Vital Signs

A patient is advised an electrocardiogram to rule out dysrhythmia. Which statement is true about an electrocardiogram? 1. It records the electrical activity of the heart for a 12-second interval. 2. It records and stores 24 hours of electrical activity. 3. It provides continuous monitoring of the heart transmitted to a stationary monitor. 4. It allows for immediate treatment if the heart rate becomes unstable.

1. It records the electrical activity of the heart for a 12-second interval. An electrocardiogram records the electrical activity of the heart for a 12-second interval. The procedure involves placing electrodes across the patient's chest followed by recording the heart rhythm. A Holter monitor is worn on the patient's body, and it records and stores 24 hours of electrical activity. The recorded information cannot be accessed before the 24 hours of assessment. A cardiac telemetry provides continuous monitoring of the heart transmitted to a stationary monitor. It records the heart activity in relation to the patient's activities. It has the advantage of allowing immediate treatment if the heart rate becomes unstable.

A patient's blood pressure is 124/87 mm Hg. What is the patient's pulse pressure? Record answer as a whole number Answer: _____ mm Hg

Answer 30 Pulse pressure is the difference between the systolic and diastolic blood pressures. If the patient's blood pressure is 124/87, the numerator indicates systolic pressure and the denominator indicates diastolic pressure. Therefore, the patient's pulse pressure would be 37 mm Hg (124 - 87).

The various Korotkoff sounds heard during the measurement of blood pressure through auscultation are listed below. Arrange the sounds in the order in which they are heard. 4. A distinct, abrupt muffling sound. 3. Crisp, loud sounds as the blood flows through an opening artery. 2. Muffled, swishing sounds. 1. Tapping sounds, which gradually increase in intensity to a thud or loud tap.

Correct 1. Tapping sounds, which gradually increase in intensity to a thud or loud tap 2. Muffled, swishing sounds. 3. Crisp, loud sounds as the blood flows through an opening artery. 4. A distinct, abrupt muffling sound. Korotkoff I: The first appearance of faint but clearly audible tapping sounds, which gradually increase in intensity to a thud or loud tap. The first sound is recorded as the systolic pressure. Korotkoff II: Muffled, swishing sounds. Korotkoff III: Crisp, loud sounds as the blood flows through an opening artery. Korotkoff IV: A distinct, abrupt muffling sound. Korotkoff V: The last sound heard before silence. This is the diastolic measurement.

A newborn with respiratory infection has a heart rate of 150 beats per minute. What term or phrase does the nurse use to record this finding in the case sheet? 1. Bradycardia 2. Heart rate within normal limits 3. Primary tachycardia 4. Tachycardia secondary to infection

Correct 2. Heart rate within normal limits An acceptable pulse in newborns is between 80 and 160 beats per minute.

A nurse records a blood pressure (BP) reading of 166/110 mm Hg in a patient. When she reviews his records, she sees that his previous recording was 159/112. What interventions are appropriate for this patient? Select all that apply. A. Refer the patient to the healthcare provider. B. Evaluate the patient again in one month. C. Reassess the blood pressure within two months. D. Recheck the blood pressure within three months. E. Recheck the blood pressure three different times in six months.

Correct A, B A blood pressure of166/110 mm Hg indicates that the patient is in stage 2 hypertension. Stage 2 hypertension is characterized by an average blood pressure reading of 160/100 mm Hg or above taken at two or more visits. The management of stage 2 hypertension includes referring the patient to the healthcare provider for diagnosis and prompt treatment and then evaluating the patient within one month to assess efficacy of treatment. For stage 1 hypertension, a confirmation is required within two months. Rechecking within three months or three different times in six months is not appropriate for stage 2 hypertension. The reevaluation should be done on a monthly basis.

A patient is admitted to the hospital with complaints of pallor, skin mottling, clamminess, and confusion. The nurse assessed the vitals and found that the blood pressure is 90/60 mm Hg. She reports it to the healthcare provider immediately. What could be the cause of low blood pressure? Select all that apply. A. Hemorrhage B. Myocardial infarction C. Heavy alcohol consumption D. Sedentary lifestyle E. High sodium intake

Correct A, B Hypotension (low blood pressure) occurs because of arterial dilation or considerable bleeding (e.g., hemorrhage), or the failure of the heart muscle to pump adequately (e.g., myocardial infarction). Modifiable risk factors for hypertension, rather than hypotension, include obesity, cigarette smoking, heavy alcohol consumption, and high sodium (salt) intake. Sedentary lifestyle and continued exposure to stress are also linked to hypertension

Which of the following patients is at most risk for tachypnea? Select all that apply. A. Patient just admitted with four rib fractures B. Woman who is 9 months' pregnant C. Adult who has consumed alcoholic beverages D. Adolescent awaking from sleep E. Patient who regularly runs marathons

Correct A, B Rib fractures would cause splinting and pain to increase respiratory rate. Pregnancy impedes diaphragmatic excursion, causing shallow, frequent breaths.

A nurse has been asked to measure the respiratory efficiency of a patient. What data is collected to reflect the processes involved in assessing respiratory efficiency? Select all that apply. A. Diffusion B. Perfusion C. Ventilation D. Spinal reflexes E. Respiratory muscle strength

Correct A, B, C Respiratory efficiency is assessed by collecting data from diffusion (movement of oxygen and carbon dioxide between alveoli and red blood cells), perfusion (distribution of red blood cells to and from the pulmonary capillaries), and ventilation (movement of gases in and out of lungs). Spinal reflexes are not involved in controlling respiration. Respiratory muscle strength is one of the factors determining ventilation. Data related to respiratory muscle strength would not directly reflect the respiratory efficiency.

A patient has developed a high fever due to a bacterial infection. What are the symptoms the nurse expects to find in the patient? Select all that apply. A. Confusion B. Increased metabolism C. Decreased respiratory rate D. Increased heart rate and angina E. Salt and water retention

Correct A, B, D During fever, the oxygen demand of the body increases and patients are at risk of developing hypoxia, which may lead to confusion. There is increased metabolism in the body owing to removal of the disease-causing bacteria from the body. As greater blood supply is required in response to increased metabolism, the workload of the heart increases during infection. This leads to an increased heart rate. Such patients may develop angina due to hypoxia, with increased metabolism and an associated increase in oxygen consumption. During fever, patients are at risk of dehydration, not water retention. There is an increase in the respiratory rate to meet the oxygen demands of the body.

A nurse has been asked to measure the arterial oxygen saturation of a patient who has consumed organic phosphorus poison. While using the pulse oximeter with digital probes, what are the factors that affect the functional ability of the device? Select all that apply. A. Nail polish B. Artificial nails. C. Hyperthermia D. Fair skin pigment E. Metal studs in nails

Correct A, B, E Nail polish, artificial nails, and metal studs in the nails interfere with light transmission of the device and yield inaccurate results. The presence of hypothermia at the assessment site interferes with the device functioning by decreasing the peripheral blood flow. Dark skin pigmentation results in device malfunction and may yield an overestimation of saturation.

On examination, a nurse finds that the patient's body temperature is high. What are the situations when the body temperature rises above the baseline? Select all that apply. A. After long-distance running B. After taking a stroll in the park C. During physical or emotional stress D. During the evening, maximum at 6.00 p.m. E. During early morning from 1.00 a.m. to 4.00 a.m.

Correct A, C, D The body maintains a balance between heat production and heat loss. This is reflected by various temperature readings throughout the day. Exercise such as long-distance running, stress, and strong emotions can increase cellular activity, thus raising body temperature. Body temperature may increase as high as 1°F because of an increase in physical activity throughout the day and is at its peak at 6.00 pm; thereafter it decreases. Taking a stroll in the park does not raise body temperature since it does not cause physical exertion. For most people, body temperature is usually lowest in the morning because of a decrease in the basal metabolic rate related to inactivity.

The nurse is taking a patient's vital signs. What are factors that affect a patient's pulse rate? Select all that apply. A. Age B. Hot beverage C. Stress levels D. Race E. A fever F. Acid-base balance

Correct A, C, E The pulse rate varies with age. Children have a higher pulse rate than adults. Increased stress also increases the pulse rate. The body metabolism accelerates during a fever and leads to an increased pulse rate. A hot beverage may affect the temperature reading but not the pulse rate. A patient's race may indicate an elevated risk for hypertension but does not affect pulse rate. An acid-base balance will not alter pulse rate.

A nurse is assessing the respiratory pattern of a patient. Which statements are true about various patterns of respiration? Select all that apply. A. Apnea is the absence of respiration for a short time. B. Apnea is the increase in rate and depth of respiration. C. Kussmaul's respiration is the increase in rate and depth of respiration. D. Kussmaul's respiration is the period of apnea following periods of rapid and shallow breathing. E. Cheyne-Stokes' respiration is the period of apnea following a period of rapid and shallow breathing.

Correct A, C. E Apnea is the cessation of breathing for a short period of time. Kussmaul's respiration is the increased rate and depth of breathing due to alterations in pH. Cheyne-Stokes' respiration is characterized by a period of apnea following a period of rapid and shallow breathing. This type is generally seen after injury to the brain stem or reduced flow of oxygenated blood to the brainstem.

A patient asks the nurse about the various factors that influence body temperature. What are the appropriate responses by the nurse? Select all that apply. A. "The hypothalamus controls body temperature." B. "The posterior pituitary is responsible for causing loss of heat." C. "The core body temperature is altered in response to changes in the external temperature." D. "Sweating and vasodilation are responsible for reducing body temperature." E. "Heat is produced in the body during muscle contraction and muscle shivering."

Correct A, D, E The hypothalamus is responsible for controlling body temperature because it acts as the thermostat of the body. Sweating and vasodilation cause heat loss from the body and thus reduce the body temperature. Heat production in the body is accomplished by vasoconstriction, muscle contraction, and muscle shivering. The posterior pituitary is responsible for heat production, not heat loss. Temperature regulatory mechanisms maintain the core body temperature in response to alterations in external temperature. A rise in the environmental temperature activates the body's heat loss mechanism to keep the core body temperature constant.

A nursing mentor is explaining orthostatic hypotension to nursing students. Which statements made by the mentor are appropriate about orthostatic hypotension? Select all that apply. A. "Measurement of blood pressure should not be delegated in such a situation." B. "Orthostatic hypotension usually occurs within 1 minute of sitting." C. "Place the patient in a sitting position if dizziness is reported." D. "Blood pressure should be obtained in supine, sitting, and standing positions." E. "Blood pressure should be obtained 1-3 minutes after changing the patient's position."

Correct A, D, E Measuring orthostatic hypotension requires critical thinking and ongoing judgment; this procedure should not be delegated. Assessment involves obtaining the blood pressure and pulse of the patient in supine, sitting, and standing positions. The blood pressure has to be obtained 1-3 minutes after the change in the patient's position. Orthostatic hypotension usually occurs within 1 minute of standing, not sitting. If the patient feels dizzy, then the patient should be placed in lying position, not in sitting position.

A nurse is conducting a class on different temperature measurement sites. In which patients should the tympanic membrane be used as a site for measurement of temperature? Select all that apply. A. Neonates B. Patients with otitis media C. Patients who had surgery of the ear D. Patients with cerumen impaction E. Patients complaining of tachypnea

Correct A, E A tympanic thermometer is fast, safe, and noninvasive and can be used for neonates and in patients complaining of tachypnea without affecting breathing. Tympanic thermometers are not recommended for patients who have had a recent ear infection such as otitis media; using a tympanic thermometer may spread the infection, and may measure inaccurately. Patients with cerumen impaction should not have their temperature measured through a tympanic thermometer as it can give an erroneous reading. Surgery on the ear is a contraindication for use of the tympanic thermometer.

A hospital replaces all sphygmomanometers with electronic blood pressure (BP) devices. In which situations is the use of electronic devices not recommended? Select all that apply. A. Seizures B. Shivering C. Faint tremors D. Irregular heart rate E. Severe hypotension

Correct A. Seizures B. Shivering D. Irregular heart rate E. Severe hypotension Electronic devices cannot be used to measure BP in any situation where the patient cannot be kept still such as in seizures and shivering. An irregular heart rate would interfere with the BP measurement so electronic BP measurement cannot be done in such patients. Electronic blood pressure devices are unable to process sounds or vibrations of low BP, thus it would not be helpful to measure BP in severe hypotensive states. Electronic devices are not appropriate if the patient has excessive tremors.

A 60-year-old male patient complains of severe breathlessness, sweating, pain in the chest, and cough. What guidelines should the nurse follow when measuring the vital signs? Select all that apply. A. Measure the vital signs 4 times per day. B. Determine the patient's medical history. C. Use equipment that is appropriate per age of the patient. D. Report any change in vital signs to the healthcare provider. E. Use vital sign measurements to determine indications for medication administration.

Correct B, C, E The nurse should know the patient's medical history to know which vital sign would be affected by medications, environmental factors, or detecting complications. Proper equipment per the age of the patient should be used to prevent errors. The vital signs should be used as an indication for administration of medication to determine its effectiveness. The frequency of measuring the vital signs has to be discussed with the primary healthcare provider. It is not necessary to immediately report changes in the vital signs to the healthcare provider unless the change is significant.

A nurse is examining a patient for circulation of blood to the foot. Which pulse site should the nurse assess? Select all that apply. A. Popliteal B. Posterior tibial C. Carotid D. Dorsalis pedis E. Femoral

Correct B, D To assess the status of circulation of blood to the foot, dorsalis pedis and posterior tibial pulses are used. Posterior tibial pulse is located at the inner side of ankle, below the medial malleolus; the dorsalis pedis pulse is located along top of the foot between the extension tendons of the great toe and first toe. Popliteal pulse, used to assess the status of circulation of the lower leg, is located behind the knee in the popliteal fossa. Carotid pulse is located along medial edge of sternocleidomastoid muscle. Femoral pulse is located below inguinal ligament, midway between the symphysis pubis and the anterior superior iliac spine. Carotid and femoral pulses are used during physiological shock or cardiac arrest.

A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant tells you his admitting vital signs. Which measurement should you reassess? Select all that apply. A. Right arm BP: 120/80 B. Radial pulse rate: 72 and irregular C. Temporal temperature: 37.4° C (99.3° F) D. Respiratory rate: 28 E. Oxygen saturation: 99%

Correct B, D, E An irregular pulse may be the result of a complication of heart disease and requires the assessment of the apical rate. A respiratory rate of 28 is abnormal, yet the oxygen saturation is normal. Both oxygen saturation and respiratory rate would be expected to be outside of the acceptable range.

The nurse records a patient's oral temperature as 39.2°C. Which nursing interventions would be beneficial to make the patient comfortable? Select all that apply. A. Providing hot soup to the patient B. Applying cool packs on the patient's body C. Providing warm clothing to the patient D. Keeping the patient's bed and clothes dry E. Administering an antipyretic medication

Correct B, D, E The normal oral temperature range for an adult is 36.0°C to 37.6°C; therefore, an oral temperature of 39.2°C indicates hyperthermia. The nurse should perform interventions to decrease the patient's body temperature by using cool packs to absorb heat from the patient's body, decreasing body temperature. The patient's bed and clothes should be kept dry to prevent shivering. The nurse can also give the patient an antipyretic agent to bring the body temperature down to normal. Drinking hot soups and wearing warm clothing would be useful when the patient feels cold.

A nurse has been asked to record the nature of the pulse in a patient. What peripheral site is appropriate for assessing the rate, rhythm, and strength of the pulse? 1. Radial 2. Carotid 3. Brachial 4. Temporal

Correct 1. Radial The radial site is commonly used for assessing the nature of the pulse and is also used for assessing circulation to the hands. The carotid site is easily accessible and is used during shock and cardiac arrest when other sites are not palpable. The brachial site is suitable for assessing circulation in the upper limb and auscultating blood pressure. The temporal site is easily accessible and is suitable for assessing the pulse in children.

A patient has regular but abnormally rapid respiration's of more than 24 breaths per minute. What term does the nurse use to record this breathing pattern? 1. Tachypnea 2. Hyperpnea 3. Hyperventilation 4. Cheyne-Stokes respiration

Correct 1. Tachypnea In tachypnea, patients exhibit regular but rapid breathing of more than 20 breaths per minute. Hyperpnea is labored respiration associated with increased rate and depth. Hyperventilation is an increase in the rate and depth of respiration. Cheyne-Stokes respiration is characterized by alternating periods of apnea and hyperventilation.

A nurse uses a Doppler ultrasound to assess a patient's blood pressure. What is the rationale for the nurse's action? 1. The patient is in shock. 2. The patient has prehypertension. 3. The patient's age is less than 10 years. 4. The patient has stage 1 hypertension.

Correct 1. The patient is in shock. Doppler ultrasound is used to measure blood flow through the blood vessels when the patient's pulse is too feeble to be heard by a stethoscope. Shock is a life-threatening condition in which there is an excessive drop in blood pressure and results in a feeble pulse. The blood pressure in patients with prehypertension, children younger than 10 years, and patients with stage 1 hypertension can easily be measured using a stethoscope and sphygmomanometer.

Which is the best site for a nurse to measure body temperature in an unconscious patient? 1. Tympanic 2. Oral 3. Rectal 4. Axillary

Correct 1. Tympanic Ear temperature is measured by placing the thermometer close to the tympanic membrane. The ear temperature gives an estimate of the core body temperature, making it the best site for measuring temperature in unconscious patients and children. Oral temperature is measured by keeping the thermometer in the mouth. However, the patient must be able to close mouth around the thermometer, which is not possible for an unconscious patient. Rectal temperatures change slowly in relation to the core temperature, and the readings are altered by the presence of stool. Therefore, this site is not preferred for unconscious patients. The axillary temperature is easy to measure, but it is influenced by environmental factors; therefore, it is not a suitable site for assessing the core body temperature.

What is a normal rectal temperature of an adult patient? 1. 33.1°C 2. 35.6°C 3. 38.2°C 4. 40.2°C

Correct 2. 35.6°C The normal rectal temperature range for an adult is 34.4° to 37.8°C; therefore, a temperature reading of 35.6°C is a normal finding in an adult. 33.1°C is below the normal range and indicates hypothermia; 38.2°C and 40.2°C are above the normal range and indicate hyperthermia.

In which patient would a resting heart rate of 55 beats/min be considered a normal finding? 1. An obese patient 2. An athlete 3. A patient who is taking a diuretic 4. A patient who weighs less than 90 lb

Correct 2. An athlete The conditioning of athletes, especially runners, allows a resting rate below 60 beats/min without interrupting the normal sinus rhythm of the heart. A heart rate below 60 beats/min is considered bradycardia. Athletes often maintain heart rates consistent with sinus bradycardia because their heart is an effective pump with a greater-than-normal stroke volume. An obese person may experience an increase in resting heart rate secondary to cardiac demand. Bradycardia is not associated with diuretics or weight less than 90 lb.

A 60-year-old male patient complains of severe breathlessness, sweating, pain in the chest, and a cough. The nurse records the vital signs and finds that his pulse is 110/min, his respiratory rate is 24 breaths per minute, his blood pressure is 160/110 mm of Hg, and his oxygen saturation (SpO2) is 80%. His temperature is 101° Fahrenheit. Based on the vital signs, what would the nurse most likely suspect? 1. Pneumonia 2. Myocardial infarction 3. Tuberculosis of kidney 4. Allergic asthma

Correct 2. Myocardial infarction Chest pain, sweating, dyspnea, and cough are most commonly seen in myocardial infarction. The normal pulse rate is 60-100 beats per minute. A pulse rate of 110 beats per minute indicates tachycardia. The normal blood pressure is 120/80 mm of Hg. The patient has a blood pressure of 160/110 mm of Hg, which is high. Pneumonia presents with very high fever and a history of respiratory tract infection. Tuberculosis of the kidney does not present with pain in the chest; instead there is pain in the

What is the normal strength of a pulse? 1. 0 2. 1+ 3. 2+ 4. 3+

Correct 3. 2+ A normal strength pulse will be documented as 2+. A diminished or barely palpable pulse is documented as 1+; a bounding pulse is documented as 3+. An absent pulse is documented as 0.

A nurse takes an infant's vital signs. Which respiratory rate is normal in a 1-year-old infant? 1. 12 breaths per minute 2. 20 breaths per minute 3. 35 breaths per minute 4. 60 breaths per minute

Correct 3. 35 breaths per minute The normal respiratory rate of a 1-year-old infant is between 24 and 40 breaths per minute. A respiratory rate of 12 or 20 breaths per minute indicates bradypnea. A respiratory rate of 60 breaths per minute indicates tachypnea.

The nurse is taking vital signs of a newborn. Which diastolic blood pressure finding is considered normal in a newborn? 1. 80 mm Hg 2. 15 mm Hg 3. 53 mm Hg 4. 74 mm Hg

Correct 3. 53 mm Hg The normal diastolic blood pressure for a newborn is between 20 and 60 mm Hg. Diastolic pressure of 53 mm Hg falls within this normal range. Diastolic pressure of 15 mm Hg falls below the normal level and thus indicates low blood pressure. A diastolic pressure of 80 mm Hg or 74 mm Hg is above the normal range and thus indicates high blood pressure.

A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a very slow radial pulse of 44. What is your priority intervention? 1. Request that the nursing assistant repeat the pulse check 2. Call for a stat electrocardiogram (ECG) 3. Assess the patient's apical pulse and evidence of a pulse deficit 4. Prepare to administer cardiac-stimulating medications

Correct 3. Assess the patient's apical pulse and evidence of a pulse deficit. Your priority is to assess the patient first. The nurse cannot delegate vital signs to an unstable patient. Therefore first you determine if the patient has a pulse deficit. Calling for an ECG and administering cardiac-stimulating medications are interventions that require notification of the healthcare provider and occur after you assess the patient.

A patient has abnormally shallow respirations followed by irregular periods of apnea. What term does the nurse use to record this breathing pattern? 1. Apnea 2. Bradypnea 3. Biot's respiration 4. Kussmaul's respiration

Correct 3. Biot's respiration Biot's respiration is the presence of abnormally shallow breaths followed by irregular periods of apnea. The cessation of respiration for several seconds is called apnea. Bradypnea is a regular, slow respiration of less than 10 breaths per minute. Kussmaul's respiration is an abnormally deep, regular, and increased rate of respiration.

Which part of the patient's brain acts as a thermoregulator? 1. Amygdala 2. Hippocampus 3. Hypothalamus 4. Wernicke's area

Correct 3. Hypothalamus The anterior part of the hypothalamus controls heat loss, and its posterior part conserves heat; thus the hypothalamus acts as a thermoregulator. The function of the amygdala is to enable the body to respond to emotions, memories, and fear. The function of the hippocampus is to strengthen and store long-term memories. The function of Wernicke's area is to understand speech.

A healthcare provider instructs a nurse to palpate the posterior tibial artery. Which site does the nurse use to palpate the posterior tibial artery? 1. Top of the foot 2. Popliteal fossa 3. Inner aspect of the ankle 4. Outer aspect of the lateral malleolus

Correct 3. Inner aspect of the ankle. The posterior tibial artery is palpated on the inner aspect of the ankle, below the medial malleolus. The dorsalis pedis artery is palpated along the top of the foot. The popliteal artery is palpated within the popliteal fossa. No artery is palpated along the lateral malleolus.

A patient has diabetic ketoacidosis. Which respiratory pattern will the nurse most likely observe? 1. Hypoventilation 2. Biot's respiration 3. Kussmaul's respiration 4. Cheyne-Stokes respiration

Correct 3. Kussmaul's respiration Kussmaul's respiration is an abnormal pattern of breathing in which the respirations are abnormally deep, regular, and increased in rate. Hypoventilation is characterized by slow and shallow breathing, which is often seen in patients with a head injury. Biot's respiration is an abnormal pattern of breathing in which the respirations are abnormally shallow for two or three breaths followed by an irregular period of apnea. This pattern of breathing is seen in conditions such as meningitis and brain injury. Cheyne-Stokes respiration is characterized by rhythmic respirations, going from very deep to very shallow, with apneic periods. This pattern of breathing is seen in conditions such as heart failure, renal failure or impending death.

You observe a nursing student taking a blood pressure (BP) on a patient. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. The student used a BP cuff that was too narrow for the patient. Which of the following BP readings made by the student is most likely caused by the incorrect choice of BP cuff? 1. 96/40 mm Hg 2. 110/66 mm Hg 3. 130/70 mm H 4. 156/82 mm Hg

Correct 4. 156/82 mm Hg When you use a blood pressure cuff that is too narrow or short, your patient will most likely have a BP reading that is higher than it really is; you will get a false-high reading.

Which site is appropriate for assessing pulse in children up to 3 years of age to determine discrepancies with the radial pulse? 1. Radial 2. Carotid 3. Femoral 4. Apical or PMI

Correct 4. Apical or PMI The apical, at the apex of the heart, and PMI, at the 5th intercostal space midclavicular line, is used for infants and children up to 3 years of age, with the child in the supine position to determine discrepancies with radial pulse. It is used in adults in conjunction with some diseases and medications and during a head-to-toe assessment.

Which arterial site does a nurse choose to assess circulation to the lower arm and auscultate blood pressure? 1. Ulnar 2. Apical 3. Carotid 4. Brachial

Correct 4. Brachial The brachial site is suitable for assessing circulation in the lower arm and auscultating blood pressure. The ulnar site is used to assess circulation to the hand. The apical site is suitable for auscultating the apical impulse. The carotid site is easily accessible and is used during shock and cardiac arrest

A patient reports having shortness of breath for 2 months. The nurse asks the patient to rate the shortness of breath on a scale of 0 to 10 and if it is affecting daily activities. The nurse also asks about exposure to passive smoking and if the patient feels comfortable when sleeping in a reclining chair. Which question asked by the nurse is about orthopnea? 1. Exposure of patient to passive smoking 2. Shortness of breath affecting daily activities 3. Rating the shortness of breath on a scale of 0 to 10 4. If patient feels comfortable when sleeping in a reclining chair

Correct 4. If patient feels comfortable when sleeping in a reclining chair Orthopnea occurs when the patient feels short of breath when sleeping, but comfortable when sleeping in a reclining chair. In a reclined position, the patient may also use multiple pillows to facilitate breathing. Orthopnea is quantified based on the number of pillows used. The question about exposure to passive smoking gives information about the predisposing factors to the complaints. The question about symptoms affecting daily activities indicates the severity of the symptoms. The question to rate dyspnea gives information about severity of the complaints.

Which part of the brain controls the patient's respiratory functions? 1. Broca's area 2. Cerebellum 3. Hypothalamus 4. Medulla oblongata

Correct 4. Medulla oblongata Respiratory centers in the medulla and pons are stimulated by impulses from chemoreceptors located throughout the body. Broca's area is present in the frontal lobe and is associated with the production of speech. The cerebellum is located at the base of the brain above the brain stem. It coordinates the voluntary functions of the body such as posture, balance, and coordination. The hypothalamus is the part of brain below the thalamus that regulates body temperature.

A patient returns to your postoperative unit following surgery for right shoulder rotator cuff repair. The licensed practical nurse (LPN) reports that she had difficulty obtaining the patient's heart rate from his right radial pulse. What is your best response? 1. Assess the patient's apical pulse to obtain the heart rate. 2. Obtain the heart rate from right and left radial sites. 3. Obtain the heart rate using the oximeter probe. 4. Perform a complete assessment of all pulses.

Correct 4. Perform a complete assessment of all pulses. When an LPN reports that one pulse is difficult to obtain, first you need to assess the patient yourself and compare the quality of all pulses.

A nurse is assessing a patient's vital signs. After assessment, the nurse immediately reports an unstable vital sign to the healthcare provider. What finding in the patient alerts the nurse to a deviation from the normal range? 1. Pulse pressure of 50 mm Hg 2. Rectal temperature of 99.5° F 3. Pulse rate of 62 beats per minute 4. Respiratory rate of 11 breaths per minute

Correct 4. Respiratory rate of 11 breaths per minute The normal acceptable range of respiratory rate is between 12 and 20 breaths per minute; hence, the patient has a reduced respiratory rate (bradypnea). The normal range of pulse pressure is between 30 and 50 mm Hg. The average rectal temperature is 99.5° F. The pulse rate of a normal patient should be in the range of 60 to 100 beats per minute.

The nurse understands that patients with dysrhythmias may have a pulse deficit. How should the nurse calculate the pulse deficit? 1. Difference in pulse rate of apical and radial pulse 2. Difference in pulse rate of left and right radial pulse 3. Difference in pulse rate of radial and femoral pulses 4. Difference in pulse rate of left and right femoral pulse

Correct 1 Difference in pulse rate of apical and radial pulse. A pulse deficit is created when an inefficient contraction of the heart fails to transmit a pulse wave to the peripheral pulse site. Pulse deficit is the difference of apical and radial pulse rate. There is usually no difference in left and right radial pulse rate, or in left and right femoral pulse rate. A pulse deficit does not indicate the difference of radial and femoral pulse rate.

Which pulse does the nurse assess using a Doppler ultrasound because it may be difficult to palpate? 1. Radial artery pulse 2. Carotid artery pulse 3. Dorsalis pedis pulse 4. Brachial artery pulse

Correct 3 Dorsalis pedis pulse Doppler ultrasound is used to measure a pulse when the pulse rate is difficult to assess through palpation. The dorsalis pedis pulse cannot easily be felt by placing the fingers on the dorsum of the foot; therefore, a Doppler scan is used to amplify the sounds of the pulsations. The radial artery pulse can easily be palpated on the radial aspect of the wrist. The carotid artery pulse can easily be felt by placing the fingers at the neck. The brachial artery pulse can easily be felt by placing the fingers near the elbow.

A patient is having dyspnea. Which position should the nurse use for this patient? 1. Supine 2. Prone 3. Fowler's 4. Left lateral recumbent

Correct 3 Fowler's Dyspnea refers to shortness of breath. In Fowler's position, the patient sits straight or leans slightly back with the legs either straight or bent. When a person sits in Fowler's position, the abdominal organs move down and give adequate space for the lungs to expand during inspiration, so this is the most beneficial position for a patient with dyspnea. In the supine position, the patient lies on his or her back. In the prone position, the patient lies facing down. In the left lateral recumbent position, the patient lies on the left side. In these positions, the upward displacement of the abdominal organs decreases the space available for the lungs to expand.

A nurse is measuring a patient's blood pressure. Where should the nurse locate the pulse to auscultate blood pressure? 1. Thumb side of forearm at wrist 2. Ulnar side of forearm at wrist 3. Groove between biceps and triceps muscles at antecubital fossa

Correct 3 Groove between biceps and triceps muscles at antecubital fossa The brachial pulse is used when measuring blood pressure. It can be located in the groove between biceps and triceps muscles at the antecubital fossa. The radial pulse is located at the thumb side of forearm at wrist. This pulse is used to assess the circulation to hand. The ulnar pulse is located at the ulnar side of forearm at the wrist. This pulse is used to assess the circulatory status to the hand and also perform Allen's test. The apical pulse can be palpated at the fourth to fifth intercostals space at the left midclavicular line

A woman experiences a rise in body temperature during ovulation. Which hormone is responsible for a rise in body temperature during ovulation? 1. Inhibin 2. Estrogen 3. Progesterone 4. Luteinizing hormone

Correct 3 Progesterone Ovulation is associated with the release of greater amounts of progesterone into circulation, which is responsible for raising body temperature. Inhibin, estrogen, and luteinizing hormone have no role in raising body temperature. Inhibin inhibits the synthesis and secretion of follicle-stimulating hormone. Estrogen is the female sex hormone responsible for development of secondary sexual characteristics in females and regulation of the menstrual cycle. Luteinizing hormone triggers the process of ovulation.

Which process lowers body temperature when a patient sweats? 1. Radiation 2. Conduction 3. Convection 4. Evaporation

Correct 4 Evaporation Evaporation is the process by which a liquid is changed to a vapor through heat. Sweating uses the process of evaporation to lower body temperature. Radiation is the transfer of heat through waves or particles. Conduction is the transfer of and reaction to heat through direct contact. Convection is the transfer of heat by movement or circulation of warm matter.

A nurse is caring for a patient who has bradypnea. Bradypnea is said to be present when breathing is regular but abnormally slow, i.e. less than how many breaths per minute? Record your answer using a whole number. ____________

Correct answer is 10 Bradypnea is said to be present when breathing is regular and abnormally slow, i.e. less than 10 breaths/minute.

A patient has an apical rate of 96 beats per minute and a radial rate of 78 beats per minute. What is the pulse deficit of this patient? Record your answer using a whole number. ________ beats

The pulse deficit is the difference between the apical rate and the radial rate. Hence the pulse deficit in the patient is 96 - 78=18.