Chapter 31: Vital Signs Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

1. Pneumonia has developed in a client, and his temperature has increased to 37.7 C. The client is shivering and feels uncomfortable. The nurse should:

a.

Apply a hypothermia mattress

b.

Apply hot packs to the axilla and groin

c.

Wrap the clients extremities

d.

Restrict fluids

ANS: c

c. Wrapping the clients extremities has been recommended to reduce the incidence and intensity of shivering.

a. Hypothermia blankets may be used to reduce fever, but if the client is already shivering, a hypothermia blanket is not used, as further stimulation of shivering should be avoided.

b. Hot packs should not be applied to the clients axilla and groin.

d. Fluids should not be restricted, but increased to replace fluids lost because of the fever.

REF: Text Reference: p. 634

2. The client comes to the emergency department after having been in the sun for an extended period. The nurse also determines that the client is taking a diuretic. Heat stroke is suspected, and the nurse observes for:

a.

Diaphoresis

b.

Confusion

c.

Temperature of 36 C

d.

Decreased heart rate

ANS: b

b. Confusion is a symptom of heatstroke, along with delirium, nausea, muscle cramps, visual disturbances, and even incontinence.

a. The most important sign of heatstroke is hot, dry skin, not diaphoresis. Victims of heatstroke do not sweat because of severe electrolyte loss and hypothalamic malfunction.

c. A normal temperature is 36 C to 38 C. With heatstroke the clients body temperature may reach as high as 45 C.

d. The heart rate is increased with heatstroke, not decreased.

REF: Text Reference: p. 622

3. A construction worker is seen in the emergency department with low blood pressure, normal pulse, diaphoresis, and weakness. These are clinical signs of:

a.

Heat exhaustion

b.

Heat stroke

c.

Heat cramp

d.

Hypothermia

ANS: a

a. The client is exhibiting signs of heat exhaustion (i.e., symptoms of fluid volume deficit).

b. If the client were experiencing heatstroke, the client would have an increased pulse and would not be sweating.

c. Muscle cramps are related to heatstroke. The client is not exhibiting signs consistent with heatstroke.

d. The client is not exhibiting signs of hypothermia such as shivering, loss of memory, or cyanosis.

REF: Text Reference: p. 623

4. The nurse is ready to take vital signs on a 6-year-old child. The child has just enjoyed a grape Popsicle. An appropriate action would be to:

a.

Take the rectal temperature

b.

Take the oral temperature as planned

c.

Have the child rinse out the mouth with warm water

d.

Wait 20 minutes and take the oral temperature

ANS: d

d. The nurse should wait 20 to 30 minutes before measuring the oral temperature.

a. The nurse should wait, rather than measuring the childs temperature rectally, as this is not an emergency situation.

b. Taking the oral temperature at this time would result in an inaccurate reading.

c. Rinsing the mouth with warm water also may provide an inaccurate reading of the childs actual body temperature. The nurse should wait 20 minutes and measure the childs oral temperature.

REF: Text Reference: p. 624

5. The client is seen in the emergency department for heat exhaustion as a result of exposure. The nurse anticipates that treatment will include:

a.

Replacement of fluid and electrolytes

b.

Antibiotic therapy

c.

Hypothermia wraps

d.

Alcohol baths

ANS: a

a. The treatment of heat exhaustion includes transporting the client to a cooler environment and restoring fluid and electrolyte balance.

b. Antibiotic therapy is not warranted.

c. Hypothermia wraps are not used to treat heat exhaustion.

d. Alcohol baths are not recommended.

REF: Text Reference: p. 623

6. The nurse is aware that the appropriate site for taking a pulse on 2-year-old is:

a.

Radial

b.

Apical

c.

Femoral

d.

Pedal

ANS: b

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

a. The radial pulse is not the best site for assessing a 2-year-olds pulse.

c. The femoral pulse is not the best site for assessing a 2-year-olds pulse.

d. The pedal pulse is not the best site for assessing a 2-year-olds pulse.

REF: Text Reference: p. 635

7. The client appears to be breathing faster than before. The nurse should:

a.

Ask the client if there have been any stressful visitors

b.

Have the client lie down

c.

Count the rate of respirations

d.

Take the radial pulse

ANS: c

c. The first action the nurse should take is to assess the clients respiratory rate. The nurse can then determine if it is within normal limits and will be able to compare it with the previous measurement to determine if the client is breathing faster than before.

a. Stress may increase an individuals respiratory rate. The nurse should first make the objective measurement of the clients rate.

b. Having the client lie down may decrease a clients respiratory rate, but the nurse should first assess the client before implementing any nursing measures.

d. The nurse should count the respirations. Based on these findings, the nurse may or may not need to take the clients pulse. Assessing the pulse will not verify whether the client is breathing faster than before.

REF: Text Reference: p. 618

8. A client complains of pain and asks the nurse for pain medication. The nurse first assesses vital signs and finds them to be as follows: Blood pressure, 134/92; pulse, 90; and respirations, 26. The nurses most appropriate action is to:

a.

Give the medication

b.

Ask if the client is anxious

c.

Check the clients dressing for bleeding

d.

Recheck the clients vital signs in 30 minutes

ANS: a

a. The clients vital signs are consistent with the client being in pain. It would be safe and appropriate for the nurse to give the pain medication.

b. Asking if the client is anxious is not the most appropriate action.

c. The client is not demonstrating signs of shock (i.e., decreased blood pressure, increased pulse). The most appropriate action is for the nurse to administer pain medication.

d. This would not be the most appropriate action. The nurse should medicate the client for pain.

REF: Text Reference: p. 642, Text Reference: p. 644, Text Reference: p. 653

9. The client has bilateral casts on the upper extremities, so the nurse will be measuring the blood pressure in the leg. The nurse expects the diastolic pressure to be:

a.

10 to 40 mm Hg higher than in the brachial artery

b.

20 to 30 mm Hg lower than in the brachial artery

c.

50 mm Hg higher than in the brachial artery

d.

Essentially the same as that in the brachial artery

ANS: d

d. When measuring the blood pressure in the legs, systolic pressure is usually higher by 10 to 40 mm Hg than that in the brachial artery, but the diastolic pressure is the same.

a. The systolic pressure, not the diastolic pressure, is 10 to 40 mm Hg higher than in the brachial artery.

b. This is not a true statement.

c. This is not a true statement.

REF: Text Reference: p. 661, Text Reference: p. 662

10. An 84-year-old diabetic client is admitted for insulin regulation. Which of the following blood pressure, pulse, and respiration measurements, respectively, is considered to be within the expected limits for a client of this age?

a.

BP, 138/88; P, 68; R, 16

b.

BP, 94/52; P, 68; R, 30

c.

BP, 108/80; P, 112; R, 15

d.

BP, 132/74; P, 90; R, 24

ANS: a

a. These measurements are within the expected limits for an older client. An adults average blood pressure is 120/80. The systolic pressure may increase with age, but the blood pressure should not exceed 140/90. The range for an adults pulse is 60- to 100 beats per minute. The expected respiratory rate is 16 to 25 breaths per minute.

b. These are not within the expected limits for a client of this age.

c. These are not within the expected limits for a client of this age.

d. These are not within the expected limits for a client of this age.

REF: Text Reference: p. 641, Text Reference: p. 653, Text Reference: p. 665

11. The student nurse is assessing the vital signs of a 10-year-old client. The expected values for a client of this age are:

a.

P, 140; R, 50; BP, 80/50

b.

P, 100; R, 40; BP, 90/60

c.

P, 80; R, 22; BP, 110/70

d.

P, 60; R, 12; BP, 160/90

ANS: c

c. These are expected findings of a 10-year-old client. The normal pulse range for a 10-year-old is 75 to 100 beats per minute; the normal respiratory rate is 20 to 30 breaths per minute. The expected blood pressure range for a 7-year-old is 87 to 117/48 to 64; children who are larger (i.e., heavier and/or taller) have higher blood pressures. The average blood pressure for a 10-year-old is 110/65 mm Hg.

a. These are not expected values of a 10-year-old client.

b. These are not expected values of a 10-year-old client.

d. These are not expected values of a 10-year-old client.

REF: Text Reference: p. 641, Text Reference: p. 647, Text Reference: p. 652, Text Reference: p. 653

12. The nurse has just taken vital signs for the 30-year-old client. Based on the results, the nurse will report the following finding that is out of the expected range for a client of this age:

a.

T, 37.4 C

b.

P, 110

c.

R, 20

d.

BP, 120/76

ANS: b

b. The expected pulse range for an adult is 60 to 100 beats per minute. This clients pulse is elevated at 110 beats per minute.

a. This clients temperature is within the normal range of 36 C to 38 C for an adult.

c. This clients respiratory rate is within the normal range of 12 to 20 for an adult.

d. This clients blood pressure reading is within the normal range of less than or equal to 120/80 for an adult.

REF: Text Reference: p. 641

13. In teaching a client at home to assess accurately the axillary temperature of a 11/2-year-old child with a glass thermometer, the nurse should tell the parent to:

a.

Hold the thermometer at the bulb end

b.

Clean the thermometer in hot water

c.

Leave the thermometer in place for 3 to 5 minutes

d.

Let the child hold the thermometer

ANS: c

c. When assessing a clients axillary temperature with a glass thermometer, the thermometer should be left in place for 3 to 5 minutes.

a. The thermometer should be held at the opposite end of the bulb.

b. The thermometer should be covered with a plastic sheath when in use, and after use, the plastic sheath is discarded. If the thermometer requires cleaning, the nurse should not use hot water, as it could cause the thermometer to break.

d. The parent, not the child, should hold the thermometer. A 11/2-year-old client may drop the thermometer, creating a mercury spill.

REF: Text Reference: p. 630

14. The postoperative vital signs of an average size adult client are BP, 110/68; P, 54; R, 8. The client appears pale, disoriented, and has minimal urinary output. The nurse should:

a.

Re-take the vital signs in 30 minutes

b.

Continue with care as planned

c.

Administer a stimulant

d.

Notify the physician

ANS: d

d. The nurse should notify the physician, as these are abnormal findings. The clients respirations are becoming dangerously low at 8 (normal, 12 to 20 breaths per minute). The clients pulse is low at 54 (expected, 60 to 100 beats per minute), and the blood pressure should be equal to or less than 120/80, which it is at 110/68. The additional assessment findings also are not normal and should be reported to the physician.

a. The nurse should not wait another 30 minutes to re-take vital signs. The present readings warrant notifying the physician.

b. These are abnormal findings. The nurse should not continue with care as planned.

c. The nurse should first notify the physician. Administering a stimulant would require a physicians order and may not be what the client requires. For example, the client may need a narcotic antagonist rather than a stimulant.

REF: Text Reference: p. 644

15. A client has just gotten out of bed to go to the bathroom. As the nurse enters the room, the client says, I feel dizzy. The nurse should:

a.

Go for help

b.

Take the clients blood pressure

c.

Assist the client to sit down

d.

Tell the client to take deep breaths

ANS: c

c. The nurses primary concern should be the patients safety and preventing an accidental fall. If the client just got up from bed and is complaining of dizziness, the client may be experiencing orthostatic hypotension. The nurse should first assist the client to sit down before performing any other assessment.

a. The nurse should not leave the client and go for help. The nurse should assist the client to a sitting position. If help is required, the nurse can then put on the clients call light.

b. The nurse may take the clients blood pressure after assisting the client to a sitting position to prevent the client from falling.

d. The nurse should first assist the client to sit down to prevent the client from falling accidentally. The nurse may then assess the client. If the nurse finds during the assessment that the clients result from pulse oximetry is low, the nurse may instruct the client to take deep breaths.

REF: Text Reference: p. 654

16. The nurse explains to the nurse assistant that a false high blood pressure reading may be assessed if the assistant:

a.

Wraps the cuff too loosely around the arm

b.

Deflates the cuff too quickly

c.

Repeats the BP assessment too soon

d.

Presses the stethoscope too firmly in the antecubital fossa

ANS: a

a. If the cuff is wrapped too loosely or unevenly around the arm, the effect on the blood pressure measurement may be a false high reading.

b. A false low systolic and false high diastolic blood pressure reading may occur if the cuff is deflated too quickly.

c. A false high systolic reading may be obtained if the blood pressure assessment is repeated too soon.

d. A false low diastolic reading may be obtained if the stethoscope is applied too firmly against the antecubital fossa.

REF: Text Reference: p. 662

17. The client is febrile, and the temperature must be reduced. The nurse anticipates that treatment will include:

a.

An alcohol and water bath

b.

Ice packs to the axillae and groin

c.

Cool, plain water sponges

d.

A cooling blanket

ANS: d

d. Blankets cooled by circulating water delivered by motorized units increase conductive heat loss. Cooling blankets are used to reduce a fever.

a. Bathing with an alcohol/water solution is not recommended because it may lead to shivering. Shivering is counterproductive and can increase energy expenditure up to 400%.

b. Ice packs to the axillae and groin are no longer recommended because they may induce shivering (which is counterproductive and increases the clients energy expenditure), and because it has no advantage over antipyretic medications.

c. Tepid sponge baths are no longer recommended because they may lead to shivering and are no more advantageous than administering antipyretics.

REF: Text Reference: p. 634

18. The nurse is alert to which of the following factors that lowers the blood pressure?

a.

Anxiety

b.

Heavy alcohol consumption

c.

Cigarette smoking

d.

Diuretic administration

ANS: d

d. Diuretics reduce blood pressure by reducing reabsorption of sodium and water by the kidneys, thus reducing circulating fluid volume.

a. The effects of sympathetic nerve stimulation, such as with anxiety, increase blood pressure.

b. Heavy alcohol consumption has been linked to hypertension.

c. Cigarette smoking has been linked to hypertension.

REF: Text Reference: p. 654

19. While the nurse is taking the clients blood pressure, the client asks if the reading is high. In accordance with the newest guidelines, the nurse informs the client that a blood pressure measurement that is consistent with hypertension is:

a.

120/70

b.

130/84

c.

120/78

d.

118/80

ANS: b

b. The diagnosis of pre-hypertension in adults is made when an average of two or more diastolic readings on at least two subsequent visits is between 80 and 89 mm Hg or when the average of multiple systolic blood pressures on two or more subsequent visits is between 120 and 139 mm Hg. Hypertension is noted with diastolic reading greater than 90 mm Hg and systolic readings greater than 140 mm Hg. According to the newest guidelines, this clients blood pressure reading (130/84) would fall into the pre-hypertension category.

a. Normal is less than or equal to 120/80; this is a normal blood pressure reading.

c. Normal is less than or equal to 120/80; this is a normal blood pressure reading.

d. Normal is 120/80 or less; this is a normal blood pressure reading.

REF: Text Reference: p. 653

20. The nurse obtains the following results after measuring the clients vital signs: Blood pressure, 180/100; pulse, 82; R, 16; and rectal temp, 37.5 C. The nurse should:

a.

Re-take the blood pressure

b.

Re-take the temperature

c.

Report all of the findings immediately

d.

Record the findings as within normal limits

ANS: a

a. The normal blood pressure reading is 120/80 or less. This clients blood pressure is significantly higher at 180/100, and may be an indication of hypertension. (One elevated blood pressure measurement dos not qualify as a diagnosis of hypertension; it would have to be elevated on at least two separate occasions). The nurse should retake the blood pressure.

b. The clients temperature is within normal limits for a rectal temperature. The average rectal temperature is 37.5 C.

c. The client should repeat the blood pressure to confirm the reading before reporting the findings.

d. The blood pressure reading is not within normal limits. The pulse, respiratory rate, and temperature are within normal limits.

REF: Text Reference: p. 653

21. The client is identified by the nurse as having a remittent fever. The student asks what that means and the nurse explains that a remittent fever is:

a.

A constant body temperature above 100.4 F with little fluctuation

b.

Spikes in temperature that are interspersed with normal temperatures at least once within 24 hours

c.

Spikes and falls in temperature, but not back down to normal

d.

Periods of febrile episodes interspersed with normal temperatures

ANS: c

c. A remittent fever spikes and falls without a return to normal temperature levels.

a. A sustained fever is a constant body temperature continuously above 38 C (100.4 F) that demonstrates little fluctuation.

b. An intermittent has fever spikes interspersed with usual temperature levels. Temperature returns to acceptable value at least once in 24 hours.

d. A relapsing fever has periods of febrile episodes interspersed with acceptable temperature values.

REF: Text Reference: p. 622

22. The nurse is working in the newborn nursery. In planning for temperature measurement, the nurse will obtain the reading on the infants by using the:

a.

Rectal site

b.

Oral site

c.

Tympanic site

d.

Axillary site

ANS: d

d. The axillary site can be used with newborns and uncooperative clients.

a. The rectal site should not be used for routine vital signs in newborns.

b. The oral site should not be used with infants.

c. The tympanic site is questioned as being accurate in newborns.

REF: Text Reference: p. 630

23. A mercury-in-glass thermometer is being used to measure a clients blood pressure in the extended care facility. While taking the clients temperature, the thermometer falls and breaks on the floor without coming in contact with the nurse or client. The nurses first action is to:

a.

Remove the client from the area

b.

Remove the clients clothing

c.

Wash his or her hands and bathe the client

d.

Notify the environmental services department

ANS: a

a. The nurses first action is to remove the client from immediate contaminated environment.

b. After removing the client from the area, the nurse may remove any clothing or linen that has been contaminated with mercury.

c. The nurse should perform hand hygiene thoroughly after changing any clothing or linen that has been contaminated with mercury. It is not required that the client be bathed unless skin contact has occurred. The first action of the nurse is to remove the client from the area.

d. After caring for the client, the nurse should notify the environmental services department.

REF: Text Reference: p. 631

24. The nurse enters the room of a client who is being monitored with pulse oximetry. On review of the following factors, the nurse suspects that the values will be influenced by the:

a.

Placement of the sensor on the extremity

b.

Clients diagnosis of peripheral vascular disease

c.

Reduced amount of light in the room

d.

Increased temperature of the room

ANS: b

b. Peripheral vascular disease can reduce pulse volume, which may affect the pulse oximetry reading.

a. The sensor should be placed on an extremity site (such as an earlobe or digit) with adequate local circulation, and the site should be free of moisture.

c. Reduced light in the room will not affect the oximetry reading. Outside light sources can interfere with the oximeters ability to process reflected light.

d. An increased temperature of the room will not affect the oximetry reading. If the room was very cold, the clients peripheral blood flow may decrease, affecting the oximetry reading.

REF: Text Reference: p. 651

25. An individual contacts the emergency room of the local hospital to ask what to do for a skiing partner who appears to be suffering from hypothermia. The victim is alert and able to respond to questions. The nurse instructs the individual who has called to have the victim:

a.

Take sips of brandy

b.

Drink warm soup

c.

Drink a cup of very hot coffee

d.

Run the affected extremities under hot water

ANS: b

b. A conscious client benefits from drinking hot liquids such as soup.

a. Alcohol should be avoided.

c. Caffeinated fluids should be avoided.

d. Extremities should be warmed gradually. Tissue damage could occur if placed under hot water. The entire body should be warmed, such as by putting heating pads next to the head and neck, which lose heat the quickest.

REF: Text Reference: p. 635

26. The visiting nurse is evaluating the measurement of the clients blood pressure by his spouse. The nurse determines that additional teaching is required if the spouse is observed:

a.

Deflating the cuff at 2 mm Hg per second

b.

Having the client sit down for the measurement

c.

Using the same time each day for the measurement

d.

Taking the blood pressure after the client comes back from a walk

ANS: d

d. The clients blood pressure should not be measured after the client has exercised, smoked, or ingested caffeine. The client should wait 30 minutes before assessment of the blood pressure.

a. The cuff should be deflated at a rate of 2 mm Hg per second.

b. When possible, the client should be sitting in a chair.

c. The blood pressure should be assessed at the same time each day.

REF: Text Reference: p. 655

27. The client has bilateral casts on the upper extremities, so the nurse will be measuring the blood pressure in the leg. The nurse palpates the pulse before the measurement at the:

a.

Popliteal fossa behind the knee

b.

Inner side of the ankle below the medial malleolus

c.

Top of the foot between the extension tendons of the great toe

d.

Inguinal ligament midway between the symphysis pubis and the anterior superior iliac spine

ANS: a

a. The popliteal artery, palpable behind the knee in the popliteal space, is the site for auscultation when taking the blood pressure in the leg.

b. This is not the correct site for assessment before measuring the blood pressure in the leg.

c. This is not the correct site for assessment.

d. This is not the correct site for assessment.

REF: Text Reference: p. 661

28. The student is preparing to take the clients apical pulse. The nurse instructs the student to place the stethoscope along the left clavicular line at the:

a.

Second to third intercostal space

b.

Third to fourth intercostal space

c.

Fourth to fifth intercostal space

d.

Fifth to sixth intercostal space

ANS: c

c. An apical pulse should be assessed at the clients PMI. The PMI is located at the intercostal space 4 to 5 at the left midclavicular line.

a. This is not the correct placement for auscultating a clients apical pulse.

b. The PMI is higher and more medial in children younger than 8 years. The client is not identified as being a child.

d. This is not the correct placement for auscultating a clients apical pulse.

REF: Text Reference: p. 638

29. The nurse enters the room to measure the clients pulse rate. The nurse recognizes that the clients rate may be increased as a result of:

a.

A febrile condition

b.

Administration of digoxin

c.

The clients athletic conditioning

d.

Unrelieved severe postoperative pain

ANS: a

a. Fever and heat may increase a clients pulse rate.

b. Digoxin is a negative chronotropic drug; it will decrease the clients pulse rate.

c. A conditioned athlete who participates in long-term exercise will have a lower heart rate at rest.

d. Unrelieved severe pain increases parasympathetic stimulation, decreasing the heart rate.

REF: Text Reference: p. 642

30. On entering the room, the nurse notes that the client has an irregular respiratory rate, with periods of apnea and increases in respiration, followed by a reversal of the pattern. The nurse reports this respiratory assessment as:

a.

Biots respirations

b.

Kussmauls respirations

c.

Hyperpneic respirations

d.

Cheyne-Stokes respirations

ANS: d

d. Cheyne-Stokes respirations are characterized by an irregular respiratory rate with alternating periods of apnea and hyperventilation. The respiratory cycle begins with slow, shallow breaths that gradually increase to an abnormal rate and depth. The pattern then reverses, breathing slows and becomes shallow, and the pattern climaxes in apnea before respiration resumes.

a. Biots respirations are abnormally shallow for two to three breaths, followed by an irregular period of apnea.

b. Kussmauls respirations are abnormally deep, regular, and increased in rate.

c. Hyperpneic respirations are labored, increased in depth, and increased in rate (more than 20 breaths per minute). Occurs normally during exercise.

REF: Text Reference: p. 648

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