Quiz 55: Vital Signs
Perry et al.: Clinical Nursing Skills & Techniques, 9th Edition
Instructor Verified Answers Included
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1. The patient is brought to the emergency department complaining of severe shortness of breath. She is cyanotic and her extremities are cold. In an attempt to quickly assess the patient’s respiratory status, the nurse should:
a. remove the patient’s nail polish to get a pulse oximetry reading.
b. use a forehead probe to get a pulse oximetry reading.
c. use a finger probe to get a pulse oximetry reading.
d. check the color of the patient’s nail polish before attempting a reading.
2. A person’s core temperature is considered the most accurate since it is:
a. reflective of the surrounding environment.
b. the same for everyone.
c. controlled by the hypothalamus.
d. independent of external influences.
3. The nurse takes the patient’s temperature using a tympanic electronic thermometer. The temperature reading is 36.5° C (97.7° F). The nurse knows that this correlates with:
a. 37.0° C (98.6° F) rectally.
b. 37.0° C (98.6° F) orally.
c. 36.0° C (97.7° F) axillary.
d. 36.0° C (97.7° F) orally.
4. The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette. The patient has just returned from his “cigarette break.” The nurse is about to take the patient’s temperature orally and should:
a. wait about 15 minutes before taking his temperature.
b. give him oral fluids to rinse the nicotine away before taking his temperature.
c. give him a stick of chewing gum to chew and then take his temperature.
d. take his oral temperature and record the findings.
5. When evaluating the patient’s temperature levels, the nurse expects the patient’s temperature to be lower:
a. in the morning.
b. after exercising.
c. during periods of stress.
d. during the postoperative period.
6. When inserting a rectal thermometer, the nurse encounters resistance. The nurse should:
a. apply mild pressure to advance.
b. ask the patient to take deep breaths.
c. remove the thermometer immediately.
d. remove the thermometer and reinsert it gently.
7. An appropriate procedure for measurement of an adult’s temperature with a tympanic membrane sensor is:
a. pulling the ear pinna down and back.
b. moving into the ear in a figure-eight pattern.
c. fitting the probe loosely into the ear canal.
d. pointing the probe toward the mouth and chin.
8. The patient is a 1-year-old male infant who is admitted with possible sepsis. The patient is irritable and agitates easily. What should the nurse do to assess the patient’s temperature?
a. Take an oral temperature before doing anything else.
b. Take an axillary temperature using the upper axilla.
c. Place the child in Sims’ position for a rectal temperature.
d. Take a rectal temperature as the last vital sign.
9. The patient is returning from a cardiac catheterization. The puncture site is in the right femoral artery. The patient is having vital signs assessed every 15 minutes. Along with vital signs, the nurse assesses the pedal pulses of the right and left feet. Which of the following would be of major concern?
a. Both pedal pulses were bounding.
b. The femoral artery could be palpated.
c. The right pedal pulse was weaker than the left.
d. The radial artery pulse was 88.
10. The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette. The patient has just returned from his “cigarette break.” The nurse is about to take the patient’s radial pulse and should:
a. wait about 15 minutes before taking his pulse.
b. use her thumb to detect the pulse and get an accurate count.
c. press hard to detect the pulse and get an accurate count.
d. take his pulse for 15 seconds and multiply by 4.
11. When evaluating the radial pulse measurement technique of the nursing assistant, the nurse identifies appropriate technique when the assistant:
a. has the patient’s arm elevated.
b. positions the patient supine or sitting.
c. applies significant pressure to the pulse site.
d. counts the pulse for 15 seconds and multiplies by 4.
12. The nurse is caring for an infant in the NICU. While taking vital signs, the nurse finds that the baby’s heart rate is 195. The nurse calls the physician, knowing that the normal heart rate should be:
a. 60 to 100 beats per minute.
b. 100 to 160 beats per minute.
c. 90 to 140 beats per minute.
d. 220 beats per minute or higher.
13. The patient has been in the hospital for several days for urosepsis. He has been responding favorably to treatment, and his vital signs have been “normal” for 2 days. When the nurse takes his vital signs, however, the patient’s apical pulse is 152 and regular. The nurse suspects that the:
a. patient is having a reaction to his narcotic medication.
b. patient may be suffering from hypothermia.
c. patient’s fever may have returned.
d. patient may be an athlete.
14. What steps should the nurse take to conduct an assessment of a possible pulse deficit?
a. A nurse measures the pulse after the patient exercises.
b. Two nurses check the same pulse on opposite sides of the body.
c. Two nurses assess the apical and radial pulses and determine the difference.
d. The current pulse is compared with previous pulse measurements for differences.
15. An appropriate method of assessing a patient’s respirations is for the nurse to:
a. place the bed flat.
b. remove all supplemental oxygen sources from documentation.
c. explain to the patient that respirations are being assessed.
d. gently place the patient’s hand in a relaxed position over the upper abdomen.
16. The nurse is about to take vital signs on a newborn patient in the nursery. She should:
a. assess respiratory rate after taking a rectal temperature.
b. observe the child’s chest while the child is sleeping.
c. call the physician if the rate is over 40.
d. expect that the child will have short periods of apnea.
17. The nurse should report an assessment of _____ respirations per minute for a(n) _____.
a. 14; adult patient
b. 16; 8-year-old patient
c. 25; toddler
d. 38; newborn
18. During the normal cardiac cycle, blood pressure reaches a peak, followed by a trough, in the cycle. What is the peak known as?
a. Pulse pressure
b. Systolic cycle
c. Diastolic cycle
d. Korotkoff phase
19. The patient is complaining of a severe headache. The nurse takes the patient’s blood pressure and finds it to be 240/110. What is the pulse pressure?
20. During his initial screening, the patient’s blood pressure was noted to be elevated. Two months after the first assessment, he was noted to have a blood pressure of 150/92 and 166/96 at different times during the visit. It is now a month and a half later, and the nurse is concerned because the patient’s initial blood pressure on this visit was 154/94. She is preparing to take a second blood pressure, understanding that another reading in this range could lead to a diagnosis of:
d. orthostatic hypotension.
21. The patient is an 86-year-old woman who is being admitted for dehydration and pneumonia. The patient is lying in bed but tells the nurse that she needs to go to the bathroom. The nurse tells the patient that she will stay with her and will help her get there. The patient states, “That’s OK. I can make it on my own.” The nurse should:
a. help the patient to the bathroom and stay with her.
b. allow the patient to get up on her own and go to the bathroom.
c. allow the patient to go to the bathroom and call for help if needed.
d. insert a Foley catheter.
22. The nurse chooses a sphygmomanometer that has a circular gauge and a needle that registers the millimeter calibrations. This type of device is known as a(n) _____ manometer.
d. direct (invasive)
23. The nurse is working on the general surgical unit and is caring for a patient who has a right total mastectomy. To take the patient’s vital signs and to accurately assess the patient’s blood pressure, it will be necessary to:
a. place the blood pressure cuff on the left upper arm.
b. place the blood pressure cuff on the right upper arm.
c. place the blood pressure cuff on the right lower arm.
d. use direct (invasive) blood pressure measurement.
24. Which site is used to auscultate blood pressure?
25. The nurse is caring for a 2-year-old child who is admitted with croup and crying. To take the child’s vital signs, the nurse should:
a. place the pediatric blood pressure cuff on the left arm.
b. place the blood pressure cuff on the right thigh.
c. skip the blood pressure measurement.
d. place the blood pressure cuff on the left thigh.
26. When the benefits of the different types of blood pressure monitoring devices are compared, which of the following patients would be the best candidate for noninvasive electronic blood pressure measurement?
a. A 49-year-old postsurgical patient with no history of heart disease on q15min vital signs
b. A 22-year-old patient undergoing active grand mal seizures
c. A 68-year-old patient with diagnosed peripheral vascular disease
d. A 54-year-old patient with chronic atrial fibrillation
27. The patient was found in an alley on a cold winter night and is admitted with hypothermia from environmental exposure. She is elderly and is having difficulty breathing. Her breath sounds are diminished, and the tip of her nose is cyanotic. The nurse wants to assess the oxygen level in the patient’s blood. She decides to use the pulse oximeter. The best way to apply this to this patient would be with a(n):
a. finger probe.
b. earlobe sensor.
c. forehead sensor.
d. toe sensor.
28. The patient is admitted in a near comatose state with a blood glucose level of 750. His respiratory rate is 42 breaths per minute, and his respiratory pattern is deep and regular. What is this type of breathing known as?
a. Cheyne-Stokes respiration
b. Biot’s respiration
d. Kussmaul’s respiration
29. What is a disadvantage of using the disposable sensor pad for pulse oximetry?
a. It is less restrictive.
b. It contains latex.
c. It is less expensive to use.
d. It is available in different sizes.
1. The nurse is preparing to take the patient’s temperature. Which of the following may cause the temperature to fluctuate? (Select all that apply.)
2. Which of the following processes are involved in respiration? (Select all that apply.)
3. The nurse is about to teach the patient about risk factors for hypertension. Which of the following are risk factors for hypertension? (Select all that apply.)
b. Cigarette smoking
c. High blood cholesterol
d. Renal disease
4. The nurse is about to take a patient’s blood pressure. Which of the following conditions would cause the nurse to obtain a false high reading? (Select all that apply.)
a. Bladder or cuff too narrow
b. Bladder or cuff too wide
c. Patient’s arm below the level of the heart
d. Inflating the cuff too slowly
1. ___________, a subjective symptom, is also referred to as a vital sign, along with the physiological signs.
2. When heat loss mechanisms are unable to keep pace with heat production, ____________ is the result.
3. The nurse is taking a rectal temperature on an adult patient. She expects to insert the thermometer __________ inches.
4. The patient has been sleeping and has been lying on his right side. The nurse is ready to take his temperature using a tympanic thermometer. She needs to insert the thermometer into his ___________ ear.
5. An irregular heartbeat, often found in children, that speeds up with inspiration and slows down with expiration is known as a sinus ___________.
6. ___________ is the sound of the tricuspid and mitral valves closing at the end of ventricular filling.
7. _________ is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction.
8. An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a ____________.
9. To take a manual blood pressure, the nurse places the cuff of the _____________ around the patient’s upper arm.
10. After applying the sphygmomanometer to the patient’s upper arm, the nurse inflates the cuff to the proper level, and then, using a stethoscope, listens for the __________________ sounds.
11. _____________ occurs when the systolic blood pressure falls to 90 mm Hg or below.
12. The percent to which hemoglobin is filled with oxygen is known as _________________.