Ch.19

____ 20. 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

2) Drinks three to four beers every day

____ 14. 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

4) Respiratory rate

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

1) Decreased blood pressure (BP) after standing up

____ 1. 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

3) 120/80 mm Hg 4) 130/86 mm Hg

____ 6. 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

____ 10. 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

1) Resting morning blood pressure is 136/86 while the afternoon BP is 128/84 mm Hg

____ 8. 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

2) 18

____ 4. 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

2) Adolescent: T 98.2°F (oral), HR 80, RR 18, BP 108/68

____ 21. 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."

3) "I can lose some weight to help lower my blood pressure."

____ 15. 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

1) Ask the client to demonstrate the use of the blood pressure device

____ 2. 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

1) Compare the left pedal pulse with the right pedal pulse

____ 11. 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."

3) "Your vital signs are stable, but there are other things to assess."

____ 7. 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

4) Remittent

____ 23. 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

1) Counting the rate for 1 full minute

____ 6. 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

2) 38.4°C

____ 13. 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.

3) Obtain a rectal temperature reading.

____ 22. 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

4) Has a heart or lung disease

____ 4. 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.

4) Have the client sit with feet flat on the floor. 2) Wrap the cuff snugly around the client's arm.

____ 5. 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.

Match the breath sound with the appropriate description. 1) High-pitched sound heard on inspiration in infants 2) High-pitched, continuous musical sound 3) High-pitched popping or low-pitched bubbling sounds 4) Low-pitched continuous sounds that clear with coughing 5) Labored, snoring sound ____ 1. Crackles ____ 2. Rhonchi ____ 3. Stridor ____ 4. Wheezes ____ 5. Stertor

1. ANS: 3 PTS: 1 DIF: Moderate REF: pp. 431-432; descriptions of the various breath sounds are as stated KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 2. ANS: 4 PTS: 1 DIF: Moderate REF: pp. 431-432; descriptions of the various breath sounds are as stated KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 3. ANS: 1 PTS: 1 DIF: Moderate REF: V1, pp. pp. 431-432; descriptions of the various breath sounds are as stated KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 4. ANS: 2 PTS: 1 DIF: Moderate REF: V1, pp. pp. 431-432; descriptions of the various breath sounds are as stated KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 5. ANS: 5 PTS: 1 DIF: Moderate REF: V1, pp. pp. 431-432; descriptions of the various breath sounds are as stated KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

____ 3. 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.

3) Blood pressure increases; heart rate and respiratory rate decline. 4) Men have higher blood pressure than women until after menopause.

____ 2. 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.

3) Offer the client fluids to drink every 1 to 2 hours. 1) Put an ice pack on the client's neck and axillae.

____ 25. 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.

4) Measure vital signs with the client supine, sitting, and standing.

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

4) Monitor the blood pressure for a pattern

____ 9. 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

2) Had surgery and lost a unit of blood intraoperatively

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.

2) Request the client take a deep breath and cough.

____ 24. 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

2) Respiratory rate 26 breaths/min and shallow

____ 12. 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."

1) "I would have the client rate her pain on a scale of 0 to 10."

___ 17. 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

1) 97.2°F

____ 16. 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.

1) Ask the client if he has had a warm drink in the last 30 minutes.

____ 18. 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."

3) "Place a cap on the infant's head."

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: 102 Heart rate increases about 10 beats per minute for each degree of temperature to meet increased metabolic needs and compensate for peripheral dilation.