Vital Signs

Question 1

A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely?

a. Pulse
b. Respirations
c. Temperature
d. Blood pressure

Answer 1

ANS: C

Disease or trauma to the hypothalamus or the spinal cord, which carries hypothalamic messages, causes serious alterations in temperature control. The hypothalamus does not control pulse, respirations, or blood pressure.

Question 2

The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient’s temperature?

a. Radiation
b. Conduction
c. Convection
d. Evaporation

Answer 2

ANS: B

Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss because of the direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement.

Question 3

. The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). The patient’s last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). Which action will the nurse take?

a. Wait 30 minutes and recheck the patient’s temperature.
b. Assume that the patient has an infection and order blood cultures.
c. Encourage the patient to move around to increase muscular activity.
d. Be aware that temperatures this high are harmful and affect patient safety.

Answer 3

ANS: A

Waiting 30 minutes and rechecking the patient’s temperature would be the most appropriate action in this case. A fever is usually not harmful if it stays below 102.2° F (39° C), and a single temperature reading does not always indicate a fever. In addition to physical signs and symptoms of infection, a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time. Nurses should base actions on knowledge, not on assumptions. Encouraging the patient to increase muscular activity will cause heat production to increase up to 50 times normal. The temperature has decreased and a symptom of infection would be an increase in temperature.

Question 4

A patient is pyrexic. Which piece of equipment will the nurse obtain to monitor this condition?

a. Stethoscope
b. Thermometer
c. Blood pressure cuff
d. Sphygmomanometer

Answer 4

ANS: B

Pyrexia, or fever, occurs because heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature; therefore, a thermometer is needed. A stethoscope is not used to take a temperature but can be used for apical pulse and blood pressure. A pulse oximeter is used to determine oxygen content in the blood. A sphygmomanometer and blood pressure cuff is used to determine blood pressure and will be used for blood pressure problems.

Question 5

The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient?

a. Hyperthermia and fever are the same thing.
b. Hyperthermia is an upward shift in the set point.
c. Hyperthermia occurs when the body cannot reduce heat production.
d. Hyperthermia results from a reduction in thermoregulatory mechanisms.

Answer 5

ANS: C

An elevated body temperature related to the inability of the body to promote heat loss or reduce heat production is hyperthermia. Whereas fever is an upward shift in the set point, hyperthermia results from an overload of the thermoregulatory mechanisms of the body.

Question 6

The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take?

a. Place the patient on oxygen.
b. Encourage the patient to cough.
c. Restrict the patient’s fluid intake.
d. Increase the patient’s metabolic rate.

Answer 6

ANS: A

Interventions during a fever include oxygen therapy. During a fever, cellular metabolism increases and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for fluid volume deficit. Fluids should not be restricted, even though the patient has heart failure; the patient needs fluids at this time due to the fever. Increasing the metabolic rate further would not be advisable. Coughing will increase muscular activity, which will increase fever.

Question 7

. The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient’s temperature?

a. Oral
b. Rectal
c. Axillary
d. Tympanic

Answer 7

ANS: D

The tympanic route is easily accessible, requires minimal patient repositioning, and often can be used without disturbing the patient. It also has a very rapid measurement time. Oral temperatures require patient cooperation and are not recommended for patients with a history of seizures. Rectal temperatures require positioning and may increase patient agitation. Axillary temperatures need long measurement times and continuous positioning. The patient’s agitation state may not allow for long periods of attention.

Question 8

The patient is being admitted to the emergency department following a motor vehicle accident. The patient’s jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature reading?

a. Oral
b. Axillary
c. Tympanic
d. Temporal

Answer 8

ANS: C

The tympanic route is the best choice in this situation. Oral temperatures are not used for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills. Axillary temperature is affected by exposure to the environment, including time to place the thermometer. It also requires a long measurement time. Temporal artery temperature is affected by skin moisture such as diaphoresis or sweating.

Question 9

The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use?

a. Radial
b. Apical
c. Carotid
d. Brachial

Answer 9

ANS: C

The heart continues to deliver blood through the carotid artery to the brain as long as possible. The carotid pulse is easily accessible during physiological shock or cardiac arrest. The radial pulse is used to assess peripheral circulation or to assess the status of circulation to the hand. The brachial site is used to assess the status of circulation to the lower arm. The apical pulse is used to auscultate the apical area.

Question 10

The nurse reviews the laboratory results for a patient and determines the viscosity of the blood is thick. Which laboratory result did the nurse check?

a. Arterial blood gas
b. Blood culture
c. Hematocrit
d. Potassium

Answer 10

ANS: C

The hematocrit, or the percentage of red blood cells in the blood, determines blood viscosity. Blood cultures determine the causative agent of an infection. Abnormal potassium levels can cause dysrhythmias. Arterial blood gases determine acid-base balance or the pH levels of the blood.

Question 11

The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do?

a. Allow the patient to breathe into a paper bag.
b. Use oxygen cautiously in this patient.
c. Administer high levels of oxygen.
d. Give CO2 via mask.

Answer 11

ANS: B

Oxygen must be used cautiously in these types of patients. Hypoxemia helps to control ventilation in patients with chronic lung disease. Because low levels of arterial O2 provide the stimulus that allows a patient to breathe, administration of high oxygen levels may be fatal for patients with chronic lung disease. Patients with chronic lung disease have ongoing hypercarbia (elevated CO2 levels) and do not need to have CO2 administered or “rebreathed” with a paper bag.

Question 12

. A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up?

a. 35 mm Hg
b. 40 mm Hg
c. 45 mm Hg
d. 50 mm Hg

Answer 12

ANS: D

50 mm Hg is abnormal so the nurse will follow up. Normal capnography results are 35 to 45 mm Hg.

Question 13

The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient’s low heart rate?

a. The patient has a fever.
b. The patient has possible hemorrhage or bleeding.
c. The patient has chronic obstructive pulmonary disease (COPD).
d. The patient has calcium channel blockers or digitalis medication prescriptions.

Answer 13

ANS: D

Negative chronotropic drugs such as digitalis, beta-adrenergic agents, and calcium channel blockers can slow down pulse rate. Fever, bleeding, hemorrhage, and COPD all increase the body’s need for oxygen, leading to an increased heart rate.

Question 14

. The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient’s symptoms?

a. Red blood cell count of 5.0 million/mm3
b. Hemoglobin level of 8.0 g/100 mL
c. Hematocrit level of 45%
d. Pulse oximetry of 95%

Answer 14

ANS: B

The concentration of hemoglobin reflects the patient’s capacity to carry oxygen, which if low can lead to shortness of breath and chest discomfort. Normal hemoglobin levels range from 14 to 18 g/100 mL in males and from 12 to 16 g/100 mL in females. Hemoglobin of 8.0 is low and indicates a decreased ability to deliver oxygen to meet bodily needs. All other values in the selection are considered normal.

Question 15

A nurse reviews blood pressures of several patients. Which finding will the nurse report as prehypertension?

a. 98/50 in a 7-year-old child
b. 115/70 in an infant
c. 120/80 in a middle-aged adult
d. 146/90 in an older adult

Answer 15

ANS: C

An adult’s blood pressure tends to rise with advancing age. The optimal blood pressure for a healthy, middle-aged adult is less than 120/80. Values of 120 to 139/80 to 89 mm Hg are considered prehypertension. Blood pressure greater than 140/90 is defined as hypertension. Blood pressure of 98/50 is normal for a child, whereas 115/70 can be normal for an infant.

Question 16

A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient’s blood pressure (BP)?

a. Smoking increases BP for up to 3 hours.
b. Caffeine increases BP for up to 15 minutes.
c. Smoking result in vasoconstriction, falsely elevating BP.
d. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement.

Answer 16

ANS: C

Smoking results in vasoconstriction, a narrowing of blood vessels. BP rises when a person smokes and returns to baseline about 15-20 minutes after stopping smoking. Caffeine increases BP for up to 3 hours. Be sure that patient has not ingested caffeine or smoked 20 to 30 minutes before BP measurement.

Question 17

The nurse is caring for an older-adult patient and notes that the temperature is 96.8° F (36° C). How will the nurse interpret this finding?

a. The patient has hyperthermia.
b. The patient has a normal temperature.
c. The patient is suffering from hypothermia.
d. The patient is demonstrating increased metabolism.

Answer 17

ANS: B

The average body temperature of older adults is approximately 35° to 36.1° C (95° to 97° F). This is not hypothermia or hyperthermia. Older adults have poor vasomotor control, reduced amounts of subcutaneous tissue, reduced sweat gland activity, and reduced metabolism. The end result is lowered body temperature.

Question 18

The nurse is caring for a patient who reports feeling light-headed and “woozy.” The nurse checks the patient’s pulse and finds that it is irregular. The patient’s blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do?

a. Apply more pressure to the radial artery to feel pulse.
b. Perform an apical/radial pulse assessment.
c. Call the health care provider immediately.
d. Obtain arterial blood gases.

Answer 18

ANS: B

If the pulse is irregular, do an apical/radial pulse assessment to detect a pulse deficit. If pulse count differs by more than 2, a pulse deficit exists, which sometimes indicates alterations in cardiac output. The nurse needs to gather as much information as possible before calling the health care provider. The radial pulse is more accurately assessed with moderate pressure. Too much pressure occludes the pulse and impairs blood flow. Arterial blood gases is a laboratory test that measures blood pH and oxygenation status. Arterial blood gases would be appropriate if respirations were abnormal or if pulse oximetry results were severely low.

Question 19

A nurse is caring for a group of patients. Which patient will the nurse see first?

a. A 17-year-old male who has just returned from outside “for a smoke” who needs a temperature taken
b. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60
c. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74
d. An 87-year-old male suspected of hypothermia whose temperature is below normal

Answer 19

ANS: B

When a blood pressure drops in a postoperative patient, bleeding may be occurring and lead to shock. The nurse should assess this patient first. Pain will cause the blood pressure to elevate so this is an expected finding, and while it does need to be assessed, it is not the first one to assess. A teenager who has returned from smoking will have to wait at least 20 minutes before a temperature can be taken, so this is not the first one to see. A patient with hypothermia is expected to have a temperature below normal, so this is not the first one to see.

Question 20

. After taking the patient’s temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse’s action?

a. Temperatures vary depending on the route used.
b. Temperatures are readings of core measurements.
c. Rectal temperatures are cooler than when taken orally.
d. Axillary temperatures are higher than oral temperatures.

Answer 20

ANS: A

Temperatures obtained vary depending on the site used. Rectal temperatures are usually 0.5° C (0.9° F) higher than oral temperatures, and axillary temperatures are usually 0.5° C (0.9° F) lower than oral temperatures. There are core temperature readings and body surface readings.

Question 21

When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding?

a. 68
b. 76
c. 138/62
d. 138/70

Answer 21

ANS: C

138/62 is the correct reading. The fifth sound marks the disappearance of sound. In adolescents and adults the fifth sound corresponds with the diastolic pressure. The fourth sound becomes muffled and low pitched as the cuff is further deflated. At this point the cuff pressure has fallen below the pressure within the vessel walls; this sound is the diastolic pressure in infants and children. 68 is the pulse pressure of 138/70; 76 is the pulse pressure for 138/62.

Question 22

A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.)

a. Rectal
b. Tympanic
c. Esophagus
d. Temporal artery
e. Pulmonary artery

Answer 22

ANS: B, C, E

Intensive care units use the core temperatures of the pulmonary artery, esophagus, and urinary bladder. Because the tympanic membrane shares the same arterial blood supply as the hypothalamus, the tympanic temperature is a core temperature. Temporal artery measurements detect the temperature of cutaneous blood flow. Oral, rectal, axillary, and skin temperature sites rely on effective blood circulation at the measurement site.

Question 23

. The patient has new-onset restlessness and confusion. Pulse rate is elevated, as is respiratory rate. Oxygen saturation is 94%. The nurse ignores the pulse oximeter reading and calls the health care provider for orders because the pulse oximetry reading is inaccurate. Which factors can cause inaccurate pulse oximetry readings? (Select all that apply.)

a. O2 saturations (SaO2) > 70%
b. Carbon monoxide inhalation
c. Hypothermic fingers
d. Intravascular dyes
e. Nail polish
f. Jaundice

Answer 23

ANS: B, C, D, E, F

Inaccurate pulse oximetry readings can be caused by outside light sources, carbon monoxide (caused by smoke inhalation or poisoning), patient motion, jaundice, intravascular dyes (methylene blue), nail polish, artificial nails, metal studs, or dark skin. SpO2 is a reliable estimate of SaO2 when the SaO2 is over 70%.

Question 24

The nurse is assessing the patient and family for probable familial causes of the patient’s hypertension. The nurse begins by analyzing the patient’s personal history, as well as family history and current lifestyle situation. Which findings will the nurse consider to be risk factors? (Select all that apply.)

a. Obesity
b. Cigarette smoking
c. Recent weight loss
d. Heavy alcohol intake
e. Regular exercise sessions

Answer 24

ANS: A, B, D

Obesity, cigarette smoking, and heavy alcohol consumption are risk factors linked to hypertension. Weight loss and regular exercise can decrease the risk for hypertension.

Question 25

. The patient is being encouraged to purchase a portable automatic blood pressure device to monitor blood pressure at home. Which information will the nurse present as benefits for this type of treatment? (Select all that apply.)

a. Patients can actively participate in their treatment.
b. Self-monitoring helps with compliance and treatment.
c. The risk of obtaining an inaccurate reading is decreased.
d. Blood pressures can be obtained if pulse rates become irregular.
e. Patients can provide information about patterns to health care providers.

Answer 25

ANS: A, B, E

Self-measurement of blood pressure has several benefits. Sometimes elevated blood pressure is detected in persons previously unaware of a problem. Persons with prehypertension provide information about the pattern of blood pressure values to their health care provider. Patients with hypertension benefit from participating actively in their treatment through self-monitoring, which promotes compliance with treatment. Disadvantages of self-measurement include the risk of inaccurate readings. Electronic devices are not recommended if the patient has an irregular heart rate.

Question 26

. A nurse is teaching the staff about alterations in breathing patterns. Which information will the nurse include in the teaching session? (Select all that apply.)

a. Apnea—no respirations
b. Tachypnea—regular, rapid respirations
c. Kussmaul’s—abnormally deep, regular, fast respirations
d. Hyperventilation—labored, increased in depth and rate respirations
e. Cheyne-Stokes—abnormally slow and depressed ventilation respirations
f. Biot’s—irregular with alternating periods of apnea and hyperventilation respirations

Answer 26

ANS: A, B, C

Apnea—Respirations cease for several seconds. Persistent cessation results in respiratory arrest. Tachypnea—Rate of breathing is regular but abnormally rapid (greater than 20 breaths/min). Kussmaul’s—Respirations are abnormally deep, regular, and increased in rate. Hyperventilation—Rate and depth of respirations increase; breaths are not labored. Hypocarbia sometimes occurs. Cheyne-Stokes—Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Biot’s—Respirations are abnormally shallow for 2 to 3 breaths followed by irregular period of apnea.

Question 27

A nurse is assessing results of vital signs for a group of patients. Match the condition to the assessment findings the nurse is reviewing.

a. Patient’s temperature is 113° F (45° C) with hot, dry skin.
b. Patient’s blood pressure sitting is 130/60 and 110/40 standing.
c. Patient’s pulse is 110 beats/min.
d. Patient’s temperature is 93.2° F (34° C).
e. Patient’s blood pressure went from 126/76 to 90/50.
1. Hypothermia
2. Shock/Hypotension
3. Heatstroke
4. Orthostatic hypotension
5. Tachycardia

Answer 27

1. ANS:D
2. ANS:E
3. ANS:A
4. ANS:B
5. ANS:C