Chapter 19. Vital Signs

When assessing the quality of a client's pedal pulses, what is the nurse assessing? Choose all that apply. 1) Rhythm of the pulses 2) Strength of the pulses 3) Bilateral equality of pulses 4) Rate compared with apical pulse

ANS: 2, 3 The quality of a pulse refers to the pulse volume (strength) and bilateral equality of the pulses. PTS:1DIF:EasyREF:pp. 427-428 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

The nurse assesses the following changes in a client's vital signs. Which client situation should be reported to the primary care provider? 1) Decreased blood pressure (BP) after standing up 2) Decreased temperature after a period of diaphoresis 3) Increased heart rate after walking down the hall 4) Increased respiratory rate when the heart rate increases

ANS: 1 A drop in the client's blood pressure when standing indicates orthostatic hypotension, and the cause should be investigated. The changes in vital signs indicated in the other options are normal changes for the situations. PTS:1DIF:ModerateREF:p. 439 for hypotension information but should read content about all of the vital signs KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

The nurse is teaching a client how to use a portable blood pressure device to monitor his blood pressure at home. It would be most important for the nurse to 1) Ask the client to demonstrate the use of the blood pressure device 2) Explain the importance of frequent calibration of the device 3) Give the client a chart to record his blood pressure readings 4) Provide written instructions of the information taught

ANS: 1 All are important things to include in client education, but self-monitoring of blood pressure is of little value unless it is done using proper technique. Requesting that the client demonstrate the procedure would allow the nurse to evaluate the client's technique. PTS: 1 DIF: Difficult REF: p. 437; not stated directly KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis

Which of the following procedure techniques has the most effect on the accuracy of an apical pulse count? 1) Counting the rate for 1 full minute 2) Exposing only the left side of the chest 3) Determining why assessment of apical pulse is indicated 4) Using your ring finger to palpate the intercostal spaces

ANS: 1 Apical pulse is generally indicated for patients with cardiac conditions or who are taking cardiac medications. Often they have irregular heartbeats or slow rates. A more accurate count is obtained when such heartbeats are counted for a full minute. Exposing the chest is, of course, necessary; exposing only the left side protects the patient's privacy but does not improve the accuracy. The nurse should know why an apical pulse is indicated, but this would not affect the accuracy of the count. Which finger the nurse uses to palpate depends on which hand is used. Even if the nurse failed to use the index or ring finger, this would be unlikely to affect the accuracy of the counting. PTS:1DIF:ModerateREF:p. 452 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

For which of the following adult clients should the nurse make follow-up observations and monitor the vital signs closely? A client whose 1) Resting morning blood pressure is 136/86 while the afternoon BP is 128/84 mm Hg 2) Oral temperature is 97.9°F in the morning and 99.8°F in the evening 3) Heart rate was 76 beats/min before eating and 88 beats/min after eating 4) Respiratory rate is 16 breaths/min when standing and 18 when lying down

ANS: 1 Both the blood pressures would be classified as prehypertension according to the JNC 7 Express guidelines. Body temperature normally increases during the course of a day. Heart rate increases for several hours after eating. Respiratory depth decreases when lying down, so it would be normal for the rate would increase; both rates are within normal limits. PTS:1DIF:ModerateREF:p. 440 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

The nurse is assessing vital signs for a client after surgical procedure on the left leg. IV fluids are infusing. It would be most important for the nurse to 1) Compare the left pedal pulse with the right pedal pulse 2) Count the client's respiratory rate for 1 full minute 3) Take the blood pressure in the arm without an IV 4) Take an oral temperature with an electronic thermometer

ANS: 1 For a client having surgery on the leg, the most important data would be whether the circulation has been compromised because of the surgery. This can be done only by comparing one leg with the other. The nurse would, of course, count the respiratory rate for 1 full minute and take the BP in the arm without the IV. Oral temperatures are commonly obtained using electronic thermometers. PTS:1DIF:ModerateREF:p. 449-450 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

The nursing instructor asks students how they would assess the fifth vital sign. Which student would be correct? 1) "I would have the client rate her pain on a scale of 0 to 10." 2) "I would ask the client when she had her last bowel movement." 3) "I would take the client's pulse oximetry reading." 4) "I would interview the client about history of tobacco use."

ANS: 1 Pain is considered to be the "fifth vital sign." PTS:1DIF:EasyREF:p. 414 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

A client's average normal temperature is 98°F. Which of the following temperatures would be expected during the night in this healthy young adult client who does not have a fever, inflammatory process, or underlying health problems? 1) 97.2°F 2) 98.0°F 3) 98.6°F 4) 99.2°F

ANS: 1 The lowest temperature occurs during sleep (usually at night) when the metabolic rate is lowest. Temperature normally increases throughout the day until it peaks in the early evening. PTS:1DIF:EasyREF:p. 417 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application

At last measurement, the client's vital signs were as follows: oral temperature 98°F (36.7°C), heart rate 76 beats/min, respiratory rate 16 breaths/min, and blood pressure (BP) 118/60 mm Hg. Four hours later, the vital signs are as follows: oral temperature 103.2°F (38.5°C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mm Hg. Which should be the nurse's first intervention at this time? 1) Ask the client if he has had a warm drink in the last 30 minutes. 2) Notify the primary care provider of the client's temperature. 3) Ask the client if he is feeling chilled. 4) Take the temperature by a different route.

ANS: 1 With a fever, the heart rate and respiratory rate are usually elevated. In this case, they are within normal limits, so the nurse should wonder about the accuracy of the temperature reading and validate it in some way. Because having a hot drink is a common cause of false readings, the nurse should determine whether that has occurred before retaking or otherwise validating the reading. PTS: 1 DIF: Moderate REF: p. 421; should know norms for all vital signs, p. 414, to answer question

All of the following clinical signs may be present with hypoxia. However, only two are specific indicators of hypoxia (that is, if they are present, it means that the patient is probably hypoxic). Which ones are specific indicators of hypoxia? Choose all that apply. 1) Feelings of anxiety 2) Crackles in the lung bases 3) Increased heart rate 4) Improved breathing in upright position

ANS: 1, 3 Apprehension, confusion, dizziness, and an increased heart rate are all specific manifestations of hypoxia. Although they are not listed in this question, cyanosis of the tongue and oral mucosa are also good indicators of hypoxia because those areas are not affected by cold or reduced circulation as are the nails, lips, and skin. Crackles and orthopnea are abnormal respiratory findings, but they do not necessarily indicate poor oxygenation. PTS:1DIFgrinifficultREF:p. 432 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

Which of the following interventions would be appropriate for a client who has a fever? Choose all that apply. 1) Put an ice pack on the client's neck and axillae. 2) Provide the client a blanket when he is shivering. 3) Offer the client fluids to drink every 1 to 2 hours. 4) Take the temperature using a tympanic thermometer.

ANS: 1, 3 If ice packs are used, they are applied to the groin, neck, or axillae. A fever increases metabolic needs, so fluids are necessary to prevent dehydration. A blanket would help with heat retention. A tympanic thermometer is not appropriate when an accurate temperature is needed, as when a client has a fever. PTS:1DIF:EasyREF:p. 423 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

Which one of the following clients would probably have a higher than normal respiratory rate? A client who has 1) Had surgery and is receiving a narcotic analgesic 2) Had surgery and lost a unit of blood intraoperatively 3) Lived at a high altitude and then moved to sea level 4) Been exposed to the cold and is now hypothermic

ANS: 2 A reduction in hemoglobin from blood loss would increase the respiratory rate. Narcotics and hypothermia slow the respiratory rate. Going from lower altitudes to higher altitudes inhibits oxygen binding, so going to a lower altitude would decrease the respiratory rate or have no effect. Hypothermia decreases the metabolic rate, so the respiratory rate would likely decrease. PTS:1DIF:ModerateREF:p. 430 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

Which of the following pieces of information in the client's health history might indicate a risk for primary hypertension? 1) Consumes a high-protein diet 2) Drinks three to four beers every day 3) Has a family history of kidney disease 4) Does not engage in physical exercise

ANS: 2 Heavy alcohol consumption, age, race, high-sodium diet, tobacco use, family history of hypertension, and high cholesterol levels put a client at risk for primary hypertension. Kidney disease is a cause of secondary hypertension. PTS:1DIF:ModerateREF:pp. 434-435 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

Which assessment data best support a report of severe pain in an adult client whose baseline vital signs are within an average normal range? 1) Oral temperature 100°F (37.8°C) 2) Respiratory rate 26 breaths/min and shallow 3) Apical heart rate 56 beats/min 4) Blood pressure 124/82 mm Hg

ANS: 2 Respiratory rate 26 breaths/min and shallow. Acute pain causes an increase in respiratory rate but a decrease in depth. Elevated temperature does not indicate pain. The apical pulse is lower than normal, but because the pulse increases with pain, a rate of 56 beats/min does not indicate pain. A blood pressure of 124/82 mm Hg is within normal limits. Blood pressure usually elevates temporarily with acute pain; it may decrease over time with unremitting chronic pain. PTS:1DIF:EasyREF:p. 430 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

The nurse hears rhonchi when auscultating a client's lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds? 1) Have the client take several deep breaths. 2) Request the client take a deep breath and cough. 3) Take the client's blood pressure and apical pulse. 4) Count the client's respiratory rate for 1 minute.

ANS: 2 Rhonchi are caused by secretions in the large airways and may clear with coughing. This is how you differentiate between rhonchi and other adventitious sounds. Deep breathing will not help to clear rhonchi. Taking the blood pressure and apical pulse and counting the respiratory rate are not effective for clearing rhonchi and would not be sufficient for the nurse to identify whether the sounds were, indeed, rhonchi. PTS:1DIF:ModerateREF:p. 431 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

Which of these steps in taking a blood pressure is correct? Choose all that apply. 1) Use a bladder that encircles 40% of the arm. 2) Wrap the cuff snugly around the client's arm. 3) Ask the client to hold the arm at heart level. 4) Have the client sit with feet flat on the floor.

ANS: 2, 4 The cuff should be wrapped snugly around the client's arm. Crossed legs or dangling legs can increase blood pressure, so feet should be flat on the floor. The bladder should encircle 80% of the arm. Holding the arm out can cause an erroneously higher blood pressure measurement; the arm should be supported. PTS: 1 DIF: Moderate REF: pp. 457-460 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension

The nurse provides client education regarding hypertension prevention and management. Which of these statements indicates that the client understands the instructions? 1) "I don't have to worry if my blood pressure is high once in a while." 2) "I guess I will have to make sure I don't drink too much water." 3) "I can lose some weight to help lower my blood pressure." 4) "I will need to reduce the amount milk and other dairy products I use."

ANS: 3 A single lifestyle change, such as weight loss, can lower blood pressure (BP). Whenever the client has an elevated BP, the reading should be monitored even when it occurs just occasionally. Drinking too much alcohol is associated with hypertension, but water consumption is not unless accompanied by high sodium intake. A diet high in calcium is recommended to prevent and manage hypertension; therefore, it is not advisable to limit the intake of dietary calcium found in dairy products. PTS:1DIF:ModerateREF:pp. 434-435 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application

The nurse is instructing a client how to appropriately dress an infant in cold weather. Which of the following instructions would be most important for the nurse to include? 1) "Be sure to put mittens on the baby." 2) "Layer the infant's clothing." 3) "Place a cap on the infant's head." 4) "Put warm booties on the baby."

ANS: 3 All interventions are correct, but because of the many blood vessels close to the skin surface in the head, infants lose approximately one third of their body heat through the head. Therefore, to prevent heat loss, it is most important to cover the head. PTS:1DIF:ModerateREF:p. 417 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

A client's axillary temperature is 100.8°F. The nurse realizes this is outside normal range for this client and that axillary temperatures do not reflect core temperature. What should the nurse do to obtain a good estimate of the core temperature? 1) Add 1°F to 100.8°F to obtain an oral equivalent. 2) Add 2°F to 100.8°F to obtain a rectal equivalent. 3) Obtain a rectal temperature reading. 4) Obtain a tympanic membrane reading.

ANS: 3 Body temperatures, from lowest to highest, are axillary, oral, rectal, and tympanic. For oral, axillary, and rectal temperatures, there is a 1°F degree difference between each site and the next higher one. However, mathematical conversions between sites are not reliable and should be used only when a rough estimate is needed—for instance, to decide whether a reading needs to be validated by another site or another thermometer. Rectal temperatures are most reliable and most accurately reflect the core temperature. Tympanic membrane readings are considered by most to be the least accurate and least reliable. PTS:1DIF:ModerateREF:pp. 415, 421-422 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

A client's vital signs at the beginning of the shift are as follows: oral temperature 99.3°F (37°C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four hours later the client's oral temperature is 102.2°F (39°C). Based on the temperature change, the nurse should anticipate the client's heart rate would be how many beats/min? 1) 62 2) 82 3) 102 4) 122

ANS: 3 Heart rate increases about 10 beats per minute for each degree of temperature to meet increased metabolic needs and compensate for peripheral dilation. PTS:1DIF:ModerateREF:p. 426 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

A client who has been hospitalized for an infection states, "The nursing assistant told me my vital signs are all within normal limits; that means I'm cured." The nurse's best response would be which of the following? 1) "Your vital signs confirm that your infection is resolved; how do you feel?" 2) "I'll let your healthcare provider know so you can be discharged." 3) "Your vital signs are stable, but there are other things to assess." 4) "We still need to keep monitoring your temperature for a while."

ANS: 3 Vital signs are one indicator of a client's physiological status, but they are not an absolute indicator of well-being from every aspect. It may be inaccurate to state that the vital signs indicate the infection is resolved; vital signs could stabilize even if the infection remains active. The healthcare provider's decision regarding the client's readiness for discharge is not based exclusively on the vital signs but rather is based on a compilation of other sources of information, primarily the client's clinical status, but also cultures, complete blood counts, and various other laboratory and possibly radiologic evidence. Although the nurse will need to continue monitoring the temperature, other clinical signs must also be monitored; therefore, the statement "We still need to keep monitoring your temperature . . ." is incomplete and less useful than the statement that begins "Your vital signs are stable, but . . ." PTS:1DIFgrinifficultREF:p. 414 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application

Comparing the changes in vital signs as a person ages, which statement is correct? Select all that apply. 1) Blood pressure decreases less than heart rate and respiratory rate. 2) Respiratory rate remains fairly stable throughout a person's life. 3) Blood pressure increases; heart rate and respiratory rate decline. 4) Men have higher blood pressure than women until after menopause.

ANS: 3, 4 Heart rate and respiratory rate tend to decrease as people age, whereas the blood pressure increases because of increased vascular resistance. Men's blood pressure tends to be higher than women's until after menopause, when women's blood pressure typically increases. PTS: 1 DIF: Moderate REF: pp. 430, 434 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Analysis

Which blood pressure has a pulse pressure within normal limits? Choose all that apply. 1) 104/50 mm Hg 2) 120/62 mm Hg 3) 120/80 mm Hg 4) 130/86 mm Hg

ANS: 3, 4 The pulse pressure is the systolic blood pressure (BP) minus the diastolic BP. The pulse pressure is usually approximately one third of the systolic pressure. (120 - 80 = 40; 40 = 1/3 of 120) (130 - 86 = 44; 1/3 of 130 = 43.3) PTS:1DIF:ModerateREF:p. 433 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

In evaluating a client's blood pressure for hypertension, it would be most important to 1) Use the same type of manometer each time 2) Auscultate all five Korotkoff sounds 3) Measure the blood pressure in both arms 4) Monitor the blood pressure for a pattern

ANS: 4 Blood pressure fluctuates a great deal during the day and is influenced by age, sex, activity, and many other factors. Any determination of hypertension must be done after two or more BP readings taken on separate occasions. The type of manometer does not greatly influence the reliability of BP readings, although the mercury manometer is more accurate. Only the first and last Korotkoff sounds are necessary to determine a BP reading. The first time BP is assessed for a patient, the nurse should compare the reading in the left and right arm; however, this is not specific to evaluating for hypertension. PTS:1DIF:ModerateREF:p. 434 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

For which of the following patients would it be most important to obtain an apical-radial pulse and calculate the pulse deficit? A patient who 1) Had abdominal surgery 2 hours ago 2) Suffered a fractured hip yesterday 3) Is dehydrated from vomiting 4) Has a heart or lung disease

ANS: 4 Conditions that require assessment of pulse deficit include digitalis therapy and blood loss, cardiac or respiratory disease, and other conditions that affect oxygenation status. PTS:1DIF:ModerateREF:p. 427 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

During a clinic interview, a client states he has been experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement? 1) Ask the client when in the day dizziness occurs. 2) Help the client to assume a recumbent position. 3) Measure both heart rate and blood pressure with the client standing. 4) Measure vital signs with the client supine, sitting, and standing.

ANS: 4 Dizziness upon standing is a symptom of orthostatic hypotension. The nurse should obtain orthostatic vital signs (measure pulse and blood pressure with the patient supine, sitting, and standing) to assess for orthostatic hypotension. The time of day is irrelevant to the diagnosis. If the nurse observes the patient become dizzy upon standing, the first action would be to help the client lie down and then obtain orthostatic vital signs; but this is not necessary when the symptom is not present. The nurse needs to measure both the heart rate and the blood pressure but not only in the standing position. PTS:1DIF:ModerateREF:p. 439 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

The client has had a fever, ranging from 99.8°F orally to 103°F orally, over the last 24 hours. The client's fever would be classified as 1) Constant 2) Intermittent 3) Relapsing 4) Remittent

ANS: 4 Remittent fevers fluctuate widely over a 24-hour period. Constant fevers stay above normal with only slight fluctuations. Intermittent fevers alternate between normal or subnormal temperatures with periods of fever. Relapsing fevers alternate between periods of fever and periods of normal temperature, each phase lasting 1 to 2 days. PTS:1DIF:ModerateREF:p. 418 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

In caring for a client who has a fever, it would be important for the nurse to monitor for increased 1) Urine output 2) Sensitivity to pain 3) Blood pressure 4) Respiratory rate

ANS: 4 The metabolic rate increases with a fever, increasing a person's respiratory rate. Urine output would more likely decrease, rather than increase, because of increased insensible loss and possible loss of intake because of loss of appetite. Change in pain sensation is not a symptom of a fever. Blood pressure is more likely to decrease with a fever because of peripheral vasodilation. PTS:1DIF:ModerateREF:p. 430 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application

Which of the following sets of vital signs are all within normal limits for patients at rest? 1) Infant: T 98.8°F (rectal), HR 160, RR 16, BP 120/54 2) Adolescent: T 98.2°F (oral), HR 80, RR 18, BP 108/68 3) Adult: T 99.6°F (oral), HR 48, RR 22, BP 130/84 4) Older adult: T 98.6°F (oral), HR 110, RR 28, BP 170/95

ANS:2 All of the adolescent's vital signs are within normal parameters for the age. The infant's temperature is below normal for a rectal reading because the core temperature is approximately 1 degree higher than readings from other sites. The heart rate (HR) for an infant is high, the respiratory rate (RR) is low, and the blood pressure (BP) is high for the age. For the typical adult, the temperature is high, the HR is low, the RR is high, and the BP is elevated for the age. For the older adult, the temperature is high-end normal, the HR is high, the RR is high, and the BP is high for the age. PTS:1DIFgrinifficultREF:p. 414; for adult vital signs ESG Table 19-1, Comparison of Normal Vital Signs for Various Ages

A client's vital signs 4 hours ago were temperature (oral) 101.4°F (38.6°C), heart rate 110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/78 mm Hg. The temperature is now 99.4°F (37.4°C). Based only on the expected relationship between temperature and respiratory rate, the nurse might best anticipate the client's respiratory rate to be 1) 16 2) 18 3) 20 4) 22

ANS:2 For every degree Fahrenheit (0.6°C) the temperature falls, the respiratory rate may decrease up to 4 breaths per minute. The client's temperature has fallen 2 degrees; multiplied by 4, this is 8. It was 26 breaths/min: 26 - 8 = 18 breaths/min. Keep in mind, this is an estimate and would vary depending on the patient's baseline health, current condition, age, and other factors. PTS:1DIF:EasyREF:p. 430 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

The client's temperature is 101.1°F. Which is the correct conversion to centigrade? 1) 38.0°C 2) 38.4°C 3) 38.8°C 4) 39.2°C

ANS:2 To convert Fahrenheit to centigrade, subtract 32 from the temperature, and multiply by 5/9. PTS:1DIFgrinifficultREF:p. 419 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application