaO2 97% right index finger, room air
d) BP 132/86 mm Hg
c) SaO2 97% right index finger, room air
34
A nurse is assessing a three month old infant during a well-child visit. Which of the following actions should the nurse take when assessing the apical pulse?
a) count the number of beats heard in 15 seconds and multiply by 4
b) notify the provider if the apical pulse rate is greater than 110/min
c) place the stethoscope over the 4th intercostal space to the left of the sternum
d) auscultate the apical pulse for an S4 heart sound
c) place the stethoscope over the 4th intercostal space to the left of the sternum
35
A nurse is caring for a group of clients. Which of the following clients is experiencing an alteration in their RR that requires intervention?
a) an adolescent who has a RR of 20/min
b) an older adult with RR of 16/min
c) an infant with RR of 52/min
d) a school-age child who has a RR of 14/min
d) a school-age child who has a RR of 14/min
36
A nurse is planning care for a group of clients. For which of the following clients should the nurse direct an AP to obtain a rectal temperature?
a) a toddler who has diarrhea
b) a client who is 1 day post op from hemorrhoid surgery
c) an infant who is receiving IV fluids
d) a client who is diaphoretic and frequently chewing ice to relieve dry mouth
d) a client who is diaphoretic and frequently chewing ice to relieve dry mouth
37
A nurse is reviewing the vitals for a group of clients obtained by an AP. The nurse should identify that which of the following clients requires a follow-up assessment due to bradycardia?
a) a school-age child who has an apical pulse of 78/min
b) a young adult who has a radial pulse of 56/min
c) an adolescent who has a radial pulse of 76/min
d) an older adult with apical pulse of 62/min
b) a young adult who has a radial pulse of 56/min
38
A nurse is teaching a group of newly licensed nurses about vital sign measurements. Which of the following factors should the nurse include in the teaching?
a) anxiety can cause a decrease in RR
b) body temperature is typically lower in olde adults
c) caffeine can cause a temporary decrease in pulse rate in adolescents
d) BP can slightly decrease immediately following the use of nicotine
b) body temperature is typically lower in older adults
39
A nurse is obtaining vital signs for a group of clients. Which of the following findings requires intervention?
a) a 17 year old who has a RR of 16/min
b) a young adult who has a pulse rate of 98/min
c) an 11 year old who has a RR of 34/min
d) an older adult who has a pulse rate of 62/min
c) an 11 year old who has a RR of 34/min
40
A nurse is reviewing the vital signs for a group of clients. Which of the following clients should the nurse identify as exhibiting tachycardia?
a) an infant who has an apical pulse rate of 132/min
b) a preschooler who has an apical pulse rate of 108/min
c) a young adult who has an apical pulse rate of 104/min
d) an older adult who has an apical pulse rate of 96/min
c) a young adult who has an apical pulse rate of 104/min
41
A charge nurse is teaching a group of AP the importance of documenting accurate vital signs. Which of the following information should the charge nurse include in the teaching?
a) record vital signs at the end of the shift
b) recording vital signs provides critical information regarding a client's condition
c) obtaining and documenting baseline vital signs is the responsibility of the AP
d) it is not necessary to record electronic BP measurements
b) recording vital signs provides critical information regarding a client's condition
42
A nurse is preparing to obtain a young adult client's apical pulse. In which of the following locations should the nurse place their stethoscope to auscultate the client's pulse?
a) apex of the heart
b) right side of the sternum
c) 4th intercostal space
d) midclavicular line below right clavicle
a) apex of the heart
43
A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. Which of the following statements should the nurse include?
a) "Convection is the loss of body heat when a client is in contact with a cooler surface."
b) "Conduction is the loss of body heat when sweat dries from a client's skin."
c) "Evaporation is the loss of body heat when a client is near a current of cool air."
d) "Radiation is the loss of body heat when a client is in close proximity to a cooler surface."
d) "Radiation is the loss of body heat when a client is in close proximity to a cooler surface."
44
A nurse is caring for a client who has a heart rate of 120/min. Which of the following actions should the nurse take?
a) instruct the client to bear down like they are having a bowel movement
b) offer the client hot caffeinated tea to drink early in the morning
c) hold the client's thyroid medication
d) encourage the client to take a warm shower
a) instruct the client to bear down like they are having a bowel movement
45
A nurse is preparing an in-service about factors affecting RR for a group of APs. Which of the following information should the nurse include?
a) anxiety can decrease a client's RR
b) opioid analgesics can increase a client's RR
c) pain can decrease a client's RR
d) Fever can increase a client's RR
d) Fever can increase a client's RR
46
```
A nurse is caring for a client who has an increase in cardiac afterload. Which of the following findings should the nurse expect?
a) increase in BP
b) increase in RR
c) decrease in cardiac output
d decrease in preload
```
a) increase in BP
47
A nurse is planning care for a client who has hypertension. Which of the following interventions should the nurse include in the plan? Select all that apply
a) provide the client with low-sodium meals and snacks
b) encourage the client to participate in physical activity each day
c) instruct the client in the use of relaxation techniques
d) inform the client of the importance of abstaining from using products that contain nicotine
e) anticipate a prescription for a 1L fluid bolus
a) provide the client with low-sodium meals and snacks
b) encourage the client to participate in physical activity each day
c) instruct the client in the use of relaxation techniques
d) inform the client of the importance of abstaining from using products that contain nicotine
48
A nurse is reviewing the vital signs obtained by an AP at 1200. For which of the following clients should the nurse plan to intervene?
a) adult male who has a RR of 18/min
b) toddler who has a RR of 44/min
c) newborn who has a RR of 56/min
d) adolescent female who has a RR of 16/min
b) toddler who has a RR of 44/min
49
A nurse is discussing oxygen saturation with a client. Which of the following information should the nurse include?
a) oxygen saturation is determined by the amount of oxygen bound to WBCs
b) oxygen saturation reflects the amount of oxygen being delivered to body tissues
c) the expected reference range for oxygen saturation s 90% to 100%
d) a capillary refill time of less than 5 seconds ensures a reliable oxygen saturation measurement
b) oxygen saturation reflects the amount of oxygen being delivered to body tissues
50
A charge nurse is discussing a client's RR data with a newly licensed nurse. Which of the following statements should the nurse include?
a) clients will exhibit an increase in their RR after using a bronchodilator
b) count the RR for 1 min who have a respiratory infection
c) expect clients who have a brainstem injury to exhibit rapid respirations
d) clients who are experiencing acute pain will have slow, deep respirations
b) count the RR for 1 min who have a respiratory infection
51
A charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. Identify the order of the steps the nurse should include.
1) select the site for obtaining the measurement
2) apply the sensor probe on the chosen site
3) confirm the pulse rate displayed o the oximeter by palpating the radial pulse
4) wait 15 seconds and observer the SaO2 percentage displayed on the pulse oximeter
52
A nurse is reviewing the vital signs fir four clients. The nurse should identify that which of the following clients has a vital sign outside of the reference range?
a) a 52 year old client who has a fever due to a would infection and a pulse rate of 100/min
b) a 76 year old client who reports moderate pain and has a RR of 20/min
c) a 46 year old client who is postoperative following a hysterectomy and has an SaO2 of 95%
d) a 23 year old client who runs marathons and has a BP of 82/54 mm Hg
c) a 46 year old client who is postoperative following a hysterectomy and has an SaO2 of 95%
53
A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. Which of the following statements should the charge nurse make?
a) the first step in checking for checking orthostatic hypotension is obtaining a client's BP while they are standing
b) an increase of 5 mm of Hg in the diastolic pressure with a position change indicates orthostatic hypotension
c) a decrease of 20 mm of Hg in the diastolic pressure with a position change indicates orthostatic hypotension
d) wait 5 minutes to check the client's BP after each position change
c) a decrease of 20 mm of Hg in the diastolic pressure with a position change indicates orthostatic hypotension
54
A nurse is preparing an in-service about vital signs for a group of newly hired APs. Which of the following information should the nurse include about measuring body temperature?
a) tympanic temperature can be affected by environmental temperature
b) temporal temperature is inaccurate in children under 3 years old
c) axillary temperature reflects rapid changes in a client's core body temperature
d) oral temperature is easily accessible despite a client's position
d) oral temperature is easily accessible despite a client's position
55
A charge nurse is evaluating a newly licensed nurse's documentation of vitals for several clients. Which of the following documentation should the charge nurse identify as being incomplete?
a) radial pulse regular at 84/min
b) respirations observed as even, nonlabored at 20/min with client in supine position
c) BP 124/82 mm Hg lying in bed
d) temporal temperature 36.9 degrees C (98.4 degrees F)
c) BP 124/82 mm Hg lying in bed
56
A nurse is assessing a client who has orthostatic hypotension. Which of the following actions should the nurse take?
a) encourage the client to change positions slowly
b) restrict the client's oral intake of fluids
c) encourage the client to take a short walk
d) discontinue IV fluids
a) encourage the client to change positions slowly
57
A nurse is preparing an in-service for a group of newly hired APs about body temperature. Which of the following information should the nurse include?
a) wait 5 min after a client has consumed a hot drink to obtain an oral temperature
b) place a tape of patch thermometer over a client's scapula
c) a tympanic thermometer reflects a client's body surface temperature
d) a temporal probe thermometer uses infrared scanning to determine a client's temperature
d) a temporal probe thermometer uses infrared scanning to determine a client's temperature
58
A nurse is discussing the physiology of BP. Which of the following information should the nurse include?
a) Diastolic BP reflects the pressure exerted during contraction of the heart
b) BP is measured and documented in mm Hg
c) BP decreases when blood viscosity increases
d) systolic BP reflects the pressure when the heart is relaxed
b) BP is measured and documented in mm Hg
59
A nurse is evaluating the effectiveness of interventions provided to a client who has an SaO2 below the expected reference range. Which of the following manifestations requires a follow up by the nurse?
a) eupnea
b) dyspnea
c) heart rate of 84/min
d) Sao2 of 96%
b) dyspnea
60
A nurse is discussing the use of a client's thigh for BP measurements with an AP. Which of the following information should the nurse include?
a) select a blood pressure cuff width that is 25% of the circumference of the client's thigh
b) palpate the femoral pulse when obtaining BP in the thigh
c) expect BP in the thigh to be 10 to 15 mm Hg less than in the arm
d) Use the thigh to obtain blood pressure when a client has severe edema in their arms
d) Use the thigh to obtain blood pressure when a client has severe edema in their arms
61
A nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings for vital signs. Which of the following findings requires follow up?
a) a client has an 8 mm Hg difference in systolic BP when moving from a sitting to a standing position
b) a client has a radial pulse of +4 bilateral
c) an older adult client has a tympanic temperature of 35.9 degrees c (96.6 degrees f)
d) a newborn has a RR of 56/min while sleeping
b) a client has a radial pulse of +4 bilateral
62
A nurse is observing an AP who is obtaining BP reading from a client. Which of the following actions by the AP requires follow up by the nurse?
a) the AP uses a cuff width that is 40% of the circumference of the client's arm
b) he AP provides support for the client's arm while taking the BP
c) the AP waits to take the client's BP 45 minutes after the client ambulates in the hallway
d) the AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second
d) the AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second
(Recommended rate is 2 mm Hg per second)
63
A nurse is evaluating the effectiveness of interventions used for clients who had alterations in vital signs. Which of the following clients' vital signs indicate that interventions were effective?
a) a preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min
b) an older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min
c) a young adult who had hypotension after receiving an opioid analgesic now has a blood pressure of 98/68 mm Hg
d) an adult client who had tachycardia 1 hr ago due to postoperative pain and has an apical pulse rate of 106/min
a) a preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min
b) an older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min
c) a young adult who had hypotension after receiving an opioid analgesic now has a blood pressure of 98/68 mm Hg
64
A nurse is reviewing vitals for a group of clients to determine the effectiveness of interventions. Which of the following findings indicates an intervention was effective?
a) an adult client who received medication for pan 30 min ago now has a RR of 18/min
b) a school-age child who received two units of packed RBCs now has a BP of 76/54 mm Hg
c) a toddler who received an antibiotic injection has a heart rate of 148/min while sleeping in their parent's arms
a) an adult client who received medication for pan 30 min ago now has a RR of 18/min
65
A nurse working on a medical-surgical unit is caring for a group of clients. Which of the following clients' vitals should the nurse identify is outside the expected reference range and notify the provider?
a) a client who has an apical pulse rate of 120/min
b) a client who has a BP of 100/74 mm Hg
c) a client who has an apical pulse rate of 84/min
d) a client who has a BP of 110/68 mm Hg
a) a client who has an apical pulse rate of 120/min
66
A nurse is planning care for a group of clients and is reviewing the recent vitals obtained by an AP. Which of the following clients should the nurse assess and recheck the vital signs prior to notifying the provider?
a) 16 year old female; RR 18/min, SaO2 98%
b) 8 year old male; RR 34/min, SaO2 97%
c) 11 year old male; RR 28/min, 99%
d) 3 year old female; RR 32/min, SaO2 96%
b) 8 year old male; RR 34/min, SaO2 97%
67
A charge nurse is reviewing the expected reference ranges of BP in adult clients with a newly licensed nurse. Which of the following statements should the charge nurse include?
a) hypertension is diagnosed with two elevated measurements on two separate occasions
b) successive BP measurements of 126 over 78 is classified as stage I hypertension
c) stage II hypertension is diagnosed when the BP measurement is 132 over 86
d) a BP measurement of 176 over 102 is classified as hypertensive crisis
a) hypertension is diagnosed with two elevated measurements on two separate occasions
68
A nurse is providing teaching about thermoregulation to a group of newly licensed nurses. Which of the following statements should the nurse include?
a) the body increases body temperature through the process known as vasodilation
b) the body loses heat through shivering
c) the body lowers body temperature through sweating
d) the body generates heat through evaporation
c) the body lowers body temperature through sweating
69
A nurse obtains a client's electronic BP reading of 188/96 mm Hg. Which of the following actions should the nurse take next?
a) provide client teaching regarding medications to control BP
b) notify the provider of the clients BP reading
c) provide the client education on measurements to decrease BP
d) obtain a manual BP reading from the client
d) obtain a manual BP reading from the client
70
A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart?
a) AV node
b) left ventricle
c) SA node
d) right ventricle
c) SA node
71
A nurse is reviewing the recent vitals of a group of clients. Which of the following clients should the nurse see first?
a) a 45 year old client who is post-op and has a BP of 130/82
b) a 28 year old client who runs marathons and has a HR of 54/min
c) a 52 year old client who has an SaO2 of 92%
d) a 78 year old client who has a temperature of 35.9 degrees c (96.6 degrees f)
c) a 52 year old client who has an SaO2 of 92%
72
A nurse is reviewing blood flow through the heart with a group of APs. The nurse should identify that blood flows to which of the following parts of the heart as it leaves the right ventricle?
a) tricuspid valve
b) pulmonary artery
c) right atrium
d) vena cava
b) pulmonary artery
73
A nurse is preparing an in-service about peripheral pulses for a group of staff nurses. Which of the following information should the nurse include?
a) a pulse strength of +4 indicates that the pulse is of normal strength upon palpation
b) a femoral pules that is bounding upon palpation is an expected finding in a young adult
c) a pulse strength of +1 indicates that the pulse is weak or diminished upon palpation
d) a pedal pulse that is weak upon palpation is an expected finding in an older adult
c) a pulse strength of +1 indicates that the pulse is weak or diminished upon palpation
74
a nurse is planning care for a group of clients and is delegating to the AP to take the client's vitals. For which of the following clients should the nurse obtain the vitals signs rather than the AP?
a) a client who just received the fourth dose of antibiotics for an infection
b) a client who has heart failure and is scheduled for a discharge later in the day
c) a client who is 24 hr post-op and is visiting with friends
d) a client who was recently admitted and reports chest pain
d) a client who was recently admitted and reports chest pain
75
A nurse s caring for a client who has a HR of 118/min. Which of the following actions should the nurse take to improve the client's HR?
a) encourages the client to reduce the amount of caffeinated soft drinks
b) inform the client to ambulate in the hallway for 10 min prior to taking vitals
c) increase the room temperature and add blankets to warm the client
d) withold the client's anti-anxiety medication
a) encourages the client to reduce the amount of caffeinated soft drinks
76
A nurse is providing care to a client who has an apical pulse rate of 54/min and is experiencing dizziness. Which of the following is the nurse's priority action?
a) teach the client how to take their pulse so they can keep the provider informed of variations
b) inform the client to ask for assistance with getting out of bed
c) educate the client on medications, including therapeutic effects and potential adverse effects
d) ensure the client has been taking medications as prescribes
b) inform the client to ask for assistance with getting out of bed
77
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 RR
d) increase in preload
a) decrease in contractility
78
A nurse us caring for a client who asks about factors that could cause their pulse rate to increase. Which of the following factors should the nurse include in their response?
a) hypothermia
b) smoking
c) sleeping
d) aging
b) smoking
79
A nurse is reviewing documentation of vital signs by a newly licensed nurse for an assigned client. Which of the following entries in the chart requires follow up by the nurse?
a) BP 130/82 mm Hg left arm, lying. Client reports experiencing post-op pain as 7 on a scale of 0-10. Prescribed analgesic administered and will re-evaluate BP in 30 min
b) Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in the hall
c) SaO2 93% left index finger, client sleeping, nasal O2 dislodged. Nasal O2 readjusted and SaO2 increased to 95%
d) RR 18/min via observation, client sitting in chair
b) Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in the hall
80
A nurse is caring for a client who is experiencing tachypnea due to an exacerbation of asthma. Which of the following medications should the nurse anticipate administering?
a) nicotine product
b) opioid antagonist
c) antihypertensive
d) bronchodilator
d) bronchodilator
81
A nurse on a pediatric unit is reviewing the medical records for a group of clients. Which of the following clients has a vital sign outside the expected reference range and requires intervention?
a) a 1 month old infant who has a RR of 58/min
b) a 3 year old preschooler who has an apical pulse of 144/min
c) an 8 year old child who has a RR of 25/min
d) an 18 month old toddler who has an apical pulse rate of 120/min
b) a 3 year old preschooler who has an apical pulse of 144/min
82
A nurse is evaluating the effectiveness of interventions provided to a client who was admitted fr decreased circulation. Which of the following findings require further intervention by the nurse?
a) pulse deficit of 0
b) left radial pulse is nonpalpable
c) peripheral pulse +2 bilateral
d) brachial pulses are symmetrical
b) left radial pulse is nonpalpable
83
a nurse is caring for a recently admitted client and as a part of the plan of care, two nurses obtained simultaneous pulse rates. the client's auscultated apical pulse was 106/min and the palpated radial pulse was 93/min. The nurse should document the findings as which of the following?
a) pulse deficit less than 10
b) radial pulse irregular
c) apical pulse greater than radial
d) pulse deficit of 13/min
d) pulse deficit of 13/min
84
A nurse is caring for a client who has an increase n cardiac output. Which of the following findings should the nurse expect?
a) increase in BP
b) decrease in RR
c) decrease in HR
d) increase in stroke volume
a) increase in BP
85
A nurse is evaluating the effectiveness of interventions used to address clients' vitals that were outside of the expected reference ranges. Which of the following findings indicates the intervention was effective?
a) an older adult client who has pneumonia and a RR of 26/min after a position change
b) an adolescent who is postoperative and has an SaO2 of 93% after receiving an opioid analgesics
c) a young adult who is experiencing an asthma attack and has a BP of 116/72 mm Hg after using an inhaler
d) an older adult client who has an infection and a pulse rate of 110/min after using relaxation techniques
c) a young adult who is experiencing an asthma attack and has a BP of 116/72 mm Hg after using an inhaler
86
A charge nurse is providing an in-service for a group of nurses about cardiac output. Which of the following statements should the nurse include?
a) cardiac output is the amount of blood flow through the heart in 1 minute
b) cardiac output is the amount of blood ejected from the atria
c) cardiac output is the ability of the muscle fibers in the ventricles to stretch
d) cardiac output is the resistance of the ventricles to pump blood through the heart
a) cardiac output is the amount of blood flow through the heart in 1 minute
87
When preparing to measure the vital signs of a patient, you should recognize that which of the following will affect the methods that you will use?
1. patient is 60lb overweight
2. patient has a stuffy nose
3. the patient is taking digoxin
4. patient had a mastectomy 2 years ago
88
You are assessing a patients vital signs. the patient has a temperature of 102F which of the following do you expect to find?
1.an elevated pulse rate
89
You are measuring a patients temperature orally. you place the covered probe...
1.in the posterior lingual pocket lateral to the midline
90
You are preparing to use a tympanic thermometer. which of the following steps has the highest priority in the accurate use of this piece of equipment for measuring body temperature?
1.gently pulling the pinna back and upward
91
The most important factor in measuring blood pressure accurately is....
1.using a cuff of the appropriate size for the patient
92
You are assessing the vital signs of a newly admitted patient. to establish an accurate baseline of the patients respiration you...
1.observe the patients chest movements while appearing to assess his pulse
93
When auscultating a patients apical pulse you listen until you hear the s1 and s2 heart sounds clearly and regularly. s2 is produced when the...
1.semilunar valves close
94
When taking an adult patients temperature rectally it is important to...
1.insert the probe about a inch and a half into the patients anus
95
the difference between a patients systolic and diastolic blood pressures is called...
1.the pulse pressure
96
You have assess a 45 year old patients vital signs. which of the following assessment values requires immediate attention...
1.a respiratory rate of 30/min
97
When assessing a patients respiration. it is recommended that the patient....
1.have the head of the bed elevated 45 to 60 degrees
98
To auscultate a patients apical pulse accurately you position the bell or the diaphragm of your stethoscope over the point of maximal impulse which is located...
1.at the fifth intercostal space at the left midclavicular line
99
When taking a patients blood pressure why is it important to notice the pressure on the manometer when you hear the fourth korotkoff sound or phase?
1.you might not hear the fifth korotkoff sound
100
the best way to determine depth of a patients respiration is to...
1.observe the degree of chest wall movement during inspiration and expiration
101
When auscultating a patient's apical pulse, you listen until you hear the S1 and S2 heart sounds clearly and regularly. S2 is produced when the...
Semilunar Valves close
-The second heart sound, S2, is generated by the closure of the semilunar valves (the aortic and pulmonic valve) and signals the start of diastole. S2 is the "dub" heard in the normal "lub-dub" sound.
102
You are preparing to use a tympanic thermometer. Which of the following steps has the highest priority in the accurate use of this piece of equipment for measuring body...
Gently pulling the pinna back and upward
-A tympanic thermometer is probably not the best choice when the patient's ears show signs of infection, inflammation, or trauma because of the risk of further damage, pain, or contamination. But the device would still register temperature accurately.
103
You are assessing the vital signs of a newly admitted patient. To establish an accurate baseline of the patient's respiration you
Observe the patient's chest movements while appearing to assess his pulse
-You are mostly likely to observe the true respiratory pattern (rate, rhythm, and depth) when the patient is unaware that he is being assessed. When patients know their respiration is being observed, it is common for them to alter their respiratory pattern either voluntarily or involuntarily.
104
When assessing a patient's respiration, it is recommended that the patient...
Have the head of the bed elevated 45 to 60 degrees
-This is a comfortable position for most patients and it allows full ventilatory movement. Also, any type of discomfort can increase respiratory rate.
105
To auscultate a patient's apical pulse accurately, you position the bell or the diaphragm on your stethoscope over the point of maximal impusel, which is located...
at the fifth intercostal space at the left midclavicular line
-To locate the point of maximal impulse, first located the angle of Louis - bony prominence just below the suprasternal notch. Slide you fingers down each side of the angle of Louis to locate the second intercostal space. Gently move your fingers down the left side of the sternum to the fifth intercostal space and laterally to the left midclavicular line. You have found the PMI.
106
The best way to determine the depth of a patient's respiration is to...
observe the degree of chest wall movements during inspiration and expiration
-You determine the depth of respiration subjectively by evaluating how much chest wall movement you can observe. The movement is generated by the movement of the diaphragm and intercostal muscles as the patient breathes. With shallow respiration, for example, you will observe very little movement. Deep respiration involves full expansions for the lungs which is usually quite visible
107
When taking a adults patient's temperature rectally, it is important to...
insert the probe about an inch and a half into the patient's anus
-An insertion depth of 1.5 inches (3.5 cm) ensures sufficient exposure of the probe to the blood vessels in the rectal wall. Positioning the probe against the blood vessels enables to measure heat maximally and accurately.
108
The most important factor in measuring blood pressure accurately is..
using a cuff of the appropriate size for the patient
109
You are assessing a patient's vital signs. the patient has a temp. of 102 degrees F. Which of the following do you expect to find?
An elevated pulse rate
-A fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate.
110
When taking a patient's BP why is it important to notice the pressure on the manometer when you hear the fourth Korotkoff sound or phase?
You might not hear a fifth Korotkoff sound
-Most clinicians consider the fifth Korotkoff sound, which is actually the disappearance of sound, an adult patient's diastolic pressure. However, with some patient's, there is no distinct fifth sound. You hear sounds all the way to 0 mm Hg. For these patients, you would record the fourth Korotkoff sound as the diastolic blood pressure.
The initial sound, or first Korotkoff sound, is a clear, rhythmic tapping sound that coincides with the patient's systolic blood pressure. The pressure on the manometer when you hear the first sound is the top number of the blood pressure.
The third Korotkoff sound is the loudest. It is the phase during which blood flows freely through an increasingly open artery. As a result, the sounds are crisper and more intense.
111
You have assessed a 45 yr old patient's vital signs. Which of the following assessment values requires immediate attention?
A respiratory rate of 30/min
An oral temp. of 100 F indicates a fever but this degree of elevation in body temp is rarely a situation that requires immediate attention
While a blood pressure of 148/88 mm Hg is above the normal range for an average adult, it does not require immediate action.
A respiratory rate of 30/min is above the normal range and indicates a respiratory problem that requires immediate attention. An adult breathing at that rate might be experiencing shortness of breath or dyspnea and, without intervention, this could become a life-threatening situation.
A radial pulse of 45 beats/30 seconds translates to 90/min for documentation purposes. While you should assess a pulse this rapid for a full minute, 90/min is still within the normal range for an adult, is not a serious finding, and does not require immediate action.
112
You are measuring a patient's temp. orally. You place the covered probe
in the posterior linguinal pocket lateral to the midline
-The heat produced by superficial blood vessels in the right and left posterior sublingual pocket is what generates an accurate oral temperature reading. Inserting the probe sideways into the back of the area under the tongue on the left or the right will access this area.
113
Symptoms to consider when checking blood pressure...
It is likely that a patient who is 60 pounds overweight would have a large than average upper arm circumference. If so, you would have to use a large blood pressure cuff (instead of a regular sized cuff) to assure an accurate blood pressure reading. ns
-Nausea, while uncomfortable and possibly a symptom of gastrointesitonal pathology, has no direct effect on how you would assess vital signs
A patient who has nasal congestion might resort to mouth breathing which would alter a temp measurement obtained orally. This condition would also require that you assess the patient's respiration for a full 60 seconds
-While the recent ingestion of foods of extreme temperatures (hot or cold) can affect the accuracy of a temperature measured orally, the lack of food has no direct baring on how you would check the patient's vital signs
The presence of a cardiovascular problem that warrants pharmacological digoxin therapy would require that you assess the patient's apical pulse for a full 60 seconds.
Lymphatic drainage might be altered in the affected arm post mastectomy. The application of pressure from the assessment of blood pressure could result in a painful condition called lymphedema.
114
The difference between a patient's systolic and diastolic blood pressure is called
pulse pressure; if the patient's blood pressure is 130/85 mm Hg, the pulse pressure is 45/min. Pulse pressure can be a predictor of heart problems, especially in older adults. For example, an elevated pulse pressure usually reflects stiffness and reduced elasticity of the aorta, most often due to hypertension or atherosclerosis.
The auscultatory gap is a phenomenon that is most common with patients who have hypertension. It is a temporary disappearance of sound, usually between the first and second Korotkoff sounds. If you do not inflate the blood-pressure cuff enough to hear the systolic pressure as you begin to deflate it, an auscultatory gap could lead to an underestimation of systolic pressure or an overestimation of diastolic pressure.
Diurnal variation is the difference between blood pressure measurements taken at different times of the day. It varies widely from patient to patient, but generally, readings are lowest in the early morning and peak in the late afternoon or early evening.
The pulse deficit is the difference between a patient's radial and apical pulse rates. Pulse deficits often reflect abnormal heart rhythms.
115
Which of the following is true regarding assessing a patient's pulse?
A. The human pulse is the palpable bounding of the blood flow in a peripheral artery.
B. The normal pulse range for a resting adult is 50 to 110 beats/min.
C. Three components that the nurse should include when documenting pulse (P) are the rate, rhythm, and depth.
D. To calculate the pulse of a patient whose rhythm is irregular, the nurse should count the pulse rate for 30 seconds and multiply by two.
A. When a peripheral artery can be compressed against an underlying bone or muscle, the pulsation created by the ejection of blood from the heart can be felt by palpating that site.
116
Which of the following temperatures is within the normal range for adults and is documented correctly?
A. T = 98.6º F
B. T = 99.6º F (O)
C. T = 101.0º F (O)
B. Normal temperatures range from 96.8° F to 100.4° F. Appropriate documentation of temperature (T) includes degrees, scale (F), and assessment site: oral (O), tympanic (T), axillary (A), or rectal (R).
117
Which of the following accurately describes body temperature?
A. The difference between heat produced by and lost from the body
B. The total amount of heat produced by the body
C. The amount of heat produced by the body plus the amount of heat lost to the external environment
A. Normal body temperature is the healthy balance between the amounts of heat the body produces as a byproduct of metabolism, muscle activity, thyroxine output, and sympathetic stimulation and the heat lost as a result of radiation, conduction, convection, and evaporation.
118
The primary reason for assessing this patient's vital signs is to
A. establish a baseline when the patient reports no specific health-related problem.
B. determine the presence of any acute or chronic illness or disease process.
C. initiate the nursing process.
A. Vital signs are assessed for various reasons that include determining the patient's response to medical and nursing therapy as well as identifying clinical problems. However, the primary reason for such assessment at an initial visit of an apparently well patient is to document baseline data. This information will be useful for comparison with vital-sign data obtained at subsequent visits.
119
Will your assessment of respiration provide information about your patient's ability to intake carbon dioxide and to expel oxygen?
A. Yes
B. No
B. Respiration is the mechanism a person uses to introduce oxygen into the body while expelling carbon dioxide into the atmosphere.
120
Which of the following is true regarding assessing a patient's respiration?
A. It is best to inform the patient that you are assessing her respiration.
B. "R = 14/min, normal, regular" is an appropriate documentation of a patient's respiration.
C. Occurrence or periods of apnea in an older adult is a normal respiratory finding.
D. Anxiety and acute pain are two factors that should not affect a patient's respiratory rate.
B. Appropriate documentation of respiration includes rate, rhythm (regular, irregular), and depth (deep, normal, shallow).
121
Which of the following describes systolic pressure?
A. The force blood exerts on the wall of a blood vessel during both the contraction and relaxation phases of the heart
B. The pressure exerted by the blood during the heart's contraction phase
C. The pressure exerted by the blood during the heart's relaxation phase
B. Systolic pressure describes the pressure exerted by the blood during the hearts contraction phase. The contraction of the heart forces the blood under high pressure into the aorta. The peak of maximum pressure when ejection occurs is the systolic pressure.
122
You recorded your patient's blood pressure as 166/88. Is this within the normal range for an adult?
A. Yes.
B. No.
B. While 120/80 mm Hg is considered a normal blood pressure for an adult, older adults may experience a rise as a result of decreased elasticity of the vessels; 140/90 is considered hypertension while a systolic pressure of 90 mm Hg or less is considered hypotension. In any case, 166/88 exceeds the normal range.
123
Your patient's blood pressure exceeds the upper limit of the normal range for an adult, so you measure it again.
Which of the following questions would be appropriate to ask your patient before you reassess her blood pressure?
A. What is your usual blood-pressure reading?
B. Have you eaten anything within the last hour? C. Did you drink any tea, coffee, or soda within the last half hour?
D. Are you currently experiencing any emotional stress such as fear or anxiety?
E. Have you smoked within the last 15 to 30 minutes?
A, C, D, E
124
How long would you wait before reassessing your patient's blood pressure on the same arm?
A. 2 to 3 minutes
B. 10 to 15 minutes
A. Waiting 2 to 3 minutes before reassessing blood pressure in the same extremity allows time for the venous congestion caused by the previous blood pressure measurement to subside.
125
Your patient is seated comfortably. You measure her blood pressure in her right arm and obtain a reading of 160/90. You ask her to return to have her blood pressure reassessed in 2 weeks since this reading indicates a blood pressure above the normal adult range.
The most appropriate way for you to document this patient's blood pressure is
A. blood pressure is 160/90
B. BP = 160/90; right arm, sitting
C. BP = hypertensive at 160/90
B. Appropriate documentation of blood pressure includes the abbreviation for blood pressure (BP), the systolic pressure separated from the diastolic pressure by a slash mark, plus the assessed limb and general position of the patient.
126
A 56-year-old female had her initial visit with a primary care provider (PCP) 2 weeks ago. At that appointment, her blood-pressure (BP) reading was above normal (160/90), so she returned today to have her BP evaluated.
You escort the patient to an examination room and prepare to measure her vital signs, including temperature, pulse, respiration, and BP. You determine that the patient has not smoked or ingested any caffeine within the last 30 minutes. She is comfortably seated on the examining table.
You prepare to check the patient's temperature using a tympanic thermometer. She denies any ear pain or drainage. You then inspect her ear canal for
A. symmetry.
B. sensitivity.
C. cerumen.
C. The visible presence of earwax can minimize the amount of tympanic membrane the thermometer probe can access, thus altering the accuracy of the reading.
127
To facilitate straightening the natural curvature of the adult ear canal, you gently pull the patient's pinna (top of the ear)
A. back, up, and out.
B. forward, up, and out.
C. back, down, and out.
A. Manipulating the ear lobe in this fashion straightens the adult ear canal, thus providing better exposure of the tympanic membrane and allowing for optimal assessment.
128
When using a tympanic membrane thermometer, correctly position the speculum probe with respect to the ear canal to ensure
A. an appropriate seal is created to prevent the ear canal from being exposed to ambient temperature. B. that the risk of transmission of micro-organisms is reduced.
A. Gentle pressure seals the ear canal from ambient temperature, which can alter readings as much as 2.8° C (5° F).
129
You prepare to assess the patient's pulse and respiratory rate. You support her arm and palpate her wrist to locate the radial pulse along a groove located
A. on the lateral aspect of the wrist.
B. down the center of the wrist.
C. on the thumb side of the wrist.
C. The radial artery lies in a groove that runs down the medial or thumb side of the wrist.
130
To assess the patient's pulse accurately, you compress the radial artery with
A. the pads of your fingers.
B. the tips of your fingers.
C. the pad of your thumb.
A. The finger pads are most sensitive and thus best suited for detecting the pulse, while the thumb pulsates strongly enough for you to mistake it for the patient's pulse.
131
The patient's pulse rhythm is regular. You count her pulse
A. for 15 seconds then multiply by 4.
B. for 20 seconds then multiply by 3.
C. for 30 seconds then multiply by 2.
C. It is appropriate to assess a pulse with a regular rhythm for 30 seconds and then multiply by 2 (since you will document the pulse rate per minute).
132
After assessing the patient's pulse, you begin to observe her breathing pattern immediately without changing the position of your hand. You do this primarily to
A. keep the patient from altering the rate, rhythm, or depth of her respiration.
B. use a time-conserving method of evaluating both respiration and pulse rate.
C. offer the reassurance of physical touch while evaluating respiration.
A. When patients are aware that their breathing is being observed, they might inadvertently or knowingly alter respiratory depth, rhythm, or rate.
133
You determine that the patient's arm seems "average" and decide to use a standard blood-pressure cuff. You check that her pulse is of equal strength in both wrists, so, after she removes her outer long-sleeved sweater, you position the lower edge of the BP cuff approximately 1 inch above the antecubital space of her right arm. You support her arm at approximately the level of her heart.
Selecting a BP cuff that is too small for the patient's arm will result in
A. a falsely high reading.
B. a falsely low reading.
A. Ideally, the cuff's width should be 40% of the circumference (or 20% wider than the diameter) of the midpoint of the limb and the bladder should encircle at least 80% of the upper arm. A cuff that is too small will result in a reading that is falsely high reading, while a cuff that is too big will yield a falsely low reading. There is no way to predetermine the amount of the error in the reading.
134
The reason for removing the outer sweater is to
A. ensure proper cuff application.
B. prevent falsely high readings.
C. make the patient more comfortable.
D. allow for proper inflation of the cuff's bladder. E. eliminate any muffling of the Korotkoff sounds.
A, B, D, E
135
You place the lower edge of the cuff at least 1 inch above the antecubital space to
A. allow for proper placement of the stethoscope over the brachial artery.
B. facilitate the proper flexing of the patient's arm at the elbow.
C. ensure appropriate application of pressure to the brachial artery.
A. Positioning the cuff this way keeps the cuff from interfering with proper placement of the bell over the brachial artery. Proper positioning is essential for hearing the Korotkoff sounds and accurately measuring blood pressure.
136
Positioning and supporting the patient's arm at heart level is important because
A. an unsupported arm can cause a falsely high reading.
B. an arm positioned below heart level can cause a falsely high reading.
C. an arm positioned above heart level can cause a falsely low reading.
D. it ensures a good blood flow conducive to an accurate reading.
A, C
137
A 56-year-old female had her initial visit with a primary care provider (PCP) 2½ months ago. At that appointment, her blood-pressure (BP) was elevated. Her BP was reassessed in 2 weeks and remained above normal limits for an adult her age. The PCP prescribed an antihypertensive medication and encouraged her to implement several lifestyle changes directed at lowering her BP. She made a 2-month follow-up appointment for re-evaluation of her response to the treatment plan.
The patient has been taking the prescribed antihypertensive medication for 2 months. You prepare to assess her BP. After you interview her to determine when she last smoked, ingested caffeine, and exercised, you make sure she is seated comfortably with her arm supported at the level of her heart. You position a standard adult blood-pressure cuff snugly on her bare arm about 1 inch above the anticubital space.
To ensure an accurate reading with the aneroid sphygmomanometer you are using, you position yourself
A. within 3 feet of the manometer.
B. at eye level with the BP gauge.
C. standing at the patient's side.
D. however you feel most comfortable.
A, B
138
You have reviewed the patient's records to determine her baseline BP, but if that had not been possible it would be appropriate for you to
A. measure her BP on one arm, remove the cuff, wait at least 2 minutes, measure it on the other arm, and average the two values.
B. measure her BP, reinflate the cuff promptly, measure it again, and average the two values.
C. inflate the cuff to 30 mm Hg above the point of the previously palpated systolic pressure.
D. ask the patient what her BP usually is and inflate the cuff to 30 mm Hg above that point.
A, C
139
The proper technique for BP cuff inflation and deflation is
A. rapid inflation followed by rapid deflation.
B. slow inflation followed by slow deflation.
C. rapid inflation followed by slow deflation.
D. slow inflation followed by rapid deflation.
C. Rapid inflation helps ensure an accurate measurement of systolic pressure. Rapid deflation interferes with the accurate assessment of both systolic and diastolic readings. It is recommended that the pressure manometer gauge fall at a rate of 2 to 3 mm Hg per second.
140
When listening to Korotkoff sounds, you would use your stethoscope's
A. bell.
B. diaphragm.
A, B
141
You inflate the cuff to 30 mm Hg higher than the patient's last recorded BP (taken at her last appointment). You note the point on the manometer where
```
A. you first hear Korotkoff sounds.
B. the swishing sounds begin.
C. you hear the loudest sounds.
D. the sound becomes muffled.
E. the sound disappears.
```
A, E
142
Wash hands with antimicrobial soap for
15-30 seconds
143
Dorsal
Back
144
Palmer
Front
145
Diurnal cycle
24 hour cycle
146
Temperature Documentation
T=98.6 (O)
147
Pulse Deficit
The difference between apical and peripheral pulse rate.
apical - radial = pulse deficit
148
Factors that affect pulse
Age, gender, circadian rhythm, blood volume, body temperature, exercise, stress, emotion, hormonal activity, medications, pathological processes
149
Heart Rate and Rhythm Documentation
HR=72 bpm RRR
150
RRR
Regular Rhythm and Rate
151
Pulse Force or Strength
```
0 = absent
+1 = weak/thready
+2 = normal/expected
+3/+4 = full/bounding
```
152
Pulse Elasticity
Artery feels springy instead of tough, hard, rope-like
153
Respiration Documentation
RR 12 regular rhythm
154
Respiration Measurement
number of breaths within 30 seconds x2
155
Heart Rate Measu
number of beats within 30 seconds x2
156
Bradycardia
slow heart rate (<60 bpm)
157
Tachycardia
fast heart rate (>100 bpm)
158
Blood Pressure (BP)
The force of blood against arterial walls
159
Systolic Pressure
Maximum on contraction of left ventricle
160
Diastolic Pressure
Pressure during resting phase of cardiac cycle
161
Pulse Pressure (PP)
Systolic - Diastolic = PP
162
Influences on blood pressure
Age, sex, race, diurnal rhythm, weight, exercise, emotions, stress, position
163
Cardiac Output (CO)
stroke volume x heart rate = CO
164
Peripheral Vascular Resistance (PVR)
BP = CO x PVR
165
BP cuff size
Too small = false high reading
| Too large = false low reading
166
When taking BP
Patient at rest for 5 minutes, arm free of clothing, arm supported at heart level, seated with back against chair, legs uncrossed, feet flat on floor
167
The best way to determine the depth of a patients respiration is to
A. observe the degree of chest-wall movement during inspiration and expiration.
B. count how many breathing cycles you observe per minute.
C. notice whether or not expiration takes longer than inspiration.
D. measure the precise amount of air the patient takes in and breathes out.
A. You determine the depth of respiration subjectively by evaluating how much chest-wall movement you can observe. The movement is generated by the movements of the diaphragm and intercostal muscles as the patient breathes. With shallow respiration, for example, you will observe very little movement. Deep respiration involves full expansion of the lungs, which is usually quite visible.
168
When taking a patient's blood pressure, why is it important to notice the pressure on the manometer when you hear the fourth Korotkoff sound or phase?
A. It corresponds to the patient's systolic pressure.
B. You need it to record the second diastolic pressure.
C. It is the loudest of the Korotkoff sounds.
D. You might not hear a fifth Korotkoff sound.
D. Most clinicians consider the fifth Korotkoff sound, which is actually the disappearance of sound, an adult patient's diastolic blood pressure. However, with some patients, there is no distinct fifth sound. You hear sounds all the way to 0 mm Hg. For these patients, you would record the fourth Korotkoff sound as the diastolic blood pressure.
169
When auscultating a patient's apical pulse, you listen until you hear the S1 and S2 heart sounds clearly and regularly. S2 is produced when
A. atria contract vigorously.
B. ventricular walls vibrate.
C. semilunar valves close.
D. mitral valve snaps open.
C. The second heart sound, S2, is generated by the closure of the semilunar vales (the aortic and pulmonic valves) and signals the start of diastole. S2 is the "dub" heard in the normal "lub-dub" sound.
170
You are assessing a patient's vital signs. The patient has a temperature of 102F (39C). Which of the following do you expect to find?
A. An elevated pulse rate
B. A decreased blood pressure
C. An elevated blood pressure
D. A decreased pulse rate
A. A fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate.
171
You are assess ing the vital signs of a newly admitted patient. To establish an accurate baseline of the patient's respiration, you
A. instruct the patient to breathe in and to exhale out as he would normally.
B. make the patient physically comfortable before beginning the assessment.
C. determine if the patient has a history of any chronic respiratory problems.
D. observe the patient's chest movements while appearing to assess his pulse.
D. You are most likely to observe the true respiratory pattern (rate, rhythm, and depth) when the patient is unaware that he is being assessed. When patients know their respiration is being observed, it is common for them to alter their respiratory pattern either voluntarily or involuntarily.
172
When taking a patient's temperature rectally, it is important to
A. rotate the probe gently if you encounter any resistance.
B. insert the probe so that you are aiming at the patient's pelvic area.
C. dip the probe about an inch to an inch and a half into a tube of lubricant.
D. insert the probe about an inch and a half into the patient's anus.
D. An insertion depth of 1.5 inches (3.5 centimeters) ensures sufficient exposure of the probe to the blood vessels in the rectal wall. Postioning the probe against the blood vessels enables it to measure heat maximally and accurately.
173
The difference between a patient's systolic and diastolic blood pressure is called
A. an auscultatory gap.
B. the pulse pressure.
C. a diurnal variation.
D. the pulse deficit.
B. The difference between the systolic and diastolic pressures is the pulse pressure; if the patient's blood pressure is 130/85 mm Hg, the pulse pressure is 45/min. Pulse pressure can be a predictor of heart problems, especially in older adults. For example, an elevated pulse pressure usually reflects stiffness and reduced elasticity of the aorta, most often due to hypertension or atherosclerosis.
174
Auscultatory Gap
A silent interval that may be present between the systolic and diastolic blood pressures; i.e., the sound disappears for a while, then reappears
175
When preparing to measure the vital signs of a patient, you should recognize that which of the following will affect the methods that you will use?
A. The patient is 60 pounds overweight.
B. The patient has been nauseated for 2 days.
C. The patient is reporting a "stuffy" nose.
D. The patient has been fasting for blood tests.
E. The patient is taking digoxin (Lanoxin).
F. The patient had a mastectomy 2 years ago.
A, C, D, E, F
176
You have assessed a 45-year-old patient's vital signs. Which of the following assessment values requires immediate attention?
A. An oral temperature of 100° F (37.8° C)
B. A blood pressure of 148/88 mm Hg
C. A respiratory rate of 30/min
D. A radial pulse rate of 45 beats per 30 seconds
C. A respiratory rate of 30/min is above the normal range and indicates a respiratory problem that requires immediate attention. An adult breathing at that rate might be experiencing shortness of breath or dyspnea and, without intervention, this could become a life-threatening situation.
177
The most important factor in measuring blood pressure accurately is
A. obtaining the reading in the early morning.
B. using a cuff of the appropriate size for the patient.
C. making sure the patient is comfortable and relaxed.
D. removing clothing from the arm before applying the cuff.
B. Using the wrong cuff size for the patient will result in an erroneous reading. A cuff that is too small will result in a reading that is falsely high while a cuff that is too big will record a false low. One way to select a cuff is to make sure that the width of the cuff is 40% of the arm circumference where the cuff will be wrapped. The bladder (inside the cuff) should surround 80% of the arm circumference.
178
You are preparing to use a tympanic thermometer. Which of the following steps has the highest priority in the accurate use of this piece of equipment for measuring body temperature?
A. Attaching the disposable probe cover
B. Assessing the external ear for redness
C. Gently pulling the pinna back and upward
D. Replacing the thermometer in its charger
C. This position helps straighten the ear canal and provides optimal access to the tympanic membrane. Good contact with sufficient tympanic membrane is essential for an accurate tympanic temperature measurement.
179
When assessing a patient's respiration, it is recommended that the patient
A. lie flat in bed with his/her head on a pillow.
B. have the head of the bed elevated 45 to 60°.
C. continue to go about his/her usual activities.
D. take several deep breaths prior to the assessment.
B. This is a comfortable position for most patients and it allows full ventilatory movement. Also, any type of discomfort can increase respiratory rate.
180
You are measuring a patient's temperature orally. You place the covered probe
A. in the posterior lingual pocket lateral to the midline.
B. so that it rests on the lower lingual frenulum.
C. centrally on top of the patient's tongue.
D. under the tongue just beyond the patient's teeth.
A. The heat produced by superficial blood vessels in the right and the left posterior sublingual pocket is what generates an accurate oral temperature reading. Inserting the probe "sideways" into the back of the area under the tongue on the left or the right will access this area.
181
To auscultate a patient's apical pulse accurately, you position the bell or the diaphragm of your stethoscope over the point of maximal impulse, which is located
A. at the right midclavicular line.
B. over the Angle of Louis.
C. at the fifth intercostal space at the left midclavicular line.
D. over the suprasternal notch.
C. To locate the point of maximal impulse, first locate the angle of Louis - a bony prominence just below the suprasternal notch. Slide your fingers down each side of the angle of Louis to locate the second intercostal space. Gently move your fingers down the left side of the sternum to the fifth intercostal space and laterally to the left midclavicular line. You have found the PMI.
