Chapter 29: Vital Signs Nursing School Test Banks

Test Bank

MULTIPLE CHOICE

1. The posterior hypothalamus helps control temperature by

a.

Causing vasoconstriction.

b.

Shunting blood to the skin and extremities.

c.

Increasing sweat production.

d.

Causing vasodilation.

ANS: A

If the posterior hypothalamus senses that the bodys temperature is lower than the set point, the body initiates heat conservation mechanisms. Vasoconstriction of blood vessels reduces blood flow to the skin and extremities. The anterior hypothalamus controls heat loss by inducing sweating, vasodilation of blood vessels, and inhibition of heat production.

DIF: Remember REF: 443

OBJ: Explain the principles and mechanism of thermoregulation.

TOP: Assessment MSC: Teaching/Learning

2. Of the following mechanisms of heat loss by the body, identify the mechanism that transfers heat away by using air movement?

a.

Radiation

b.

Conduction

c.

Convection

d.

Evaporation

ANS: C

Convection is the transfer of heat away from the body by air movement. Conduction is the transfer of heat from one object to another with 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.

DIF: Understand REF: 443-444

OBJ: Explain the principles and mechanism of thermoregulation.

TOP: Assessment MSC: Teaching/Learning

3. The patient has a temperature of 105.2 F. The nurse is attempting to lower his temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. The nurse is attempting to lower the patients temperature through the use of

a.

Radiation.

b.

Conduction.

c.

Convection.

d.

Evaporation.

ANS: B

Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss. 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.

DIF: Apply REF: 443-444

OBJ: Explain the principles and mechanism of thermoregulation.

TOP: Implementation MSC: Caring

4. When focusing on temperature regulation of newborns and infants, the nurse understands that

a.

Temperatures are basically the same for infants and older adults.

b.

Infants have well-developed temperature-regulating mechanisms.

c.

The normal temperature range gradually increases as the person ages.

d.

Newborns need to wear a cap to prevent heat loss.

ANS: D

A newborn loses up to 30% of body heat through the head and therefore needs to wear a cap to prevent heat loss. Temperature control mechanisms in newborns are immature and respond drastically to changes in the environment. The normal temperature range gradually drops as individuals approach older adulthood.

DIF: Understand REF: 444

OBJ: Describe nursing measures that promote heat loss and heat conservation.

TOP: Assessment MSC: Teaching/Learning

5. The nurse is working the night shift on a surgical unit and is making 4 AM rounds. She notices that the patients temperature is 96.8 F (36 C), whereas at 4 PM the preceding day, it was 98.6 F (37 C). What should the nurse do?

a.

Call the physician immediately to report a possible infection.

b.

Realize that this is a normal temperature variation.

c.

Provide another blanket to conserve body temperature.

d.

Provide medication to lower the temperature further.

ANS: B

Body temperature normally changes 0.5 C to 1 C (0.9 F to 1.8 F) during a 24-hour period and is usually lowest between 1:00 and 4:00 AM, making this variation normal for the time of day. Unless the patient is complaining of being cold, there is no physiological need for providing an extra blanket or medication to lower the body temperature further. There is also no need to call a physician to report a normal temperature variation.

DIF: Apply REF: 445

OBJ: Describe nursing measures that promote heat loss and heat conservation.

TOP: Implementation MSC: Nursing Process

6. The nurse is caring for a patient who has a temperature reading of 100.4 F (38 C). His last two temperature readings were 98.6 F (37 C) and 96.8 F (36 C). The nurse should

a.

Call the physician and anticipate an order to treat the fever.

b.

Assume that the patient has an infection and order blood cultures.

c.

Wait an hour and recheck the patients temperature.

d.

Be aware that temperatures this high are harmful and affect patient safety.

ANS: C

Waiting an hour and rechecking the patients temperature would be the most appropriate action in this case. A fever usually is 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. Mild temperature elevations enhance the bodys immune system by stimulating white blood cell production. Usually, staff nurses do not order blood cultures, and nurses should base actions on knowledge, not on assumptions.

DIF: Apply REF: 445

OBJ: Describe nursing measures that promote heat loss and heat conservation.

TOP: Implementation MSC: Nursing Process

7. When heat loss mechanisms of the body are unable to keep pace with excess heat production, the result is known as

a.

Pyrexia.

b.

The plateau phase.

c.

The set point.

d.

Becoming afebrile.

ANS: A

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. The set point is the temperature point determined by the hypothalamus. When pyrogens trigger immune system responses, the hypothalamus reacts to raise the set point, and the body produces and conserves heat. During the plateau phase, chills subside and the person feels warm and dry as heat production and loss equilibrate at the new level. When the fever breaks, the patient becomes afebrile.

DIF: Remember REF: 445

OBJ: Discuss physiological changes associated with fever. TOP: Assessment

MSC: Nursing Process

8. The nurse is caring for a patient who has an elevated temperature. The nurse understands that

a.

Fever and hyperthermia are the same thing.

b.

Hyperthermia occurs when the body cannot reduce heat loss.

c.

Hyperthermia is an upward shift in the set point.

d.

Hyperthermia occurs when the body cannot reduce heat production.

ANS: D

Fever and hyperthermia are not the same things. An elevated body temperature related to the bodys inability to promote heat loss or reduce heat production is hyperthermia. Fever is an upward shift in the set point. Hyperthermia is not a shift in the set point.

DIF: Understand REF: 446

OBJ: Discuss physiological changes associated with fever. TOP: Assessment

MSC: Nursing Process

9. The patient is restless with a temperature of 102.2 F (39 C). One of the first things the nurse should do is

a.

Place the patient on oxygen.

b.

Restrict fluid intake.

c.

Increase patient activity.

d.

Increase patients metabolic rate.

ANS: A

During a fever, cellular metabolism increases and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Interventions during a fever include oxygen therapy. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for fluid volume deficit. Fluids should not be restricted. Increasing activity would increase the metabolic rate further, which would not be advisable.

DIF: Apply REF: 446

OBJ: Discuss physiological changes associated with fever. TOP: Implementation

MSC: Nursing Process

10. The patient requires temperatures to be taken every two hours. Which of the following cannot be delegated to nursing assistive personnel?

a.

Selecting appropriate route and device

b.

Obtaining temperature measurement at ordered frequency

c.

Being aware of the usual values for the patient

d.

Assessing changes in body temperature

ANS: D

The nurse is responsible for assessing changes in body temperature. The nurse instructs nursing assistive personnel to select the appropriate route and device to measure temperature, to obtain temperature measurement at ordered frequency, and to be aware of the usual values for the patient.

DIF: Apply REF: 467

OBJ: Accurately assess tympanic, oral, rectal, and axillary temperatures.

TOP: Implementation MSC: Nursing Process

11. The patient requires routine temperature assessment but is confused and easily agitated and has a history of seizures. The nurses best option would be to take his temperature

a.

Orally.

b.

Tympanically.

c.

Rectally.

d.

By the axillary method.

ANS: B

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 epilepsy. Rectal temperatures require positioning and may increase patient agitation. Axillary temperatures need long measurement times and continuous positioning by the nurse. The patients agitation state may not allow for long periods of attention.

DIF: Apply REF: 448

OBJ: Accurately assess tympanic, oral, rectal, and axillary temperatures.

TOP: Implementation MSC: Nursing Process

12. The patient is being admitted to the emergency department following a motor vehicle accident. His jaw is broken, and he has several broken teeth. He is ashen, and his skin is cool and diaphoretic. To obtain an accurate temperature, the nurse uses which of the following routes?

a.

Oral

b.

Axillary

c.

Rectal

d.

Temporal

ANS: C

The rectal route is argued to be more reliable when oral temperature cannot be obtained. 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.

DIF: Apply REF: 448

OBJ: Accurately assess tympanic, oral, rectal, and axillary temperatures.

TOP: Implementation MSC: Nursing Process

13. The nurse is caring for an infant and is obtaining the patients vital signs. The best site for the nurse to obtain the infants pulse would be the _____ artery.

a.

Radial

b.

Brachial

c.

Femoral

d.

Popliteal

ANS: B

The brachial or apical pulse is the best site for assessing an infants or a young childs pulse because other peripheral pulses such as the radial, femoral, and popliteal arteries are deep and are difficult to palpate accurately.

DIF: Apply REF: 453

OBJ: Accurately assess pulse, respirations, oxygen saturation, and blood pressure.

TOP: Implementation MSC: Nursing Process

14. The patient is found to be unresponsive and not breathing. To determine the presence of central blood circulation and circulation of blood to the brain, the nurse checks the patients _____ pulse.

a.

Radial

b.

Brachial

c.

Posterior tibial

d.

Carotid

ANS: D

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 lower arm. The posterior tibial pulse is used to assess the status of circulation to the foot.

DIF: Apply REF: 453

OBJ: Accurately assess pulse, respirations, oxygen saturation, and blood pressure.

TOP: Implementation MSC: Nursing Process

15. The nurse needs to obtain a radial pulse from a patient. To obtain the correct measure, what must the nurse do?

a.

Place the tips of the first two fingers over the groove along the thumb side of the patients wrist.

b.

Place the thumb over the groove along the thumb side of the patients wrist.

c.

Apply a very light touch so that the pulse is not obliterated.

d.

Apply very strong pressure to detect the pulse.

ANS: A

Place the tips of the first two or middle three fingers of the hand over the groove along the radial or thumb side of the patients inner wrist. Fingertips are the most sensitive parts of the hand to palpate arterial pulsation. The thumb has a pulsation that interferes with accuracy. The pulse is more accurately assessed with moderate pressure. Too much pressure occludes the pulse and impairs blood flow.

DIF: Apply REF: 473

OBJ: Accurately assess pulse, respirations, oxygen saturation, and blood pressure.

TOP: Implementation MSC: Nursing Process

16. While the nurse is assessing the patients respirations, it is important for the patient to

a.

Be aware of the procedure being done.

b.

Not know that respirations are being assessed.

c.

Understand that respirations are estimated to save time.

d.

Not be touched until the entire process is finished.

ANS: B

Do not let a patient know that respirations are being assessed. A patient who is aware of the assessment can alter the rate and depth of breathing. Respirations are the easiest of all vital signs to assess, but they are often the most haphazardly measured. Do not estimate respirations. Accurate measurement requires observation and palpation of chest wall movement.

DIF: Apply REF: 456

OBJ: Accurately assess pulse, respirations, oxygen saturation, and blood pressure.

TOP: Implementation MSC: Nursing Process

17. The patients blood pressure is 140/60. The nurse realizes that this equates to a pulse pressure of

a.

140.

b.

60.

c.

80.

d.

200.

ANS: C

The difference between the systolic pressure and the diastolic pressure is the pulse pressure. For a blood pressure of 140/60, the pulse pressure is 80 (140 60 = 80). 140 is the systolic pressure. 60 is the diastolic pressure. 200 is the systolic (140) added to the diastolic (60), but this has no clinical significance.

DIF: Remember REF: 459

OBJ: Explain the physiology of normal regulation of blood pressure, pulse, oxygen saturation, and respirations. TOP: Implementation MSC: Nursing Process

18. The thickness or viscosity of the blood affects the ease with which blood flows through small vessels. The nurse examines what value, which might help determine the amount of blood viscosity?

a.

Hematocrit

b.

Cardiac output

c.

Arterial size

d.

Blood volume

ANS: A

The hematocrit, or the percentage of red blood cells in the blood, determines blood viscosity. Blood pressure also depends on the cardiac output or volume pumped by the heart, but cardiac output does not affect viscosity. Arterial size helps to modify blood pressure. The smaller lumen of a vessel increases vascular resistance but does not affect viscosity. Blood volume also affects blood pressure, but it does not directly affect viscosity.

DIF: Understand REF: 459

OBJ: Explain the physiology of normal regulation of blood pressure, pulse, oxygen saturation, and respirations. TOP: Assessment MSC: Nursing Process

19. The patient is being admitted to the emergency department with complaints of shortness of breath. The patient has had chronic lung disease for many years but still smokes. The nurse should

a.

Administer high levels of oxygen.

b.

Use oxygen cautiously in this patient.

c.

Place a paper bag over the patients face to allow rebreathing of carbon dioxide.

d.

Administer CO2 via mask.

ANS: B

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

DIF: Apply REF: 456

OBJ: Explain the physiology of normal regulation of blood pressure, pulse, oxygen saturation, and respirations. TOP: Implementation MSC: Nursing Process

20. Which statement is true of the ovulation phase?

a.

Progesterone levels are below normal.

b.

Body temperature is below baseline levels.

c.

Body temperature is at previous baseline levels or higher.

d.

Intense body heat and sweating occur.

ANS: C

Progesterone levels rise and fall cyclically during the menstrual cycle. When progesterone levels are low, the body temperature is a few tenths of a degree below the baseline. The lower temperature persists until ovulation occurs. During ovulation, greater amounts of progesterone enter the circulatory system and raise the body temperature to previous baseline levels or higher. These temperature variations help to predict a womans most fertile time to achieve pregnancy. Women who undergo menopause (cessation of menstruation) often experience periods of intense body heat and sweating lasting from 30 seconds to 5 minutes (hot flashes).

DIF: Remember REF: 444

OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, and blood pressure. TOP: Assessment MSC: Nursing Process

21. The nurse is caring for a patient who has a pulse rate of 44. His blood pressure is within normal limits. In trying to determine the cause of the patients low heart rate, the nurse would suspect

a.

That the patient would have a fever.

b.

Possible hemorrhage or bleeding.

c.

Calcium channel blockers or digitalis medications.

d.

Chronic obstructive pulmonary disease (COPD).

ANS: C

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 bodys need for oxygen, leading to an increased heart rate.

DIF: Understand REF: 455

OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, and blood pressure. TOP: Assessment MSC: Nursing Process

22. The patient was found unresponsive in her apartment and is being brought to the emergency department. She has arm, hand, and leg edema, her temperature is 95.6 F, and her hands are cold secondary to her history of peripheral vascular disease. It is reported that she has a latex allergy. To quickly measure the patients oxygen saturation, what should the nurse do?

a.

Attach a finger probe to the patients index finger.

b.

Place a nonadhesive sensor on the patients ear lobe.

c.

Attach a disposable adhesive sensor to the bridge of the patients nose.

d.

Place the sensor on the same arm that the electronic blood pressure cuff is on.

ANS: B

Select ear or bridge of nose if an adult patient has a history of peripheral vascular disease. Do not attach sensor to finger, ear, or bridge of nose if area is edematous or skin integrity is compromised. Do not use disposable adhesive probes if the patient has latex allergy. Do not attach probe to fingers that are hypothermic. Do not place sensor on the same extremity as electronic blood pressure cuff because blood flow to finger will be temporarily interrupted when cuff inflates.

DIF: Apply REF: 479

OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, and blood pressure. TOP: Implementation

MSC: Nursing Process

23. The patient is admitted with shortness of breath and chest discomfort. Which of the following laboratory values could account for the patients symptoms?

a.

Hemoglobin level of 8.0

b.

Hematocrit level of 45%

c.

Red blood cell count of 5.0 million/mm3

d.

Pulse oximetry of 90%

ANS: A

The concentration of hemoglobin reflects the patients capacity to carry oxygen. Normal hemoglobin levels range from 10 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.

DIF: Analyze REF: 458

OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, and blood pressure. TOP: Implementation

MSC: Nursing Process

24. Of the following values, which value would be considered prehypertension?

a.

98/50 in a 7-year-old child

b.

115/70 in an infant

c.

140/90 in an older adult

d.

120/80 in a middle-aged adult

ANS: D

An adults 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.

DIF: Evaluate REF: 459

OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, and blood pressure. TOP: Evaluation MSC: Nursing Process

25. The incidence of hypertension is greater in which of the following?

a.

Non-Hispanic Caucasians

b.

African Americans

c.

Asian Americans

d.

Native Americans

ANS: B

The incidence of hypertension is greater in diabetic patients, older adults, and African Americans.

DIF: Remember REF: 461

OBJ: Describe cultural and ethnic variations in blood pressure assessment.

TOP: Assessment MSC: Nursing Process

26. A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before she assesses the patients blood pressure?

a.

Neither caffeine nor smoking affects blood pressure.

b.

She needs to insist that the patient stop smoking for at least 3 hours.

c.

The nurse should have the patient perform mild exercises.

d.

Caffeine and smoking can cause false BP elevations.

ANS: D

Smoking immediately increases BP, and this increase lasts up to 15 minutes. Caffeine increases BP for up to 3 hours. Both affect a patients blood pressure. The patient should rest at least 5 minutes before BP is measured.

DIF: Understand REF: 481

OBJ: Describe cultural and ethnic variations in blood pressure assessment.

TOP: Implementation MSC: Nursing Process

27. When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. The nurse realizes that his rate is

a.

Normal for an infant.

b.

The proper rate for a toddler.

c.

Too slow for an infant.

d.

The same as that of a normal adult.

ANS: A

The normal rate for an infant is 120 to 160 beats/min. The rate obtained (145 beats/min) is within the normal range for an infant. The normal rate for a toddler is between 90 and 140 beats/min. The normal rate for an adult is between 60 and 100 beats/min.

DIF: Remember REF: 454

OBJ: Identify ranges of acceptable vital sign values for an infant, a child, and an adult.

TOP: Assessment MSC: Nursing Process

28. The nurse is caring for an elderly patient and notes that his temperature is 96.8 F (36 C). She understands that this patient is

a.

Suffering from hypothermia.

b.

Expressing a normal temperature.

c.

Hyperthermic relative to his age.

d.

Demonstrating the increased metabolism that accompanies aging.

ANS: B

The average body temperature of older adults is approximately 96.8 F (36 C). This is not hypothermia or hyperthermia. Older adults have poor vasomotor control, reduced amounts of subcutaneous tissue, and reduced metabolism. The end result is lowered body temperature.

DIF: Understand REF: 444

OBJ: Identify ranges of acceptable vital sign values for an infant, a child, and an adult.

TOP: Assessment MSC: Nursing Process

29. When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. Why is this preferable to methods used for adults?

a.

It is accurate even when the forehead is covered with hair.

b.

It is not affected by skin moisture.

c.

It reflects rapid changes in radiant temperature.

d.

There is no risk of injury to patient or nurse.

ANS: D

The temporal artery thermometer is especially beneficial when used in premature infants, newborns, and children because there is no risk of injury to the patient or nurse. However, it is inaccurate with head covering or hair on the forehead and is affected by skin moisture such as diaphoresis or sweating. It provides very rapid measurement and reflects rapid changes in core temperature, not radiant temperature.

DIF: Understand REF: 448

OBJ: Explain variations in technique used to assess an infants, a childs, and an adults vital signs.

TOP: Assessment MSC: Nursing Process

30. Which artery is the most appropriate for assessing the pulse of a small child?

a.

Radial

b.

Femoral

c.

Brachial

d.

Ulnar

ANS: C

The brachial or apical pulse is the best site for assessing an infants or a young childs pulse because other peripheral pulses are deep and difficult to palpate accurately.

DIF: Apply REF: 453

OBJ: Explain variations in technique used to assess an infants, a childs, and an adults vital signs.

TOP: Implementation MSC: Nursing Process

31. The nurse is caring for a newborn infant in the hospital nursery. She notices that the infant is breathing rapidly but is pink, warm, and dry. The nurse knows that the normal respiratory rate for a newborn is _____ breaths per minute.

a.

30 to 60

b.

25 to 32

c.

16 to 19

d.

12 to 20

ANS: A

The acceptable respiratory rate range for a newborn is 30 to 60 breaths per minute. An infant (6 months) is expected to have a rate between 30 and 50 breaths per minute. A toddlers respiratory range is 25 to 32 breaths per minute. A child should breathe 20 to 30 times a minute. An adolescent should breathe 16 to 19 times a minute. An adult should breathe 12 to 20 times a minute.

DIF: Remember REF: 454

OBJ: Explain variations in technique used to assess an infants, a childs, and an adults vital signs.

TOP: Assessment MSC: Nursing Process

32. While attempting to obtain oxygen saturation readings on a toddler, what should the nurse do?

a.

Place the sensor on the earlobe.

b.

Place the sensor on the bridge of the nose.

c.

Determine whether the toddler has a tape allergy.

d.

Ignore any variation between the oximeter pulse rate and the patients apical pulse rate.

ANS: C

The nurse should determine whether the patient has latex allergy because disposable adhesive probes should not be used on patients with latex allergies. Earlobe and bridge of the nose sensors should not be used on infants and toddlers because of skin fragility. Oximeter pulse rate and the patients apical pulse rate should be the same. Any difference requires re-evaluation of oximeter sensor probe placement and reassessment of pulse rates.

DIF: Apply REF: 479

OBJ: Explain variations in technique used to assess an infants, a childs, and an adults vital signs.

TOP: Implementation MSC: Nursing Process

33. The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed?

a.

Choose the cuff that says Child instead of Infant.

b.

Obtain the reading before the child has a chance to settle down.

c.

Use the diaphragm portion of the stethoscope to detect Korotkoff sounds.

d.

Explain to the child what the procedure will be.

ANS: D

Preparing the child for the blood pressure cuffs unusual sensation increases cooperation. Most children will understand the analogy of a tight hug on your arm. Different arm sizes require careful and appropriate cuff size selection. Do not choose a cuff based on the name of the cuff. An Infant cuff is too small for some infants. Readings are difficult to obtain in restless or anxious infants and children. Allow at least 15 minutes for children to recover from recent activities and become less apprehensive. Korotkoff sounds are difficult to hear in children because of low frequency and amplitude. A pediatric stethoscope bell is often helpful.

DIF: Apply REF: 462-463

OBJ: Explain variations in technique used to assess an infants, a childs, and an adults vital signs.

TOP: Implementation MSC: Nursing Process

34. One benefit of using a stationary automatic blood pressure device is that the cuff

a.

Fits over clothing.

b.

Is extremely reliable.

c.

Is the method of choice for irregular heart rhythms.

d.

Is more reliable when pressure is less than 90 mm Hg systolic.

ANS: A

The cuff fits over clothing. However, the reliability of stationary machines is limited. Electronic blood pressure measurement is not recommended with irregular heart rates or when blood pressure is less than 90 mm Hg systolic.

DIF: Remember REF: 465

OBJ: Describe the benefits and precautions involving self-measurement of blood pressure.

TOP: Assessment MSC: Nursing Process

35. The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take his blood pressure three times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. The nurse also instructs the patient that the

a.

Patient can apply the cuff in any manner he chooses because the machine is designed to be used by nonprofessionals.

b.

Machine requires frequent calibration to ensure accuracy.

c.

Cuff can be placed over clothing if necessary.

d.

Machine is accurate when blood pressures are low.

ANS: B

Electronic devices are easier to manipulate but require frequent recalibrationmore than once a year. Because of their sensitivity, improper cuff placement or movement of the arm causes electronic devices to give incorrect readings. Stationary blood pressure devices are often found in public places, and the cuff fits over clothing. The same is not true for portable devices. Electronic blood pressure measurement is not recommended when pressure is less than 90 mm Hg systolic.

DIF: Understand REF: 465

OBJ: Describe the benefits and precautions involving self-measurement of blood pressure.

TOP: Assessment MSC: Nursing Process

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

a.

Call the physician immediately.

b.

Perform an apical/radial pulse assessment.

c.

Apply more pressure to the radial artery to assess the pulse.

d.

Use his thumb to detect the patients pulse.

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 physician. The radial pulse is more accurately assessed with moderate pressure. Too much pressure occludes the pulse and impairs blood flow. Fingertips are the most sensitive parts of the hand to palpate arterial pulsations. The thumb has a pulsation of its own that interferes with accuracy.

DIF: Apply REF: 473 OBJ: Identify when to take vital signs.

TOP: Implementation MSC: Nursing Process

37. Of the following patients, which one is the best candidate to have his temperature taken orally?

a.

A 27-year-old postoperative patient with an elevated temperature

b.

A teenage boy who has just returned from outside for a smoke

c.

An 87-year-old confused male suspected of hypothermia

d.

A 20-year-old male with a history of epilepsy

ANS: A

An elevated temperature needs to be evaluated, and there is no contraindication in this patient. Ingestion of hot/cold fluids or foods, smoking, or receiving oxygen by mask/cannula can require delays in taking oral temperature. Oral temperatures are not taken for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills, nor for infants, small children, or confused patients.

DIF: Evaluate REF: 448 OBJ: Identify when to take vital signs.

TOP: Assessment MSC: Nursing Process

38. The physician order reads Lopressor (metoprolol) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic. The patients blood pressure is 92/66. The nurse does not give the medication and

a.

Does not tell the patient what the blood pressure is.

b.

Documents only what the blood pressure was.

c.

Documents that the medication was not given owing to low blood pressure.

d.

Does not need to inform the health care provider that the medication was held.

ANS: C

The nurse must document any interventions initiated as a result of vital sign measurement such as holding an antihypertensive drug. The nurse should inform the patient of the blood pressure value and the need for periodic reassessment of the blood pressure. Documenting the blood pressure only is not sufficient. Any intervention must be documented as well. Abnormal findings must be reported to the nurse in charge or to the health care provider.

DIF: Apply REF: 466| 483

OBJ: Accurately record and report vital sign measurements. TOP: Implementation

MSC: Nursing Process

39. After taking the patients temperature, the nurse documents the value and the route used to obtain the reading. Why is this done?

a.

Temperatures are the same regardless of the route used.

b.

Temperatures vary depending on the route used.

c.

Temperatures are cooler when taken rectally than when taken orally.

d.

Axillary temperatures are higher than oral temperatures.

ANS: B

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 C (0.9 F) lower than oral temperatures.

DIF: Understand REF: 447

OBJ: Accurately record and report vital sign measurements. TOP: Implementation

MSC: Nursing Process

40. When temperature assessment is required, which of the following cannot be delegated to nursing assistive personnel?

a.

Temperature measurement

b.

Assessment of changes in body temperature

c.

Selection of appropriate route and device

d.

Consideration of factors that falsely raise temperature

ANS: B

The skill of temperature measurement can be delegated. The nurse is responsible for assessing changes in body temperature. The nurse instructs nursing assistive personnel to select the appropriate route and device to measure temperature and to consider specific factors that falsely raise or lower temperature.

DIF: Understand REF: 467 OBJ: Appropriately delegate vital sign measurement.

TOP: Implementation MSC: Nursing Process

41. The nursing assistive person is taking vital signs and reports that a patients blood pressure is abnormally low. The nurse should

a.

Have the nursing assistive person retake the blood pressure.

b.

Ignore the report and have it rechecked at the next scheduled time.

c.

Retake the blood pressure herself and assess the patients condition.

d.

Have the nursing assistive person assess the patients other vital signs.

ANS: C

The nursing assistive person should report abnormalities to the nurse, who should further assess the patient. The nursing assistive person should not retake the blood pressure or other vital signs because the nurse needs to assess the patient. The report cannot be ignored. Assessment must be done by the nurse.

DIF: Apply REF: 480| 484 OBJ: Appropriately delegate vital sign measurement.

TOP: Implementation MSC: Nursing Process

MULTIPLE RESPONSE

1. Of the following sites, which are used for obtaining a core temperature? (Select all that apply.)

a.

Oral

b.

Rectal

c.

Tympanic

d.

Axillary

e.

Pulmonary artery

ANS: 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. Oral, rectal, axillary, and skin temperature sites rely on effective blood circulation at the measurement site.

DIF: Understand REF: 447

OBJ: Accurately assess tympanic, oral, rectal, and axillary temperatures.

TOP: Assessment MSC: Nursing Process

2. The patient has new-onset restlessness and confusion. His pulse rate is elevated, as is his respiratory rate. His oxygen saturation, however, is 94% according to the portable pulse oximeter. The nurse ignores the oximeter reading and calls the physician to obtain an order for an arterial blood gas (ABG). The nurse does this because many things can cause inaccurate pulse oximetry readings, including which of the following? (Select all that apply.)

a.

O2 saturations (SaO2) >70%

b.

Carbon monoxide inhalation

c.

Nail polish

d.

Hypothermia at the assessment site

e.

Intravascular dyes

ANS: B, C, D, E

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. Other factors include peripheral vascular disease (atherosclerosis), hypothermia at the assessment site, pharmacological vasoconstrictors (e.g., epinephrine), low cardiac output, hypotension, peripheral edema, and tight probes.

DIF: Understand REF: 458

OBJ: Accurately assess tympanic, oral, rectal, and axillary temperatures.

TOP: Assessment MSC: Nursing Process

3. The nurse is assessing the patient and his family for probable familial causes of the patients hypertension. The nurse begins by analyzing the patients personal history, as well as family history and current lifestyle situation. Which of the following issues would be considered risk factors? (Select all that apply.)

a.

Obesity

b.

Cigarette smoking

c.

Recent weight loss

d.

Heavy alcohol consumption

e.

Low blood cholesterol levels

ANS: A, B, D

Obesity, cigarette smoking, heavy alcohol consumption, high blood cholesterol and triglyceride levels, and continued exposure to stress are risk factors linked to hypertension. Weight loss and low blood cholesterol levels are not risk factors for hypertension.

DIF: Analyze REF: 466

OBJ: Describe cultural and ethnic variations in blood pressure assessment.

TOP: Evaluation MSC: Nursing Process

4. The patient is being encouraged to purchase a portable automatic blood pressure device so he can monitor his own blood pressure at home. What are some of the benefits of this? (Select all that apply.)

a.

Blood pressures can be obtained if pulse rates become irregular.

b.

Patients can provide information about patterns to health care providers.

c.

Patients can actively participate in their treatment.

d.

Self-monitoring helps with compliance and treatment.

e.

The risk of obtaining an inaccurate reading is decreased.

ANS: B, C, D

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.

DIF: Understand REF: 465 OBJ: Identify when to take vital signs.

TOP: Assessment MSC: Nursing Process

5. When recording the patients respiratory status, what must be recorded? (Select all that apply.)

a.

Respiratory rate

b.

Character of respirations

c.

Amount of oxygen therapy

d.

Only normal findings

e.

Only in the graphic section

ANS: A, B, C

Record respiratory rate and character in nurses notes or on vital sign flow sheet. Indicate type and amount of oxygen therapy if used during assessment. Document respiratory assessment after administration of specific therapies in narrative form in nurses notes. The nurse should document normal and abnormal findings.

DIF: Remember REF: 478

OBJ: Accurately record and report vital sign measurements. TOP: Implementation

MSC: Nursing Process

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