NUR 33630 Vital Signs Nursing Test Banks

NUR 33630 Vital Signs Nursing Test Banks Chapter 30: Vital Signs Chapter 30: Vital Signs MULTIPLE CHOICE 1. A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most ...

NUR 33630 Vital Signs Nursing Test Banks Chapter 30: Vital Signs Chapter 30: Vital Signs MULTIPLE CHOICE 1. A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? a. Pulse b. Respirations c. Temperature d. Blood pressure ANS: C Disease or trauma to the hypothalamus or the spinal cord, which carries hypothalamic messages, causes serious alterations in temperature control. The hypothalamus does not control pulse, respirations, or blood pressure. DIF:Understand (comprehension)REF:488 OBJ:Explain the principles and mechanism of thermoregulation. TOP: Assessment MSC: Physiological Adaptation 2. A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss? 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 (comprehension)REF:489 OBJ:Explain the principles and mechanism of thermoregulation. TOP: Implementation MSC: Basic Care and Comfort 3. The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient’s temperature? 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 because of the 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. Convection is the transfer of heat away from the body by air movement. DIF:Understand (comprehension)REF:489 OBJ:Explain the principles and mechanism of thermoregulation. TOP: Implementation MSC: Basic Care and Comfort 4. A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take? a. Apply just a diaper. b. Double the clothing. c. Place a cap on their heads. d. Increase room temperature to 90 degrees. ANS: C 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; do not increase the room temperature to 90 degrees. Take extra care to protect newborns from environmental temperatures. Provide adequate clothing; do not double the clothing or apply just a diaper. DIF:Apply (application)REF:489 OBJ: Describe nursing measures that promote heat loss and heat conservation. TOP: Implementation MSC: Health Promotion and Maintenance 5. The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The nurse notices that the patient’s temperature is 96.8° F (36° C), whereas at 4:00 PM the preceding day, it was 98.6° F (37° C). What should the nurse do? a. Call the health care provider immediately to report a possible infection. b. Administer medication to lower the temperature further. c. Provide another blanket to conserve body temperature. d. Realize that this is a normal temperature variation. ANS: D Body temperature normally changes 0.5° to 1° C (0.9° to 1.8° F) during a 24-hour period and is usually lowest between 1:00 and 4:00 AM, with a maximum temperature at 4:00 PM, making this variation normal for the time of day. Unless the patient reports 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 health care provider to report a normal temperature variation. DIF:Apply (application)REF:490 OBJ: Describe nursing measures that promote heat loss and heat conservation. TOP: Implementation MSC: Health Promotion and Maintenance 6. The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). The patient’s last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). Which action will the nurse take? a. Wait 30 minutes and recheck the patient’s temperature. b. Assume that the patient has an infection and order blood cultures. c. Encourage the patient to move around to increase muscular activity. d. Be aware that temperatures this high are harmful and a᯿అect patient safety. ANS: A Waiting 30 minutes and rechecking the patient’s temperature would be the most appropriate action in this case. A fever is usually 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 di᯿అerent times of the day compared with the usual value for that person at that time. Nurses should base actions on knowledge, not on assumptions. Encouraging the patient to increase muscular activity will cause heat production to increase up to 50 times normal. The temperature has decreased and a symptom of infection would be an increase in temperature. DIF:Analyze (analysis)REF:490 OBJ: Describe nursing measures that promote heat loss and heat conservation. TOP: Implementation MSC: Reduction of Risk Potential 7. A patient is pyrexic. Which piece of equipment will the nurse obtain to monitor this condition? a. Stethoscope b. Thermometer c. Blood pressure cu᯿అ d. Sphygmomanometer ANS: B 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; therefore, a thermometer is needed. A stethoscope is not used to take a temperature but can be used for apical pulse and blood pressure. A pulse oximeter is used to determine oxygen content in the blood. A sphygmomanometer and blood pressure cu᯿అ is used to determine blood pressure and will be used for blood pressure problems. DIF:Apply (application)REF:490 OBJ: Discuss physiological changes associated with fever. TOP: Assessment MSC:Health Promotion and Maintenance 8. The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient? a. Hyperthermia and fever are the same thing. b. Hyperthermia is an upward shift in the set point. c. Hyperthermia occurs when the body cannot reduce heat production. d. Hyperthermia results from a reduction in thermoregulatory mechanisms. ANS: C An elevated body temperature related to the inability of the body to promote heat loss or reduce heat production is hyperthermia. Whereas fever is an upward shift in the set point, hyperthermia results from an overload of the thermoregulatory mechanisms of the body. DIF:Understand (comprehension)REF:491 OBJ: Discuss physiological changes associated with fever. TOP: Planning MSC: Physiological Adaptation 9. The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take? a. Place the patient on oxygen. b. Encourage the patient to cough. c. Restrict the patient’s ᯿贄uid intake. d. Increase the patient’s metabolic rate. ANS: A Interventions during a fever include oxygen therapy. During a fever, cellular metabolism increases and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for ᯿贄uid volume de᯿贄cit. Fluids should not be restricted, even though the patient has heart failure; the patient needs ᯿贄uids at this time due to the fever. Increasing the metabolic rate further would not be advisable. Coughing will increase muscular activity, which will increase fever. DIF:Apply (application)REF:491 OBJ: Discuss physiological changes associated with fever. TOP: Implementation MSC: Reduction of Risk Potential 10. The patient requires temperatures to be taken every 2 hours. Which task will the nurse assign to an RN? a. Using appropriate route and device b. Assessing changes in body temperature c. Being aware of the usual values for the patient d. Obtaining temperature measurement at ordered frequency ANS: B The nurse is responsible for assessing changes in body temperature. The nursing assistive personnel can use the appropriate route and device to measure temperature, obtain temperature measurement at ordered frequency, and be aware of the usual values for the patient. DIF:Apply (application)REF:487 | 512 OBJ: Appropriately delegate measurement of vital signs to nursing assistive personnel. TOP:ImplementationMSC:Management of Care 11. The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient’s temperature? a. Oral b. Rectal c. Axillary d. Tympanic ANS: D 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 seizures. Rectal temperatures require positioning and may increase patient agitation. Axillary temperatures need long measurement times and continuous positioning. The patient’s agitation state may not allow for long periods of attention. DIF:Apply (application)REF:493 OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Implementation MSC: Health Promotion and Maintenance 12. The patient is being admitted to the emergency department following a motor vehicle accident. The patient’s jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature reading? a. Oral b. Axillary c. Tympanic d. Temporal ANS: C The tympanic route is the best choice in this situation. Oral temperatures are not used for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills. Axillary temperature is a᯿అected by exposure to the environment, including time to place the thermometer. It also requires a long measurement time. Temporal artery temperature is a᯿అected by skin moisture such as diaphoresis or sweating. DIF:Apply (application)REF:493 OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Implementation MSC: Health Promotion and Maintenance 13. The nurse is caring for an infant and is obtaining the patient’s vital signs. Which artery will the nurse use to best obtain the infant’s pulse? a. Radial b. Brachial c. Femoral d. Popliteal ANS: B The brachial or apical pulse is the best site for assessing an infant’s or a young child’s pulse because other peripheral pulses such as the radial, femoral, and popliteal arteries are deep and di᯿ᜇcult to palpate accurately. DIF:Understand (comprehension)REF:497 OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Implementation MSC: Health Promotion and Maintenance 14. The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use? a. Radial b. Apical c. Carotid d. Brachial ANS: C 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 the lower arm. The apical pulse is used to auscultate the apical area. DIF:Apply (application)REF:497-498 OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Implementation MSC: Physiological Adaptation 15. The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement? a. Place the tips of the ᯿贄rst two ᯿贄ngers over the groove along the thumb side of the patient’s wrist. b. Place the tips of the ᯿贄rst two ᯿贄ngers over the groove along the little ᯿贄nger side of the patient’s wrist. c. Place the thumb over the groove along the little ᯿贄nger side of the patient’s wrist. d. Place the thumb over the groove along the thumb side of the patient’s wrist. ANS: A Place the tips of the ᯿贄rst two or middle three ᯿贄ngers of the hand over the groove along the radial or thumb side of the patient’s 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 groove along the little ᯿贄nger is the ulnar pulse. DIF:Apply (application)REF:498 | 518 OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Implementation MSC: Health Promotion and Maintenance 16. The nurse is assessing the patient’s respirations. Which action by the nurse is most appropriate? a. Inform the patient that she is counting respirations. b. Do not touch the patient until completed. c. Obtain without the patient knowing. d. Estimate respirations. ANS: C Do not let a patient know that you are assessing respirations. A patient aware of the assessment can alter the rate and depth of breathing. Assess respirations immediately after measuring pulse rate, with your hand still on the patient’s wrist as it rests over the chest or abdomen. Respirations are the easiest of all vital signs to assess, but they are often the most haphazardly measured. Do not estimate respirations. DIF:Apply (application)REF:501 OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Implementation MSC: Health Promotion and Maintenance 17. The patient’s blood pressure is 140/60. Which value will the nurse record for the pulse pressure? a. 60 b. 80 c. 140 d. 200 ANS: B The di᯿అerence 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 signi᯿贄cance. DIF:Apply (application)REF:503 OBJ:Explain the physiology of normal regulation of blood pressure, pulse, oxygen saturation, and respirations.TOP:Implementation MSC:Health Promotion and Maintenance 18. The nurse reviews the laboratory results for a patient and determines the viscosity of the blood is thick. Which laboratory result did the nurse check? a. Arterial blood gas b. Blood culture c. Hematocrit d. Potassium ANS: C The hematocrit, or the percentage of red blood cells in the blood, determines blood viscosity. Blood cultures determine the causative agent of an infection. Abnormal potassium levels can cause dysrhythmias. Arterial blood gases determine acid-base balance or the pH levels of the blood. DIF:Apply (application)REF:503 OBJ: Explain the physiology of normal regulation of blood pressure, pulse, oxygen saturation, and respirations. TOP: Assessment MSC: Physiological Adaptation 19. The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do? a. Allow the patient to breathe into a paper bag. b. Use oxygen cautiously in this patient. c. Administer high levels of oxygen. d. Give CO2 via mask. ANS: B Oxygen must be used cautiously in these types of patients. Hypoxemia helps to control ventilation in patients with chronic lung disease. Because low levels of arterial O2 provide the stimulus that allows a patient to breathe, administration of high oxygen levels may be fatal for patients with chronic lung disease. Patients with chronic lung disease have ongoing hypercarbia (elevated CO2 levels) and do not need to have CO2 administered or “rebreathed” with a paper bag. DIF:Apply (application)REF:500 OBJ: Explain the physiology of normal regulation of blood pressure, pulse, oxygen saturation, and respirations. TOP: Implementation MSC: Physiological Adaptation 20. A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up? a. 35 mm Hg b. 40 mm Hg c. 45 mm Hg d. 50 mm Hg ANS: D 50 mm Hg is abnormal so the nurse will follow up. Normal capnography results are 35 to 45 mm Hg. DIF:Understand (comprehension)REF:487 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Assessment MSC:Management of Care 21. The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which ᯿贄nding will help the nurse determine the cause of the patient’s low heart rate? a. The patient has a fever. b. The patient has possible hemorrhage or bleeding. c. The patient has chronic obstructive pulmonary disease (COPD). d. The patient has calcium channel blockers or digitalis medication prescriptions. ANS: D 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 body’s need for oxygen, leading to an increased heart rate. DIF:Apply (application)REF:499 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Assessment MSC: Physiological Adaptation 22. The patient was found unresponsive in an apartment and is being brought to the emergency department. The patient has arm, hand, and leg edema, temperature is 95.6° F, and hands are cold secondary to a history of peripheral vascular disease. It is reported that the patient has a latex allergy. What should the nurse do to quickly measure the patient’s oxygen saturation? a. Attach a ᯿贄nger probe to the patient’s index ᯿贄nger. b. Place a nonadhesive sensor on the patient’s earlobe. c. Attach a disposable adhesive sensor to the bridge of the patient’s nose. d. Place the sensor on the same arm that the electronic blood pressure cu᯿అ is on. ANS: B A nonadhesive sensor is best for latex allergy, and the earlobe site is the best choice for this patient with peripheral vascular disease and edema. Select forehead, ear or bridge of nose if an adult patient has a history of peripheral vascular disease. Do not attach probe to ᯿贄nger, ear, forehead, 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 ᯿贄ngers that are hypothermic. Do not place the sensor on the same extremity as the electronic blood pressure cu᯿అ because blood ᯿贄ow to the ᯿贄nger will be temporarily interrupted when the cu᯿అ in᯿贄ates. DIF:Apply (application)REF:524 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Implementation MSC: Physiological Adaptation 23. The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient’s symptoms? a. Red blood cell count of 5.0 million/mm3 b. Hemoglobin level of 8.0 g/100 mL c. Hematocrit level of 45% d. Pulse oximetry of 95% ANS: B The concentration of hemoglobin re᯿贄ects the patient’s capacity to carry oxygen, which if low can lead to shortness of breath and chest discomfort. Normal hemoglobin levels range from 14 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 (analysis)REF:501 | 522 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Assessment MSC: Reduction of Risk Potential 24. A nurse reviews blood pressures of several patients. Which ᯿贄nding will the nurse report as prehypertension? a. 98/50 in a 7-year-old child b. 115/70 in an infant c. 120/80 in a middle-aged adult d. 146/90 in an older adult ANS: C An adult’s 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 de᯿贄ned as hypertension. Blood pressure of 98/50 is normal for a child, whereas 115/70 can be normal for an infant. DIF:Analyze (analysis)REF:504-505 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Assessment MSC:Health Promotion and Maintenance 25. The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address? a. Non-Hispanic Caucasians b. European Americans c. African-Americans d. Asian Americans ANS: C The incidence of hypertension is greater in diabetic patients, older adults, and African-Americans. The incidence of hypertension (high BP) is higher in African-Americans than in European Americans. DIF:Understand (comprehension)REF:504-505 OBJ: Describe cultural and ethnic variations with blood pressure assessment. TOP lanningMSC:Health Promotion and Maintenance 26. A nurse is caring for a patient who smokes and drinks ca᯿అeine. Which point is important for the nurse to understand before assessing the patient’s blood pressure (BP)? a. Smoking increases BP for up to 3 hours. b. Ca᯿అeine increases BP for up to 15 minutes. c. Smoking result in vasoconstriction, falsely elevating BP. d. Ca᯿అeine intake should not have occurred 30 to 40 minutes before BP measurement. ANS: C Smoking results in vasoconstriction, a narrowing of blood vessels. BP rises when a person smokes and returns to baseline about 15-20 minutes after stopping smoking. Ca᯿అeine increases BP for up to 3 hours. Be sure that patient has not ingested ca᯿అeine or smoked 20 to 30 minutes before BP measurement. DIF:Apply (application)REF:504 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Assessment MSC:Health Promotion and Maintenance 27. When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this ᯿贄nding? a. This is normal for an infant. b. This is too fast for an infant. c. This is too slow for an infant. d. This is not a rate for an infant but for a toddler. 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; 145 is too high for a toddler. DIF:Understand (comprehension)REF:499 OBJ: Identify ranges of acceptable vital sign values for an infant, a child, and an adult. TOP:AssessmentMSC:Health Promotion and Maintenance 28. The nurse is caring for an older-adult patient and notes that the temperature is 96.8° F (36° C). How will the nurse interpret this ᯿贄nding? a. The patient has hyperthermia. b. The patient has a normal temperature. c. The patient is su᯿అering from hypothermia. d. The patient is demonstrating increased metabolism. ANS: B The average body temperature of older adults is approximately 35° to 36.1° C (95° to 97° F). This is not hypothermia or hyperthermia. Older adults have poor vasomotor control, reduced amounts of subcutaneous tissue, reduced sweat gland activity, and reduced metabolism. The end result is lowered body temperature. DIF:Understand (comprehension)REF:489 OBJ: Identify ranges of acceptable vital sign values for an infant, a child, and an adult. TOP:AssessmentMSC:Health Promotion and Maintenance 29. When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse’s action? a. It is not a᯿అected by skin moisture. b. It has no risk of injury to patient or nurse. c. It re᯿贄ects rapid changes in radiant temperature. d. It is accurate even when the forehead is covered with hair. ANS: B The temporal artery thermometer is especially bene᯿贄cial when used in premature infants, newborns, and children because there is no risk of injury to the patient or nurse. Temporal artery temperature is a reliable noninvasive measure of core temperature. However, it is inaccurate with head covering or hair on the forehead and is a᯿అected by skin moisture such as diaphoresis, or sweating. It provides very rapid measurement and re᯿贄ects rapid changes in core temperature, not radiant temperature. DIF:Understand (comprehension)REF:493 OBJ: Explain variations in technique used to assess an infant’s, a child’s, and an adult’s vital signs. TOP:AssessmentMSC:Health Promotion and Maintenance 30. The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to praise the NAP? a. Ulnar site b. Radial site c. Brachial site d. Femoral site ANS: C The nurse will praise the NAP when obtaining the pulse from the brachial site. The brachial or apical pulse is the best site for assessing an infant’s or a young child’s pulse because other peripheral pulses are deep and di᯿ᜇcult to palpate accurately. DIF:Apply (application)REF:497 OBJ: Explain variations in technique used to assess an infant’s, a child’s, and an adult’s vital signs. TOP:AssessmentMSC:Management of Care 31. The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn? a. 30 to 60 b. 22 to 28 c. 16 to 20 d. 10 to 15 ANS: A The acceptable respiratory rate range for a newborn is 30 to 60 breaths/min. An infant (6 months) is expected to have a rate between 30 and 50 breaths/min. A toddler’s respiratory range is 25 to 32 breaths/min. A child should breathe 20 to 30 times a minute. An adolescent should breathe 16 to 20 times a minute. An adult should breathe 12 to 20 times a minute. DIF:Apply (application)REF:501 OBJ: Explain variations in technique used to assess an infant’s, a child’s, and an adult’s vital signs. TOP lanningMSC:Health Promotion and Maintenance 32. The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take? a. Secure the sensor to the toddler’s earlobe. b. Determine whether the toddler has a latex allergy. c. Place the sensor on the bridge of the toddler’s nose. d. Overlook variations between an oximeter pulse rate and the toddler’s pulse rate. ANS: B 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 patient’s apical pulse rate should be the same. Any di᯿అerence requires re-evaluation of oximeter sensor probe placement and reassessment of pulse rates. DIF:Apply (application)REF:524 OBJ: Explain variations in technique used to assess an infant’s, a child’s, and an adult’s vital signs. TOP: Implementation MSC: Health Promotion and Maintenance 33. The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed? a. Use the diaphragm portion of the stethoscope to detect Korotko᯿అ sounds. b. Obtain the reading before the child has a chance to “settle down.” c. Choose the cu᯿అ that says “Child” instead of “Infant.” d. Explain the procedure to the child. ANS: D The child’s cooperation is increased when you or the parent have prepared the child for the unusual sensation of the BP cu᯿అ. Most children understand the analogy of a “tight hug on your arm.” Di᯿అerent arm sizes require careful and appropriate cu᯿అ size selection. Do not choose a cu᯿అ based on the name of the cu᯿అ. An “Infant” cu᯿అ is too small for some infants. Readings are di᯿ᜇcult 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. Korotko᯿అ sounds are di᯿ᜇcult to hear in children because of low frequency and amplitude. A pediatric stethoscope bell is often helpful. DIF:Apply (application)REF:507 OBJ: Explain variations in technique used to assess an infant’s, a child’s, and an adult’s vital signs. TOP: Implementation MSC: Health Promotion and Maintenance 34. A nurse is caring for a group of patients. Which patient will the nurse see ᯿贄rst? a. A crying infant with P-165 and R-54 b. A sleeping toddler with P-88 and R-23 c. A calm adolescent with P-95 and R-26 d. An exercising adult with P-108 and R-24 ANS: C A calm adolescent should have the following ᯿贄ndings: P—60-90 and R—16-20. Since both ᯿贄ndings are elevated, the nurse should see this patient ᯿贄rst. An infant should have the following ᯿贄ndings: P—120-160 and R—30-50; however, since the infant is crying these values will be elevated and this is normal. A toddler should have the following ᯿贄ndings: P—90-140 and R—25-32; however, since the toddler is sleeping these values can be slightly decreased and this is normal. An adult should have the following ᯿贄ndings: P—60-100 and R—12-20; however, since the adult is exercising these values will be elevated and this is normal. DIF:Analyze (analysis)REF:499 | 501 OBJ: Identify ranges of acceptable vital sign values for an infant, a child, and an adult. TOP:AssessmentMSC:Management of Care 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 blood pressure 3 times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient? a. You can apply the cu᯿అ in any manner. b. You will need to recalibrate the machine. c. You can move your arm during the reading. d. You will need to use a stethoscope properly. ANS: B Electronic devices are easier to manipulate but require frequent recalibration—more than once a year. Because of their sensitivity, improper cu᯿అ placement or movement of the arm causes electronic devices to give incorrect readings. The portable home devices include the aneroid sphygmomanometer and electronic digital readout devices that do not require the use of a stethoscope. The cu᯿అ will need to be applied correctly, and the patient’s arm needs to be still during the reading. DIF:Apply (application)REF:510 OBJ: Describe the bene᯿贄ts and precautions involving self-measurement of blood pressure. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 36. The nurse is caring for a patient who reports feeling light-headed and “woozy.” The nurse checks the patient’s pulse and ᯿贄nds that it is irregular. The patient’s blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do? a. Apply more pressure to the radial artery to feel pulse. b. Perform an apical/radial pulse assessment. c. Call the health care provider immediately. d. Obtain arterial blood gases. ANS: B If the pulse is irregular, do an apical/radial pulse assessment to detect a pulse de᯿贄cit. If pulse count di᯿అers by more than 2, a pulse de᯿贄cit exists, which sometimes indicates alterations in cardiac output. The nurse needs to gather as much information as possible before calling the health care provider. The radial pulse is more accurately assessed with moderate pressure. Too much pressure occludes the pulse and impairs blood ᯿贄ow. Arterial blood gases is a laboratory test that measures blood pH and oxygenation status. Arterial blood gases would be appropriate if respirations were abnormal or if pulse oximetry results were severely low. DIF:Analyze (analysis)REF:519 OBJ: Identify when to measure vital signs. TOP: Implementation MSC: Reduction of Risk Potential 37. A nurse is caring for a group of patients. Which patient will the nurse see ᯿贄rst? a. A 17-year-old male who has just returned from outside “for a smoke” who needs a temperature taken b. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60 c. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74 d. An 87-year-old male suspected of hypothermia whose temperature is below normal ANS: B When a blood pressure drops in a postoperative patient, bleeding may be occurring and lead to shock. The nurse should assess this patient ᯿贄rst. Pain will cause the blood pressure to elevate so this is an expected ᯿贄nding, and while it does need to be assessed, it is not the ᯿贄rst one to assess. A teenager who has returned from smoking will have to wait at least 20 minutes before a temperature can be taken, so this is not the ᯿贄rst one to see. A patient with hypothermia is expected to have a temperature below normal, so this is not the ᯿贄rst one to see. DIF:Analyze (analysis)REF:503-505 OBJ: Identify when to measure vital signs. TOP: Assessment MSC:Management of Care 38. The health care provider prescription reads “Metoprolol (Lopressor) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic.” The patient’s blood pressure is 92/66. The nurse does not give the medication. Which action should the nurse take? a. Documents that the medication was not given because of low blood pressure b. Does not inform the health care provider that the medication was held c. Does not tell the patient what the blood pressure is d. Documents only what the blood pressure was. ANS: A 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 su᯿ᜇcient. Any intervention must be documented as well. Abnormal ᯿贄ndings must be reported to the nurse in charge or to the health care provider. DIF:Apply (application)REF:510 OBJ:Accurately record and report vital sign measurements. TOP: Communication and Documentation MSC: Management of Care 39. After taking the patient’s temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse’s action? a. Temperatures vary depending on the route used. b. Temperatures are readings of core measurements. c. Rectal temperatures are cooler than when taken orally. d. Axillary temperatures are higher than oral temperatures. ANS: A 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 0.5° C (0.9° F) lower than oral temperatures. There are core temperature readings and body surface readings. DIF:Understand (comprehension)REF:492 OBJ: Accurately record and report vital sign measurements. TOP: Implementation MSC:Health Promotion and Maintenance 40. When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the mu᯿ᜇed sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this ᯿贄nding? a. 68 b. 76 c. 138/62 d. 138/70 ANS: C 138/62 is the correct reading. The ᯿贄fth sound marks the disappearance of sound. In adolescents and adults the ᯿贄fth sound corresponds with the diastolic pressure. The fourth sound becomes mu᯿ᜇed and low pitched as the cu᯿అ is further de᯿贄ated. At this point the cu᯿అ pressure has fallen below the pressure within the vessel walls; this sound is the diastolic pressure in infants and children. 68 is the pulse pressure of 138/70; 76 is the pulse pressure for 138/62. DIF:Apply (application)REF:507 | 528 OBJ:Accurately record and report vital sign measurements. TOP:Communication and Documentation MSC:Health Promotion and Maintenance 41. The nursing assistive personnel (NAP) is taking vital signs and reports that a patient’s blood pressure is abnormally low. What should the nurse do next? a. Ask the NAP retake the blood pressure. b. Instruct the NAP to assess the patient’s other vital signs. c. Disregard the report and have it rechecked at the next scheduled time. d. Retake the blood pressure personally and assess the patient’s condition. ANS: D The nursing assistive personnel should report abnormalities to the nurse, who should further assess the patient. The nursing assistive personnel should not retake the blood pressure or other vital signs because the nurse needs to assess the patient. The report cannot be disregarded. Assessment must be done by the nurse. DIF:Apply (application)REF:492 | 525 OBJ: Appropriately delegate measurement of vital signs to nursing assistive personnel. TOP:ImplementationMSC:Management of Care MULTIPLE RESPONSE 1. A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.) a. Rectal b. Tympanic c. Esophagus d. Temporal artery e. Pulmonary artery ANS: B, 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. Temporal artery measurements detect the temperature of cutaneous blood ᯿贄ow. Oral, rectal, axillary, and skin temperature sites rely on e᯿అective blood circulation at the measurement site. DIF:Understand (comprehension)REF:492 OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Assessment MSC: Physiological Adaptation 2. The patient has new-onset restlessness and confusion. Pulse rate is elevated, as is respiratory rate. Oxygen saturation is 94%. The nurse ignores the pulse oximeter reading and calls the health care provider for orders because the pulse oximetry reading is inaccurate. Which factors can cause inaccurate pulse oximetry readings? (Select all that apply.) a. O2 saturations (SaO2) > 70% b. Carbon monoxide inhalation c. Hypothermic ᯿贄ngers d. Intravascular dyes e. Nail polish f. Jaundice ANS: B, C, D, E, F 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, arti᯿贄cial nails, metal studs, or dark skin. SpO2 is a reliable estimate of SaO2 when the SaO2 is over 70%. DIF:Understand (comprehension)REF:503 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Assessment MSC: Reduction of Risk Potential 3. The nurse is assessing the patient and family for probable familial causes of the patient’s hypertension. The nurse begins by analyzing the patient’s personal history, as well as family history and current lifestyle situation. Which ᯿贄ndings will the nurse consider to be risk factors? (Select all that apply.) a. Obesity b. Cigarette smoking c. Recent weight loss d. Heavy alcohol intake e. Regular exercise sessions ANS: A, B, D Obesity, cigarette smoking, and heavy alcohol consumption are risk factors linked to hypertension. Weight loss and regular exercise can decrease the risk for hypertension. DIF:Apply (application)REF:505 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Assessment MSC:Health Promotion and Maintenance 4. The patient is being encouraged to purchase a portable automatic blood pressure device to monitor blood pressure at home. Which information will the nurse present as bene᯿贄ts for this type of treatment? (Select all that apply.) a. Patients can actively participate in their treatment. b. Self-monitoring helps with compliance and treatment. c. The risk of obtaining an inaccurate reading is decreased. d. Blood pressures can be obtained if pulse rates become irregular. e. Patients can provide information about patterns to health care providers. ANS: A, B, E Self-measurement of blood pressure has several bene᯿贄ts. 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 bene᯿贄t 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 (comprehension)REF:509-510 OBJ: Describe the bene᯿贄ts and precautions involving self-measurement of blood pressure. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 5. A nurse is teaching the sta᯿అ about alterations in breathing patterns. Which information will the nurse include in the teaching session? (Select all that apply.) a. Apnea—no respirations b. Tachypnea—regular, rapid respirations c. Kussmaul’s—abnormally deep, regular, fast respirations d. Hyperventilation—labored, increased in depth and rate respirations e. Cheyne-Stokes—abnormally slow and depressed ventilation respirations f. Biot’s—irregular with alternating periods of apnea and hyperventilation respirations ANS: A, B, C Apnea—Respirations cease for several seconds. Persistent cessation results in respiratory arrest. Tachypnea— Rate of breathing is regular but abnormally rapid (greater than 20 breaths/min). Kussmaul’s—Respirations are abnormally deep, regular, and increased in rate. Hyperventilation—Rate and depth of respirations increase; breaths are not labored. Hypocarbia sometimes occurs. Cheyne-Stokes—Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Biot’s—Respirations are abnormally shallow for 2 to 3 breaths followed by irregular period of apnea. DIF:Understand (comprehension)REF:502 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Teaching/Learning MSC:Management of Care MATCHING A nurse is assessing results of vital signs for a group of patients. Match the condition to the assessment ᄭ஗ndings the nurse is reviewing. a. Patient’s temperature is 113° F (45° C) with hot, dry skin. b. Patient’s blood pressure sitting is 130/60 and 110/40 standing. c. Patient’s pulse is 110 beats/min. d. Patient’s temperature is 93.2° F (34° C). e. Patient’s blood pressure went from 126/76 to 90/50. 1. Hypothermia 2. Shock/Hypotension 3. Heatstroke 4. Orthostatic hypotension 5. Tachycardia 1. ANS DIF:Understand (comprehension)REF:491 | 499 | 505 OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Assessment MSC: Physiological Adaptation 2. ANS:EDIF:Understand (comprehension)REF:491 | 499 | 505 OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Assessment MSC: Physiological Adaptation 3. ANS:ADIF:Understand (comprehension)REF:491 | 499 | 505 OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Assessment MSC: Physiological Adaptation 4. ANS:BDIF:Understand (comprehension)REF:491 | 499 | 505 OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Assessment MSC: Physiological Adaptation 5. ANS:CDIF:Understand (comprehension)REF:491 | 499 | 505 OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Assessment MSC: Physiological Adaptation