Chapter 32: Vital Signs Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 7th Edition

Test Bank

MULTIPLE CHOICE

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

1.

Apply hot packs to the axilla and groin

2.

Wrap the clients four extremities

3.

Restrict oral fluid consumption

4.

Apply a hypothermia mattress

ANS: 3

Wrapping the clients extremities has been recommended to reduce the incidence and intensity of shivering. Hot packs should not be applied to the clients axilla and groin. Fluids should not be restricted, but increased to replace fluids lost as a result of the fever. 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.

DIF: A REF: 506 OBJ: Comprehension

TOP: Nursing Process: Application

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

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

1.

Diaphoresis

2.

Confusion

3.

Temperature of 36 C

4.

Decreased heart rate

ANS: 2

Confusion is a symptom of heatstroke, along with delirium, nausea, muscle cramps, visual disturbances, and even incontinence. 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. A normal temperature is 36 to 38 C. With heatstroke the clients body temperature may reach as high as 45C. The heart rate is increased with heatstroke, not decreased.

DIF: A REF: 507 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

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

1.

Heatstroke

2.

Heat cramp

3.

Hypothermia

4.

Heat exhaustion

ANS: 4

The client is exhibiting signs of heat exhaustion (e.g., symptoms of fluid volume deficit). If the client were experiencing heatstroke, the client would have an increased pulse rate and would not be sweating. Muscle cramps are related to heatstroke. The client is not exhibiting signs consistent with heatstroke. The client is not exhibiting signs of hypothermia such as shivering, loss of memory, or cyanosis.

DIF: A REF: 508 OBJ: Comprehension

TOP: Nursing Process: Diagnosis

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

4. A 6-year-old boy has just eaten a grape popsicle and the nurse is ready to take vital signs. An appropriate action would be to:

1.

Take the rectal temperature

2.

Take the oral temperature as planned

3.

Have the child rinse out the mouth with warm water

4.

Wait 20 minutes before assessing the oral temperature

ANS: 4

The nurse should wait 20 to 30 minutes before measuring the oral temperature. The nurse should wait, rather than measuring the childs temperature rectally, as this is not an emergency situation. Taking the oral temperature at this time would result in an inaccurate reading. Rinsing the mouth with warm water may also provide an inaccurate reading of the childs actual body temperature. The nurse should wait 20 minutes and measure the childs oral temperature.

DIF: A REF: 510 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

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

1.

Replacement of fluid and electrolytes

2.

Initiation of oral antibiotic therapy

3.

Application of hypothermia wraps

4.

Alcohol sponge baths

ANS: 1

The treatment of heat exhaustion includes transporting the client to a cooler environment and restoring fluid and electrolyte balance. Antibiotic therapy is not warranted. Hypothermia wraps are not used to treat heat exhaustion. Alcohol baths are not recommended.

DIF: A REF: 508 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

6. The appropriate site for taking the pulse of a 2-year-old is:

1.

Radial

2.

Apical

3.

Femoral

4.

Pedal

ANS: 2

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

DIF: A REF: 521 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

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

1.

Ask the client if he has felt stressful

2.

Have the client lay down on the bed

3.

Count the clients rate of respirations

4.

Palpate the clients own radial pulse

ANS: 3

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 to the previous measurement to determine if the client is breathing faster than before. Stress may increase an individuals respiratory rate. The nurse should first make the objective measurement of the clients rate. Having the client lay down may decrease a clients respiratory rate, but the nurse should first assess the client before implementing any nursing measures. The nurse should count the respiratory rate. Based on these findings the nurse may or may not need to take the clients pulse. Assessing the pulse will not verify if the client is breathing faster.

DIF: A REF: 529 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

8. A nurse administers pain medication for a client complaining of pain. The nurse first assesses vital signs and finds them to be as follows: blood pressure, 134/92 mm Hg; pulse, 90 beats per minute; respirations, 26 breaths per minute. The nurses most appropriate action is to:

1.

Give the medication

2.

Ask if the client is anxious

3.

Check the clients dressing for bleeding

4.

Recheck the clients vital signs in 30 minutes

ANS: 1

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. Asking if the client is anxious is not the most appropriate action. The client is not demonstrating signs of shock (e.g., decreased blood pressure, increased pulse). The most appropriate action is for the nurse to administer pain medication. Rechecking would not be the most appropriate action. The nurse should medicate the client for pain.

DIF: C REF: 529 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

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:

1.

10 to 40 mm Hg higher than in the brachial artery

2.

20 to 30 mm Hg lower than in the brachial artery

3.

40 to 50 mm Hg higher than in the brachial artery

4.

Essentially the same as that in the brachial artery

ANS: 4

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

Measurements of 20 to 30 mm Hg lower and 40 to 50 mm Hg higher are not true statements.

DIF: A REF: 546 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

10. An 84-year-old client with diabetes 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?

1.

BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/min

2.

BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min

3.

BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min

4.

BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min

ANS: 1

These measurements are within the expected limits for an older client. An adults average blood pressure is 120/80 mm Hg. The systolic pressure may increase with age, but the blood pressure should not exceed 140/90 mm Hg. The range for an adults pulse is 60-100 beats/min. The expected respiratory rate is 16-25 breaths/min. BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min; BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min; and BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min are not within the expected limits for a client of this age.

DIF: A REF: 527 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

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:

1.

P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg

2.

P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm Hg

3.

P = 80 beats/min, R = 22 breaths/min, BP = 110/70 mm Hg

4.

P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hg

ANS: 3

These are expected findings of a 10-year-old client. The normal pulse range for a 10-year-old is 75-100 beats/min; the normal respiratory rate is 20-30 breaths/min. The expected blood pressure range for a 7-year-old is 87-117/48-64 mm Hg; children who are larger (e.g., heavier and/or taller) have higher blood pressures. The average blood pressure for a 10-year-old is 110/65 mm Hg mm Hg. P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg; P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm Hg; and P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hg are not expected values of a 10-year-old client.

DIF: A REF: 537 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

12. The nurse has just taken vital signs for a 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:

1.

T = 37.4 C

2.

P = 110 beats/min

3.

R = 20 breaths/min

4.

BP = 120/76 mm Hg

ANS: 2

The expected pulse range for an adult is 60-100 beats/min. This clients pulse is elevated at 110 beats/min. This clients temperature is within the normal range of 36 to 38 C for an adult. This clients respiratory rate is within the normal range of 12-20 breaths/min for an adult. This clients blood pressure reading is within the normal range of 120/80 mm Hg for an adult.

DIF: A REF: 527 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

13. When using a glass thermometer at home to accurately assess axillary temperature, the nurse should tell the parent of a 1 1/2-year-old child to:

1.

Hold the thermometer at the bulb end

2.

Cleanse the thermometer in hot water

3.

Assess the thermometer for 5 minutes

4.

Allow the child to hold the thermometer

ANS: 3

When assessing a clients axillary temperature with a glass thermometer, the thermometer should be left in place for 3 to 5 minutes. The thermometer should be held at the opposite end of the bulb. The thermometer should be covered with a plastic sheath when in use and after used 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. The parent should hold the thermometer, not the child. A 1 1/2-year-old client may drop the thermometer, creating a mercury spill.

DIF: A REF: 630 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

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

1.

Retake the vital signs in 30 minutes

2.

Continue with care as planned

3.

Administer a stimulant

4.

Notify the physician

ANS: 4

The nurse should notify the physician, as these are abnormal findings. The clients respirations are becoming dangerously low at 8 breaths/min (normal 12-20 breaths/min). The clients pulse rate is low at 54 beats/min (expected 60-100 beats/min), and the blood pressure should be =120/80 mm Hg, which it is at 110/68 mm Hg. The additional assessment findings are also not normal, and should be reported to the physician. The nurse should not wait another 30 minutes to retake vital signs. The present readings warrant notifying the physician. These are abnormal findings. The nurse should not continue with care as planned. 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.

DIF: B REF: 504 OBJ: Application

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

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:

1.

Go for help

2.

Take the clients blood pressure

3.

Assist the client into a sitting position

4.

Tell the client to take several deep breaths

ANS: 3

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. 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.

The nurse may take the clients blood pressure after assisting the client to a sitting position to prevent the client from falling. 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 pulse oximetry is low, the nurse may instruct the client to take deep breaths.

DIF: B REF: 538 OBJ: Application

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

16. A false high blood pressure reading may be assessed, as the nurse explains to the nurse assistant, if the assistant:

1.

Wraps the cuff too loosely around the arm

2.

Deflates the blood pressure cuff too quickly

3.

Repeats the blood pressure assessment too soon

4.

Presses the stethoscope too firmly in the antecubital fossa

ANS: 1

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. A false low systolic and false high diastolic blood pressure reading may occur if the cuff is deflated too quickly. A false high systolic reading may be obtained if the blood pressure assessment is repeated too soon. A false low diastolic reading may be obtained if the stethoscope is applied too firmly against the antecubital fossa.

DIF: A REF: 541 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

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

1.

An alcohol and water bath

2.

Ice packs to the axillae and groin

3.

Tepid, plain water sponge down

4.

Application of a cooling blanket

ANS: 4

Blankets cooled by circulating water delivered by motorized units increase conductive heat loss. Cooling blankets are used to reduce a fever. 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%. Application of ice packs to the axillae and groin is no longer recommended because they may induce shivering (which is counterproductive and increases the clients energy expenditure), and because they have no advantage over antipyretic medications.

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

DIF: A REF: 520 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

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

1.

Stress-producing anxiety

2.

Heavy alcohol consumption

3.

Cigarette, cigar, or pipe smoking

4.

Prescribed diuretic administration

ANS: 4

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

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

Heavy alcohol consumption has been linked to hypertension.

Cigarette smoking has been linked to hypertension.

DIF: A REF: 537 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

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:

1.

120/70 mm Hg

2.

130/84 mm Hg

3.

120/78 mm Hg

4.

118/80 mm Hg

ANS: 2

The diagnosis of prehypertension 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 readings 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 mm Hg) would fall into the pre-hypertension category.

Normal is 120/80 mm Hg; this is a normal blood pressure reading.

Normal is 120/80 mm Hg; this is a normal blood pressure reading.

Normal is 120/80 mm Hg; this is a normal blood pressure reading.

DIF: A REF: 537 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

20. After measuring the clients vital signs, the nurse obtains the following results: blood pressure = 180/100 mm Hg, pulse = 82 beats/min, R = 16 breaths/min, and rectal temp = 37.5 C. The nurse should:

1.

Retake the blood pressure

2.

Retake the clients temperature

3.

Report all of the findings immediately

4.

Record the findings as within normal limits

ANS: 1

The normal blood pressure reading is 120/80 mm Hg. This clients blood pressure is significantly higher at 180/100 mm Hg, and may be an indication of hypertension. (One elevated blood pressure measurement does 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. The clients temperature is within normal limits for a rectal temperature. The average rectal temperature is 37.5 C. The nurse should repeat the blood pressure measurement to confirm the reading before reporting the findings. The blood pressure reading is not within normal limits. The pulse rate, respiratory rate, and temperature are within normal limits.

DIF: B REF: 537 OBJ: Application

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

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:

1.

A constant body temperature above 100.4 F with little fluctuation

2.

Spikes that are interspersed with normal temperatures within 24 hours

3.

Spikes and falls in temperature, but temperature does not return to the normal limits

4.

Periods of febrile episodes interspersed with normal body temperatures

ANS: 3

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

A sustained fever is a constant body temperature continuously above 38 C (100.4 F) that demonstrates little fluctuation. An intermittent fever has fever spikes interspersed with usual temperature levels. Temperature returns to acceptable levels at least once in 24 hours.

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

DIF: A REF: 508 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

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:

1.

Oral site

2.

Rectal site

3.

Axillary site

4.

Tympanic site

ANS: 3

The axillary site can be used with newborns and uncooperative clients. The oral site should not be used with infants. The rectal site should not be used for routine vital signs in newborns. The tympanic site is questioned as being accurate in newborns.

DIF: A REF: 515 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

23. A client is being monitored with pulse oximetry. On review of the following factors, the nurse suspects that the values will be influenced by:

1.

The placement of the sensor on the extremity

2.

A diagnosis of peripheral vascular disease

3.

A reduced amount of artificial light in the room

4.

The increased ambient temperature of the clients room

ANS: 2

Peripheral vascular disease can reduce pulse volume, which may affect the pulse oximetry reading. 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. Reduced light in the room will not affect the oximetry reading. Outside light sources can interfere with the oximeters ability to process reflected light. 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.

DIF: A REF: 533 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

24. An individual contacts the emergency department 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:

1.

Take sips of brandy

2.

Drink a bowl of warm soup

3.

Drink a cup of very hot coffee

4.

Run the affected extremities under hot water

ANS: 2

A conscious client benefits from drinking hot liquids such as soup. Alcohol should be avoided.

Caffeinated fluids should be avoided. 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 that lose heat the quickest.

DIF: B REF: 508 OBJ: Application

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

25. A spouse assists the nurse evaluating the measurement of the clients blood pressure. The nurse feels additional teaching is required if the spouse is observed:

1.

Deflating the cuff at 2 mm Hg/second

2.

Having the client sit down for the measurement

3.

Using the same time each day for the measurement

4.

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

ANS: 4

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.

The cuff should be deflated at a rate of 2 mm Hg per second. When possible, the client should be sitting in a chair. The blood pressure should be assessed at the same time each day.

DIF: A REF: 537 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

26. The nurse measures the blood pressure in the leg due to the fact that the client has bilateral casts on the upper extremities. The nurse palpates the pulse before the measurement at the:

1.

Popliteal fossa behind the knee

2.

Inner side of the ankle below the medial malleolus

3.

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

4.

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

ANS: 1

The popliteal artery, palpable behind the knee in the popliteal space, is the site for auscultation when taking the blood pressure in the leg. The inner side of the ankle, top of the foot, and inguinal ligament are not the correct sites for assessment.

DIF: A REF: 546 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

27. The clients apical pulse will be taken by a student. According to the nurse the stethoscope should be placed along the left clavicular line at the:

1.

Second to third intercostal space

2.

Third to fourth intercostal space

3.

Fourth to fifth intercostal space

4.

Fifth to sixth intercostal space

ANS: 3

An apical pulse should be assessed at the clients PMI. The PMI is located at the fourth to fifth intercostal space at the left midclavicular line. Second to third intercostals space is not the correct placement for auscultating a clients apical pulse. The PMI is higher and more medial in children under 8 years old, thus the third to fourth is incorrect. The client is not identified as being a child.

Fifth to sixth is not the correct placement for auscultating a clients apical pulse.

DIF: A REF: 525 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

28. 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:

1.

A febrile condition

2.

Administration of digoxin

3.

The clients athletic conditioning

4.

Unrelieved severe postoperative pain

ANS: 1

Fever and heat may increase a clients pulse rate. Digoxin is a negative chronotropic drug; it will decrease the clients pulse rate. A conditioned athlete who participates in long-term exercise will have a lower heart rate at rest. Unrelieved severe pain increases parasympathetic stimulation; decreasing the heart rate.

DIF: A REF: 526 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

29. Upon 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:

1.

Biots respirations

2.

Kussmauls respirations

3.

Hyperpneic respirations

4.

Cheyne-Stokes respirations

ANS: 4

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. Biots respirations are abnormally shallow for two to three breaths followed by an irregular period of apnea. Kussmauls respirations are abnormally deep, regular, and increased in rate. Hyperpneic respirations are labored, increased in depth, and increased in rate (>20 breaths/min); they normally occur during exercise.

DIF: A REF: 532 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

30. The nurse has assigned the vital signs of the elderly clients residing in the facilitys assisted living unit to the nursing assistant. Which of the following statements made by the ancillary personnel requires immediate correction by the RN?

1.

As you age your blood pressure may go up, but it doesnt have to if your vessels are healthy.

2.

If anyones oral temperature is over 100 F, Ill let you know right away since that means they have a fever.

3.

I always wait a good 30 minutes after returning the older client back to bed before I count their pulse.

4.

I watch the elderly clients stomach and count the number of times it rises when I am counting respirations.

ANS: 2

RAT: The temperature of older adults is at the lower end of the normal temperature range, 36 to 36.8 C (96.9 to 98.3 F) orally and 36.6 to 37.2 C (98 to 99 F) rectally. Therefore temperatures considered within normal range sometimes reflect a fever in an older adult. The normal range for blood pressure is the same for older adults and younger people, while older adults depend more on accessory abdominal muscles during respiration than on weaker thoracic muscles, so observing the rise and fall of the abdomen would not be inappropriate. Once elevated, the pulse rate of an older adult takes longer to return to normal resting rate, so waiting 30 minutes would not be inappropriate.

DIF: C REF: 506 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

31. The nurse appropriately instructs trained ancillary personnel to avoid using an electronic blood pressure cuff to take the blood pressure of which of the following clients?

1.

A 25-year-old who was admitted for depression and anxiety

2.

A 69-year-old diagnosed with Parkinsons disease 5 years ago

3.

A 57-year-old prescribed antihypertensive medication 6 weeks ago

4.

An 80-year-old client whose systolic BP is routinely assessed in the low 90s

ANS: 2

Blood pressure less than 90 mm Hg systolic, irregular heart rate, peripheral vascular obstruction (e.g., clots, narrowed vessels), shivering, seizures, excessive tremors, and the inability to cooperate are reasons to avoid using an electronic BP monitor. The clients Parkinsons disease causes tremors, so a manual cuff should be used when assessing this clients BP.

DIF: C REF: 546 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

32. The nurse appropriately instructs trained ancillary personnel to use an electronic blood pressure cuff to take the blood pressure of which of the following clients?

1.

A 25-year-old who was admitted for alcohol detoxification

2.

A 69-year-old diagnosed with Parkinsons disease 5 years ago

3.

A 57-year-old placed on antihypertensive medication therapy 2 months ago

4.

An 80-year-old client whose systolic BP is routinely assessed in the high 80s

ANS: 1

Blood pressure less than 90 mm Hg systolic, irregular heart rate, peripheral vascular obstruction (e.g., clots, narrowed vessels), shivering, seizures, excessive tremors, and inability to cooperate are reasons to avoid using an electronic BP monitor. The answer reflects the client whose BP is most stable and best assessable via electronic BP monitor.

DIF: A REF: 546 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

33. The nurse has assigned nursing assistive personnel to obtain the blood pressures on the units clients. Which of the following statements made by the assistive personnel shows the best understanding regarding appropriate communication of the BP readings?

1.

Ill ask the clients what their blood pressure usually runs.

2.

Ill give you a list of all the readings I get before I chart them.

3.

Ill chart the results and let you know whose pressure is high.

4.

Ill recheck any pressure that seems higher than their normal.

ANS: 2

The nurse is responsible for assessing the impact of changes in blood pressure and so must be aware of each clients reading, not merely the values that the assistive personnel believes to be high. Asking the client to share what their BP is routinely and/or retaking a questionable reading is appropriate but not directly related to effective communication of the findings.

DIF: C REF: 539 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

34. The nurse has assigned nursing assistive personnel to obtain the blood pressures on the units clients. Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate communication of the BP readings?

1.

Ill give you a list of all the readings after I chart them.

2.

May I ask the clients what their blood pressure usually runs?

3.

Ill chart the results and let you know whose pressure is running high.

4.

Do you want me to take the readings before they get their medications?

ANS: 3

The nurse is responsible for assessing the impact of changes in blood pressure and so must be promptly made aware of each clients reading, not merely the values that the assistive personnel believes to be high. The questions asked may reflect a need for further instruction, but the issues are not as critical as the need to report all readings for the nurse to evaluate.

DIF: C REF: 539 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

35. The nurse has assessed a clients blood pressure (BP) using the left thigh because of bilateral upper arm casts. The clients precasting left arm BP was 108/70 mm Hg. The nurse expects the present BP reading to be:

1.

10-40 mm Hg higher systolic pressure than before the casting

2.

5-10 mm Hg higher reading in both systolic and diastolic pressures

3.

Representative of the original baseline established before the casting

4.

A slight decrease in the diastolic pressure when compared to precasting pressure

ANS: 1

Systolic pressure in the legs is usually higher by 10 to 40 mm Hg than in the brachial artery, but the diastolic pressure is the same.

DIF: A REF: 546 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

36. The nurse is using a manual cuff to assess the blood pressure of a client experiencing hypertension. To best ensure accommodation for a possible auscultatory gap, the nurse should use which of the following as a guide for inflating the cuff appropriately?

1.

Review the clients chart for his last blood pressure reading.

2.

Ask the client what his typical blood pressure reading is when taken manually.

3.

Inflate 30 mm Hg higher than where the radial pulse can no longer be palpated.

4.

Take the clients blood pressure both sitting and standing and use the higher reading.

ANS: 3

The examiner needs to be certain to inflate the cuff high enough to hear the true systolic pressure before the auscultatory gap. Palpation of the radial artery helps to determine how high to inflate the cuff. The examiner inflates the cuff 30 mm Hg above the pressure at which the radial pulse was palpated. Taking the blood pressure in various positions will not help eliminate the possible loss of auditory sound between the systolic and diastolic sounds. While asking the client and/or reviewing the chart may provide information concerning the clients pressure, these options are not the recommended method for minimizing the effect of the auditory gap on the assessment process.

DIF: C REF: 541 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

37. The nurse is assessing an elderly clients blood pressure during a routine visit. When asked, the client volunteers that when he took his pressure at home yesterday it was 126/72 mm Hg. The nurse determines that the clients pressure today is 134/70 mm Hg. The nurse recognizes that the most likely cause of the elevation is:

1.

The difference between the monitoring equipment being used

2.

The client may be experiencing mild anxiety regarding the check-up

3.

The effects of aging on the clients ability to hear the first Korotkoff sound

4.

The client is not inflating the cuff sufficiently to detect the systolic pressure

ANS: 2

Blood pressure measurements taken at the clients place of employment or in a health care providers office are higher than those taken at the clients home. The remaining options may be a factor but they are not the most likely.

DIF: C REF: 537 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

38. The nurse is assessing a clients blood pressure to establish a baseline. The pressure in the right arm is 12 mm Hg lower than that in the left arm. The nurse most appropriately realizes that these data:

1.

Reflect a normal variation

2.

Should be reported to the clients health care provider

3.

Dictate that pressure should be monitored in the left arm

4.

Indicate that the client may be experiencing vascular problems

ANS: 2

During the initial assessment, obtain and record the blood pressure in both arms. Normally there is a difference of 5 to 10 mm Hg between the arms (Lane and others, 2002). In subsequent assessments, measure the blood pressure in the arm with the higher pressure. Pressure differences greater than 10 mm Hg indicate vascular problems and are reported to the health care provider or nurse in charge. Reporting the assessment findings is the most appropriate outcome.

DIF: C REF: 536 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

39. The nurse recognizes that which of the following clients present at the annual July 4th marathon is at greatest risk for hyperthermia and the resulting heatstroke?

1.

A 34-year-old running for the first time in the July 4th marathon who is sweating profusely

2.

A 16-year-old volunteer, with type 1, insulin-dependent diabetes, who is checking runners in for the marathon at the starting gate

3.

A 75-year-old who is prescribed medication for Crohns disease and who is sitting outdoors watching her granddaughter run the marathon

4.

A 55-year-old diagnosed with bipolar disease and prescribed a phenothiazine (Serentil), who will be walking the marathon course

ANS: 2

Clients at risk include those who are very young or very old and those who have cardiovascular disease, hypothyroidism, diabetes, or alcoholism. Also at risk are those who take medications that decrease the bodys ability to lose heat (e.g., phenothiazines, anticholinergics, diuretics, amphetamines, and beta-adrenergic receptor antagonists) and those who exercise or work strenuously (e.g., athletes, construction workers, and farmers). While all the options represent risk factors, the degree of exercise, medical history, and age are greatest for the 16-year-old client with diabetes.

DIF: C REF: 506 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

40. The nurse recognizes that which of the following clients present at the annual July 4th marathon is showing the most compelling signs of hyperthermia and the resulting heatstroke?

1.

The 75-year-old who has forgot where the car is parked

2.

The 16-year-old volunteer whose skin appears sunburned but dry

3.

The 34-year-old who finished the race and is reporting leg cramps

4.

The 55-year-old observer who complains of nausea and being thirsty

ANS: 2

Signs and symptoms of heatstroke include giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and even incontinence. Vital signs reveal a body temperature sometimes as high as 45 C (113 F) with an increase in heart rate and lowering of blood pressure. The most important sign of heatstroke is hot, dry skin. Victims of heatstroke do not sweat because of severe electrolyte loss and hypothalamic malfunction. If the condition progresses, the client with heatstroke becomes unconscious with fixed, unreactive pupils. Permanent neurological damage occurs unless cooling measures are rapidly started.

DIF: C REF: 508 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

41. The nurse has assigned nursing assistive personnel to obtain the temperatures on the units clients. Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate temperature monitoring orally?

1.

Are all the clients cooperative enough to take the temperatures orally?

2.

Do you want me to take the temperature tympanically on everyone?

3.

Ill wait until breakfast is over so I wont distract them from eating.

4.

Ill chart the results and let you know whose temperature is running high.

ANS: 3

When taking oral temperature, wait 20 to 30 min before measuring temperature if the client has smoked or ingested hot or cold liquids or foods. The nurse needs to reinforce this information so that the assessment will occur before breakfast or to allow enough time to pass after breakfast so as not to affect the readings. The options containing a question reflect a need for knowledge but do not have priority over an obvious indication of possible poor assessment technique. The nurse needs to evaluate the readings and so should be sure to give the assistive personnel guidance as to what readings are running high.

DIF: C REF: 510 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

42. Which of the following sites is best suited for measuring oxygen saturation (pulse oximetry)?

1.

A polished ring finger of a client with pneumonia whose nail capillary refill time is 2.5 seconds

2.

A pierced earlobe of a client with a closed head injury whose nail capillary refill time is 3.5 seconds

3.

The ring finger of a client with Parkinsons disease that has a capillary refill time of less than 3 seconds

4.

An earlobe of a client who is experiencing moderate diaphoresis with a nail capillary refill time of 3.5 seconds

ANS: 2

Determine most appropriate client-specific site (e.g., finger, earlobe) for sensor probe placement by measuring capillary refill. If capillary refill is greater than 3 seconds, select an alternate site. Sites should be free of moisture and tremors, and the nail should be free of polish (no artificial nails).

DIF: C REF: 534 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

43. The nurse has asked the assistive personnel to take the blood pressure of a client who experienced a left mastectomy 3 days ago. Which of the following statements by the assistive personnel shows the best understanding regarding the appropriate assessment technique for this particular client?

1.

Is there anything affecting her right arm?

2.

Has she been experiencing any edema in that left arm?

3.

How long has it been since she had her breast removed?

4.

Ill wait until shes been medicated for pain before I take it.

ANS: 1

Avoid applying the cuff to the extremity when intravenous fluids are infusing; an arteriovenous shunt or fistula is present; breast or axillary surgery has been performed on that side; or the extremity has been traumatized, diseased, or requires a cast or bulky bandage. The answer reflects an understanding that the right arm is the extremity of choice for monitoring this clients blood pressure.

DIF: C REF: 539 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

MULTIPLE RESPONSE

1. The nurse is assisting the wife of a client who has been diagnosed with hypertension to monitor his blood pressure. The nurse states that the blood pressure should be taken: (Select all that apply.)

1.

At the same time each day

2.

On the same arm each time

3.

In the same position each time

4.

After the client has had a brief rest

5.

After his blood pressure medication

6.

Right before getting up in the morning

ANS: 1, 2, 3, 4

Instruct the client or primary caregiver to take BP at same time each day and after the client has had a brief rest. Take BP sitting or lying down; use the same position and arm each time pressure is taken. The other options are not necessary because they do not affect blood pressure readings.

DIF: C REF: 537 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

2. Which of the following factors make using a pulse oximeter on an elderly client challenging? (Select all that apply.)

1.

Possibility of decreased cardiac output

2.

Potential for peripheral vascular disease

3.

Existence of decreased red blood cell count

4.

Uncooperative behavior related to senility

5.

Inability to comprehend rationale for monitoring

6.

Vasoconstriction related to impaired heat regulation

ANS: 1, 2, 3, 6

Identifying an acceptable pulse oximeter probe site is difficult with older adults because of the likelihood of peripheral vascular disease, decreased cardiac output, cold-induced vasoconstriction, and anemia. It would be inappropriate to assume that the process is made more difficult because of the remaining options because they are not seen in the majority of the elderly population.

DIF: C REF: 533 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

3. The nurse is providing a health promotion session regarding the factors that contribute to heatstroke for members of a college cross-country running team. Which of the following statements should the nurse include in the discussion? (Select all that apply.)

1.

Take frequent breaks to rest out of the sun.

2.

The greater the humidity, the greater the hazard.

3.

Wear clothing that will absorb the perspiration.

4.

The higher the temperature, the higher the risk.

5.

The more fluids you drink, the fewer chances you take.

6.

Pay attention to pacing yourself when its hot and muggy.

ANS: 2, 4, 5, 6

Teach clients risk factors for heatstroke: strenuous exercise in hot, humid weather; tight-fitting clothing in hot environments; exercising in poorly ventilated areas; sudden exposures to hot climates; poor fluid intake before, during, and after exercise. When paying close attention to avoiding risk factors for heatstroke, the remaining options are not required.

DIF: C REF: 507-508 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

4. The nurse is discussing risk factors for hypertension with family members attending a self-help group meeting for clients in cardiac rehabilitation. Which of the following statements made by the nurse are relevant to this discussion on prevention of this disorder? (Select all that apply.)

1.

Low fat foods are your blood pressures best friend.

2.

Have your triglycerides checked on a regular basis.

3.

Ideal weight is ideal for keeping blood pressure under control.

4.

Nicotine is a no-no when attempting to control blood pressure.

5.

If they are prescribed, take your blood pressure medicine as suggested.

6.

Keep alcohol consumption down and your blood pressure will be down.

ANS: 1, 2, 3, 4, 6

Persons with a family history of hypertension are at significant risk. Obesity, cigarette smoking, heavy alcohol consumption, high blood cholesterol and triglyceride levels, and continued exposure to stress are risk factors linked to hypertension. Medication compliance, while important, is related to the management of hypertension, not prevention.

DIF: C REF: 537-538 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

5. The nurse is discussing the correct technique for taking a blood pressure with clients and their caregivers. Which of the following nursing statements would appropriately identify the most likely causes for experiencing difficulty actually hearing the blood pressure? (Select all that apply.)

1.

The cuff cannot be too small or too big.

2.

Dont release the air out of the cuff to quickly.

3.

Keep the arm you are using at the level of the heart.

4.

If you are having difficulty, try taking it in the other arm.

5.

The stethoscope needs to be placed directly over a pulse point.

6.

Remember to pump up the cuff until you can no longer feel the pulse.

ANS: 1, 2, 5, 6

Instruct the client or primary caregiver that if it is difficult to hear the pressure, the cuff is probably too loose, not big enough, or too narrow; the stethoscope is not over an arterial pulse; the cuff was deflated too quickly or too slowly; or the cuff was not inflated enough for systolic readings. The remaining options do not directly affect the actual hearing of the blood pressure.

DIF: C REF: 539 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

6. The nurse is discussing the proper technique for obtaining an accurate blood pressure reading with assistive nursing personnel. Which of the following statements reflect techniques that will minimize the risk of a false high systolic reading? (Select all that apply.)

1.

Slowly deflate the pressure from the cuff.

2.

Wrap the cuff snuggly around the clients arm.

3.

Always support the clients arm at the level of the heart.

4.

Be sure that the cuff is wide enough for the clients arm.

5.

Allow the arm to rest before repeating the blood pressure.

6.

Make sure your stethoscope is fitted in your ears appropriately.

ANS: 2, 3, 4, 5

Using a bladder or cuff that is too narrow or too short, wrapping the cuff too loosely or unevenly, resting the arm below heart level, and repeating assessments too quickly all contribute to a falsely high systolic reading. The rapid deflation of the cuff and an ill-fitted stethoscope will likely result in a falsely low systolic reading.

DIF: C REF: 539 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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