Chapter 17- Vital Signs Nursing School Test Banks

 

1.

The nurse is taking the apical pulse of a 6-month-old infant. Upon completion, the nurse tells the parent the babys pulse is 140 beats per minute. The parent is concerned, stating, That seems kind of high! The nurse responds:

A)

Yes, this is termed tachycardia. I will let the doctor know right away.

B)

Yes, it seems fast but actually, normal infant heart rates are 150-200 beats per minute so it is a bit slow.

C)

I know it seems fast, but normal infant heart rates are 100-160 beats per minute.

D)

Yes, this is termed tachypenia. I will let the doctor know right away.

Ans:

C

Feedback:

The average pulse rate of an infant ranges from 100 to 160 beats per minute.

2.

A patient has had a left-side mastectomy. How does this affect the blood pressure assessment?

A)

Assess the blood pressure in the wrist

B)

There is no effect on the blood pressure

C)

Assessment of blood pressure is impeded

D)

The blood pressure stays within normal range

Ans:

C

Feedback:

If the patient has had a mastectomy, blood-pressure monitoring on the same side can further impede circulation, contributing to lymphedema.

3.

A patient has smoked most of his life and has labored respirations. He is experiencing

A)

Dyspnea

B)

Fremitus

C)

Stridor

D)

Wheeze

Ans:

A

Feedback:

Dyspnea describes respirations that require excessive effort.

4.

Patients demonstrating apnea have

A)

Usually have a temporary cessation of breathing

B)

Decreased rate and depth of respirations

C)

Increased rate and depth of respirations

D)

Normal respiratory rate of 20

Ans:

A

Feedback:

Apnea, the absence of respirations, is often described by the length of time in which respirations do not occur.

5.

A pulse deficit is the difference between

A)

The systolic and diastolic blood pressure readings

B)

Palpated and auscultated blood pressure readings

C)

The radial pulse and the ulnar pulse rates

D)

The apical pulse and the radial pulse rate

Ans:

D

Feedback:

When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate.

6.

An adult pulse greater than 100 beats per minute is

A)

Bradycardia

B)

Bradypnea

C)

Tachycardia

D)

Tachypnea

Ans:

C

Feedback:

Adult pulse rates above 100 beats per minute are termed tachycardia.

7.

An ultrasonic Doppler is used for

A)

Auscultating a pulse that is difficult to palpate

B)

Auscultating diastolic blood pressure

C)

Aiding palpation of pulse and rhythm

D)

Aiding palpation of diastolic blood pressure

Ans:

A

Feedback:

A Doppler device can be used to detect a pulse that is not easily palpable.

8.

A nurse can most accurately assess a patients heart rate and rhythm by which of the following methods?

A)

Listen with the stethoscope at the fifth intercostals space left mid-clavicular line

B)

Listen with the stethoscope at the fifth intercostals space at the sternum

C)

Listen with a stethoscope at the neck to the right of the cricoid process

D)

Listen with a stethoscope at the second intercostal space left sternum

Ans:

A

Feedback:

To assess the apical pulse, the nurse places the stethoscope over the left ventricle. The stethoscope is placed at the level of the fifth intercostals space left mid-clavicular line.

9.

A nurse is assessing an apical pulse on a cardiac patient. The patient is taking digoxin. The nurse can anticipate that the digoxin will

A)

Decrease the blood glucose

B)

Decrease the blood volume

C)

Decrease the apical pulse

D)

Decrease the respiratory rate

Ans:

C

Feedback:

Certain cardiac medications, such as digoxin, decrease the heart rate.

10.

Infants and childrens pulses vary most with

A)

Respirations

B)

Rest

C)

Eating

D)

Sleep

Ans:

A

Feedback:

The heart rhythm in infants and children varies markedly with respiration, increasing during inspiration and decreasing with expiration.

11.

To assess the patients pulse, the nurse knows the normal range for pulse rate of a healthy adult is

A)

50100 beats per minute

B)

60100 beats per minute

C)

60120 beats per minute

D)

70120 beats per minute

Ans:

B

Feedback:

In adults, the SA node initiates the impulse 60 to 100 times per minute.

12.

Of the following patients, who should not have a temperature assessed rectally?

A)

Patient with ALS

B)

Patient with cancer

C)

Patient with diarrhea

D)

Patient with a herniated disc

Ans:

C

Feedback:

The rectal route is contraindicated in patients with diarrhea, those who have undergone rectal surgery, those with rectal diseases, and those with cancer who are neutropenic.

13.

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?

A)

3:00 AM

B)

11:00 AM

C)

3:00 PM

D)

5:00 PM

Ans:

D

Feedback:

Body temperature fluctuates throughout the day. Temperature is usually lowest around 3 AM and highest from 5 to 7 PM.

14.

An 80-year-old patient has a body temperature of 97F. Which condition best accounts for this patients temperature reading?

A)

Altered endocrine function

B)

Hypothyroidism

C)

Temperature drops with age

D)

The patient is anemic

Ans:

C

Feedback:

It is not uncommon for elderly persons to have body temperatures less than 97.6 because normal temperature drops as a person ages.

15.

Body temperature regulation occurs in a part of the brain known as the

A)

Hypophysis

B)

Hypothalamus

C)

Pineal gland

D)

Thalamus

Ans:

B

Feedback:

The hypothalamus, located in the pituitary gland in the brain, is the bodys built-in thermostat.

16.

When assessing an infants axillary temperature, it will be

A)

One degree lower than an oral temperature

B)

One degree higher than a rectal temperature

C)

One degree higher than an oral temperature

D)

The same as the tympanic temperature

Ans:

A

Feedback:

Rectal temperatures may be one degree higher than oral temperatures, and axillary temperatures are one degree lower than oral temperatures.

17.

The temperature is 102 during a heat wave. The nurse can expect admissions to the emergency room to present with

A)

Increased temperature

B)

Increased cardiac output

C)

Decreased heart rate

D)

Decreased respirations

Ans:

A

Feedback:

Body temperature can fluctuate with exercise, changes in hormone levels, changes in metabolic rate, and extremes of external temperature.

18.

The normal adult temperature obtained through the oral route ranges from

A)

96.698.6 F

B)

97.699.6 F

C)

98.6100.4 F

D)

98.2100.2 F

Ans:

B

Feedback:

Normal adult oral temperature ranges from 97.699.6 F.

19.

A patient in the acute care setting is noted with a rapid, thready pulse. This patient will require

A)

Transfer to the critical care unit

B)

Assessment of cardiac output

C)

Vital sign assessment every hour

D)

An EKG ordered by the physician

Ans:

C

Feedback:

The nurse caring for the patient may decide to monitor vital signs more frequently if the patients condition changes.

20.

During a routine vital sign assessment, you note the patients blood pressure is 212/110. Why is this finding particularly significant?

A)

It allows the nurse to have a baseline value

B)

It deviates from normal and is significant

C)

It is due to the fact the patient is fearful

D)

It is related to a tumor of the adrenal

Ans:

B

Feedback:

Vital sign trends that deviate from normal are much more significant than isolated abnormal values.

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