Ch 32 - Vitals - foundations

34. The nurse has assigned nursing assistive personnel to obtain the blood pressures on the unit's 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. "I'll 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. "I'll 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?"

"I'll chart the results and let you know whose pressure is running high."

35. The nurse has assessed a client's blood pressure (BP) using the left thigh because of bilateral upper arm casts. The client's 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

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

19. While the nurse is taking the client's 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

130/84 mm Hg

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 Crohn's 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

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

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 Parkinson's 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

A 69-year-old diagnosed with Parkinson's disease 5 years ago

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 client's room

A diagnosis of peripheral vascular disease

28. The nurse enters the room to measure the client's pulse rate. The nurse recognizes that the client's rate may be increased as a result of: 1. A febrile condition 2. Administration of digoxin 3. The client's athletic conditioning 4. Unrelieved severe postoperative pain

A febrile condition

6. The appropriate site for taking the pulse of a 2-year-old is: 1. Radial 2. Apical 3. Femoral 4. Pedal

Apical

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

Axillary site

27. The client's 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

Fourth to fifth intercostal space

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

Heat exhaustion

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

P = 110 beats/min

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

Wraps the cuff too loosely around the arm

33. The nurse has assigned nursing assistive personnel to obtain the blood pressures on the unit's clients. Which of the following statements made by the assistive personnel shows the best understanding regarding appropriate communication of the BP readings? 1. "I'll ask the clients what their blood pressure usually runs." 2. "I'll give you a list of all the readings I get before I chart them." 3. "I'll chart the results and let you know whose pressure is high." 4. "I'll recheck any pressure that seems higher than their normal."

"I'll give you a list of all the readings I get before I chart them."

41. The nurse has assigned nursing assistive personnel to obtain the temperatures on the unit's 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. "I'll wait until breakfast is over so I won't distract them from eating." 4. "I'll chart the results and let you know whose temperature is running high."

"I'll wait until breakfast is over so I won't distract them from eating."

30. The nurse has assigned the vital signs of the elderly clients residing in the facility's 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 doesn't have to if your vessels are healthy." 2. "If anyone's oral temperature is over 100° F, I'll 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 client's stomach and count the number of times it rises when I am counting respirations."

"If anyone's oral temperature is over 100° F, I'll let you know right away since that means they have a fever."

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. "I'll wait until she's been medicated for pain before I take it."

"Is there anything affecting her right arm?"

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 Parkinson's 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

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

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 Parkinson's 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

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

7. 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

Application of a cooling blanket

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

Assess the thermometer for 5 minutes

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 client's blood pressure 3. Assist the client into a sitting position 4. Tell the client to take several deep breaths

Assist the client into a sitting position

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

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

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. Biot's respirations 2. Kussmaul's respirations 3. Hyperpneic respirations 4. Cheyne-Stokes respirations

Cheyne-Stokes respirations

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

Confusion

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 client's rate of respirations 4. Palpate the client's own radial pulse

Count the client's rate of respirations

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

Drink a bowl of warm soup

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

Essentially the same as that in the brachial artery

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 nurse's most appropriate action is to: 1. Give the medication 2. Ask if the client is anxious 3. Check the client's dressing for bleeding 4. Recheck the client's vital signs in 30 minutes

Give the medication

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 client's 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 client's blood pressure both sitting and standing and use the higher reading.

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

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

Notify the physician

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

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

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

Popliteal fossa behind the knee

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

Prescribed diuretic administration

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

Replacement of fluid and electrolytes

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 client's four extremities 3. Restrict oral fluid consumption 4. Apply a hypothermia mattress

Restrict oral fluid consumption

20. After measuring the client's 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 client's temperature 3. Report all of the findings immediately 4. Record the findings as within normal limits

Retake the blood pressure

38. The nurse is assessing a client's 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 client's health care provider 3. Dictate that pressure should be monitored in the left arm 4. Indicate that the client may be experiencing vascular problems

Should be reported to the client's health care provider

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

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

25. A spouse assists the nurse evaluating the measurement of the client's 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

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

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

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

37. The nurse is assessing an elderly client's 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 client's 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 client's ability to hear the first Korotkoff sound 4. The client is not inflating the cuff sufficiently to detect the systolic pressure

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

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

Wait 20 minutes before assessing the oral temperature