Chapter 25: Vital Signs Practice Questions

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure?

the ability of the arteries to stretch

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?

1700

When assessing an infant's axillary temperature, it will be:

1°F (0.5°C) lower than an oral temperature.

Which client would the nurse consider at risk for low blood pressure?

A client with low blood volume

The nurse walks into the client's room to pick up the dinner tray and notes the client has not eaten. Which action should the nurse prioritize after noting the client appears sleepy, has perspiration on the forehead, and the face appears flushed?

Assess temperature

When assessing a client's radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next?

Auscultate the apical pulse for 60 seconds

A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation?

Auscultate the lung sounds and count respirations.

Which guideline should the nurse follow when assessing a client's blood pressure using a Doppler ultrasound?

Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery.

The nurse is preparing to measure a child's temperature with a temporal artery thermometer. For which reason(s) would the nurse choose this method of obtaining temperature in this client? Select all that apply

Children often cannot keep lips closed tight enough to capture a true reading of an oral measurement. Temporal temperature is close to oral temperature readings. Research states temporal thermometers are more accurate than axillary temperature measurement. There is a built-in verification of temperature by touching behind the ear.

Which statement describes diastolic blood pressure?

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.

A nurse is caring for a client with orthostatic hypotension. The client is currently not taking any antihypertensive medications. Which actions will the nurse take to reduce the client's risk of falls? Select all that apply.

Ensure that the client is taking an adequate volume of fluids. Assist the client in applying compression stockings to lower extremities Ask the client to wait one hour after meals to engage in physical activity Encourage the client to stand up from a sitting position slowly.

A client monitoring his BP at home notices that his BP is higher in one arm than the other. He calls his health care provider for guidance. What is the most appropriate information for the nurse to give this client?

It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results.

The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that would explain the tachycardia? Select all that apply.

The client has reports of pain of 8 on a scale of 0 to 10 The client just finished ambulating with physical therapy The client has a temperature of 101.8°F (38.8°C)

The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this?

The client is covered with a couple of thick blankets.

A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify?

The client's most recent temperature

A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which action should the nurse perform to obtain the accurate temperature of the client?

Wait for 30 minutes before measuring the oral temperature

The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mmHg. What is the priority nursing intervention?

ask the client to demonstrate self-blood pressure assessment

The nurse is attempting to assess a client's radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurse take next?

assess the apical pulse

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?

auscultate the client's apical pulse

While assessing for orthostatic hypotension, the nurse follows which step(s) when taking the blood pressure? Select all that apply.

check and record blood pressure taken while the client is in bed assist the client to standing position and wait 2 to 3 minutes before taking blood pressure Record measurements and note if the drop is > or equal to 20 mmHg and > or equal to 10 mmHg use the same blood pressure cuff the whole time

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:

decrease the apical pulse.

The nurse is assessing the pulse amplitude for a client. Documentation by the nurse states, "Pulses are +1 in the lower left extremity." What amplitude is the nurse assessing?

diminished, weaker than expected

The nurse is caring for a client who has smoked for more than 20 years and is now experiencing labored respirations. The nurse documents the client is experiencing:

dyspnea

The nurse notes that the temperature of an ill client is 101°F (38.3°C). Which intervention would the nurse take to regulate the client's body temperature?

give the client a bath in tepid water

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem?

peripheral vascular disease

The nurse is caring for a 77-year-old client who is recovering from surgery. After notifying the health care provider of the incident recorded in the client's chart (above), what will the nurse anticipate teaching the client?

postural hypotension