Vital Signs
A 52-year-old woman is admitted with pneumonia, dyspnea, and discomfort in her left chest when taking deep breaths. She has smoked for 35 years and recently lost over 10 lb. She is started on intravenous antibiotics, high-protein shakes, and 2 L O2 via nasal cannula. Her most recent vital signs are HR 112, BP 138/82, RR 22, tympanic temperature 37.9° C (100.2° F), and oxygen saturation 94%. Which vital signs reflect a positive outcome of the treatment interventions? (Select all that apply.) 1. Temperature: 37° C (98.6° F) 2. Radial pulse: 98 3. Respiratory rate: 18 4. Oxygen saturation: 96% 5. Blood pressure: 134/78
1, 2, 3, 4. Radial pulse has dropped as temperature has become within expected range. Respiratory rate has decreased with lower temperature, and oxygen saturation has improved with improved respiratory rate.
Which of the following patients are at most risk for tachypnea? (Select all that apply.) 1. Patient just admitted with four rib fractures 2. Woman who is 9 months' pregnant 3. A patient admitted with hypothermia 4. Postoperative patient waking from general anesthesia 5. Three-pack-per-day smoker with pneumonia
1, 2, 5. The patient with rib fractures is unlikely to breathe deeply, and a large fetus restricts diaphragmatic movement; both result in decreased ventilatory volume and increased respiratory rate. Pneumonia decreases gas exchange surface area; thus tachypnea occurs to increase minute ventilation. Hypothermia and general anesthesia depress respiratory rates.
A healthy adult patient tells the nurse that he obtained his blood pres- sure in "one of those quick machines in the mall" and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/92? (Select all that apply.) 1. Cuff too small 2. Arm positioned above heart level 3. Slow inflation of the cuff by the machine 4. Patient did not remove his long-sleeved shirt 5. Insufficient time between measurements
1, 5. Using too small of a cuff and not allowing for insufficient time between measurements will result in false-high readings. Arm above heart level and slow infla- tion result in false low readings.
The nurse is assessing the status of pain in an alert older client who was recently admitted to the hospital with a diagnosis of ruptured lumbar disc. What are some of the beliefs and concerns older adults have about pain? Select all that apply. 1.Pain is something that must be lived with. 2.Nurses are too busy to listen to reports of pain. 3.Pain signifies a serious illness or impending death. 4.Reporting pain will result in being labeled as a "bad" client. 5.Expressing pain is only done by people who want attention. 6.Nurses and other caregivers often give too much medication to older clients.
1,2,3,4 Some beliefs and concerns of older adults about pain include the following: pain is something that must be lived with, nurses are too busy to listen to reports of pain, pain signifies a serious illness or impending death, and reporting pain will result in being labeled as a "bad" client. The options "Expressing pain is only done by people who want attention" and "Nurses and other caregivers often give too much medication to older clients" are not beliefs held by older clients.
The nurse is instructing a client about receiving patient-controlled analgesia to control postoperative pain. What comment by the client indicates that further instruction is needed? 1."That's great that overdosing can't happen." 2."It will keep my pain at a pretty consistent level." 3."I feel a lot less nervous because I can control my own pain." 4."I'm glad I can give myself some medication and not have to wait for the nurse to give me something."
1. Because human error is always a possibility, overdosing can happen. Naloxone is always ordered if quick reversal of the effects of the opioid is needed. With patient-controlled analgesia, the client adjusts the dosage of the analgesic based on the pain level and response to the medication. It allows more consistent pain relief and more control by the client.
The nurse is caring for a client who is receiving morphine sulfate by the intravenous route for acute pain. The nurse ensures that which medication is available in the event that the client's respiratory status and level of consciousness deteriorate? 1.Naloxone 2.Promethazine 3.Atropine sulfate 4.Protamine sulfate
1. Naloxone is an opioid antagonist that is used to treat opioid overdose. Atropine sulfate is an anticholinergic. Promethazine is an antiemetic medication, and protamine sulfate is the antidote for heparin.
The nurse is discussing pain management with a student who is caring for a 1-day postoperative abdominal surgery client who is a known opioid substance abuser. What comment by the student indicates a need for further education? 1.Opioid substance abusers are less tolerant to opioids and require decreased doses. 2.These clients should be allowed to choose their pain medications and dosing regimen. 3.Nonopioid therapies such as cutaneous stimulation are generally effective if used alone. 4.These clients are at an increased risk for abrupt physiological withdrawal when opioid agonists are abruptly withdrawn.
1. Opioid substance abusers have developed a tolerance to opioids and require higher, not decreased, doses for a therapeutic effect. The other statements are appropriate comments.
The nurse is caring for a client who had a cholecystectomy 1 day ago. The nurse plans pain-management techniques, knowing that the severity of the client's pain can be related to which factor? 1.Positioning of the client during surgery 2.How long the client had pain before surgery 3.The type of general anesthesia used during surgery 4.The use of nonsteroidal anti-inflammatory medications before surgery
1. The duration of the operation, the degree of tissue trauma, and the positioning of the client during surgery all may contribute to the presence and severity of postoperative pain. How long the client had pain before surgery, the type of general anesthesia, and nonsteroidal anti-inflammatory medications used before surgery are unrelated to the severity of pain in the postoperative period.
The nurse is setting up a transcutaneous electrical nerve stimulation unit on a client with chronic pain. As the nurse turns up the level of stimulation, the client complains of discomfort. Based on this finding, the nurse should make which interpretation? 1.The maximal stimulation has been reached, and it should be decreased slightly. 2.This is a temporary effect, and the stimulation should continue to be increased. 3.The maximal stimulation has been far exceeded, and it should be decreased by half. 4.This is a complication of the device's use, and it should be discontinued immediately.
1. Use of a transcutaneous electrical nerve stimulation (TENS) unit involves applying 2 electrodes from the machine to the skin and adjusting the level of stimulation to 1 lead at a time. Usually a physical therapist is responsible for administering TENS therapy, although nurses can be trained in the technique. The amount of stimulation is increased until the client feels discomfort, which indicates that the maximal stimulation necessary to block pain stimuli has been reached. The volume is then reduced by a small amount until no further muscle discomfort or contractions occur. The other options are incorrect.
The licensed practical nurse (LPN) provides you with the change- of-shift vital signs on four of your patients. Which patient does the nurse need to assess first? 1. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% 2. 54-year-old woman admitted after surgery for repair of a fractured arm, BP 160/86 mm Hg, HR 72 3. 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84 4. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62
1. SpO2 89% is a critical value and requires imme- diate attention. Other values require attention but are not life threatening.
A patient presents in the clinic with dizziness and fatigue. The assis- tive personnel (AP) reports a slow but regular radial pulse of 44. Place the following care activities in priority order. 1. Direct the AP to obtain a blood pressure. 2. Request that the patient lie on the clinical stretcher. 3. Assess the patient's apical pulse for a full minute. 4. Prepare to administer cardiac-stimulating medications.
2, 1, 3, 4. The first priority is patient safety. Getting the patient to lie on a stretcher prevents falls. Directing the AP to obtain BP relates to the patient's symptom of dizziness while the nurse assesses apical pulse. If BP is abnormal, the nurse should recheck value. The patient may require medications to increase heart rate.
A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The assistive personnel reports his admitting vital signs to the nurse. Which measurements should the nurse reas- sess? (Select all that apply.) 1. Right arm BP: 118/72 2. Radial pulse rate: 72 and irregular 3. Temporal temperature: 37.4° C (99.3° F) 4. Respiratory rate: 28 5. Oxygen saturation: 99%
2, 4, 5. Irregular pulse and elevated respiratory rate are outside expected values and require further assess- ment by the nurse. Pneumonia and shortness of breath can cause low oxygen saturation; an assessment of 99% may be a false-high value. Blood pressure and temperature are within expected values for the patient history.
During admission of an obese patient with heart failure the assis- tive personnel (AP) reports to the nurse that the blood pressure (BP) is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? (Select all that apply.) 1. Notify the health care provider immediately .2. Repeat the measurements on both arms using a stetho- scope. 3. Ask the patient if she has taken her blood pressure medications recently. 4. Obtain blood pressure measurements on lower extremities. 5. Verify that the correct cuff size was used during the measure- ments. 6. Review the patient's record for her baseline vital signs. 7. Compare right and left radial pulses for strength.
2, 6. The systolic BP measurements are signifi- cantly different and may reflect some vascular abnormali- ties. However, unexpected findings require reassessment by the nurse with a comparison to previous values. It is prema- ture to notify the provider without further assessment. The differences are not caused by medications. An inappropri- ate cuff size would reflect similar systolic pressures; pulse strength would be similar for these BP measurements.
The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2° F (36.2° C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next? 1. Document the findings. 2.Attempt to arouse the client. 3.Contact the primary health care provider (PHCP) immediately. 4.Check the medication administration history on the PCA pump.
2. The primary concern with opioid analgesics is respiratory depression and hypotension. Based on the assessment findings, the nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vital signs. The vital signs may begin to normalize once the client is aroused, because sleep can also cause decreased heart rate, blood pressure, respiratory rate, and oxygen saturation. The nurse should also check to see how much medication has been taken via the PCA pump and should continue to monitor the client closely to determine whether further action is needed. The nurse should contact the PHCP and document the findings after all data are collected, after the client is stabilized, and if an abnormality still exists after arousing the client.
The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient? 1. Hyperthermia and fever are the same thing. 2. Hyperthermia is an upward shift in the set point. 3. Hyperthermia occurs when the body cannot reduce heat production. 4. Hyperthermia results from a reduction in thermoregulatory mechanisms.
3. 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.
The nurse is monitoring the respiratory status of a client after creation of a tracheostomy. Which coexisting condition in the client may cause an inaccurate pulse oximetry reading? 1.Fever 2.Epilepsy 3.Hypotension 4.Respiratory failure
3. Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings as a result of impaired peripheral perfusion. Fever and epilepsy would not affect the accuracy of measurement. Respiratory failure also would not affect the accuracy of measurement, although the readings may be abnormally low.
A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic tempera- tures of 38.7° C (101.6° F) at 0400, 36.6° C (97.9° F) at 0800, 36.9° C (98.4° F) at 1200, 37.6° C (99.6° F) at 1600, and 38.3° C (100.9° F) at 2000. How would the nurse describe this pattern of temperature measurements? 1. Usual range of circadian rhythm measurements 2. Sustained fever pattern 3. Intermittent fever pattern 4. Resolving fever pattern
3. Temperature was elevated above acceptable range, returned to normal, and then elevated
The assistive personnel (AP) informs the nurse that the electronic blood pressure machine on the patient who has recently returned from surgery after removal of her gallbladder is flashing a blood pres- sure of 65/46 and alarming. Place the care activities in priority order. 1. Press the start button of the electronic blood pressure machine to obtain a new reading. 2. Obtain a manual blood pressure with a stethoscope. 3. Check the patient's pulse distal to the blood pressure cuff. 4. Assess the patient's mental status. 5. Remind the patient not to bend her arm with the blood pres- sure cuff.
4, 1, 3, 2, 5. First priority is to verify that the patient's blood pressure is providing adequate blood flow to the brain and critical organs. Movement interferes with electronic blood pressure measurement; recycling the machine will obtain a blood pressure while you are assess- ing the patient. Check the distal pulse to verify circulation to the extremity and then obtain manual blood pressure if needed. Patient education can prevent false values and decrease patient anxiety with alarms.
Which number marks the location where the nurse would auscul- tate the point of maximal impulse (PMI)? 1. 1 2. 2 3. 3 4. 4 5. 5 6. 6
5 (Apex of heart) This is the spot where you would auscultate the PMI.
A nurse is teaching the staff 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
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.
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 findings 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
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.
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 fluid intake. d. Increase the patient's metabolic rate.
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 fluid volume deficit. Fluids should not be restricted, even though the patient has heart failure; the patient needs fluids 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.
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 fingers d. Intravascular dyes e. Nail polish f. Jaundice
B, C, D, E, FInaccurate 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, artificial nails, metal studs, or dark skin. SpO2 is a reliable estimate of SaO2 when the SaO2 is over 70%.
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
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 flow. Oral, rectal, axillary, and skin temperature sites rely on effective blood circulation at the measurement site.
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
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.
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
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 difficult to palpate accurately.
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%
B. The concentration of hemoglobin reflects 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.
A nurse reviews blood pressures of several patients. Which finding 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
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 defined as hypertension. Blood pressure of 98/50 is normal for a child, whereas 115/70 can be normal for an infant.
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
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.
A nurse is caring for a patient who smokes and drinks caffeine. 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. Caffeine increases BP for up to 15 minutes. c. Smoking result in vasoconstriction, falsely elevating BP. d. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement.
C. Smoking results in vasoconstriction, a narrowing of blood vessels. BP rises when a person smokes and returns to baseline about 15 to 20 minutes after stopping smoking. Caffeine increases BP for up to 3 hours. Be sure that patient has not ingested caffeine or smoked 20 to 30 minutes before BP measurement.
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
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.
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
D. 50 mm Hg is abnormal, so the nurse will follow up. Normal capnography results are 35 to 45 mm Hg.
The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding 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.
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.
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 to 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
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.
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
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
