VITAL SIGNS Flashcards
The most important factor in measuring blood pressure accurately is:
using a cuff of the appropriate size for the patient
When assessing a patient’s respiration, it is recommended that the patient:
have the head of the bed elevated 45 to 60 degrees.
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
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:
at the fifth intercostal space at the left midclavicular line.
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?
An elevated pulse rate
The best way to determine the depth of a patient’s respiration is to:
observe the degree of chest-wall movement during inspiration and expiration
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)
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
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
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?
Gently pulling the pinna back and upward
You are measuring a patient’s temperature orally. You place the covered probe:
in the posterior lingual pocket lateral to the midline
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
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?
You might not hear a fifth korotkoff sound
When taking an adult patient’s temperature rectally, it is important to:
insert the probe about an inch and a half into the patient’s anus
The difference between a patient’s systolic and diastolic blood pressures is called:
the pulse pressure
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
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.
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
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.
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
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.
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. 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.
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 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.
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
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.
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
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.
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?
-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.
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
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.
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. 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.
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.
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.
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.
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.
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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.”
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
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
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
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
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
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
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
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
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%
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
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
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
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
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
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
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
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
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
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)
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
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
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
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%
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
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
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
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
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%
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
