Chapter 19

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

Which information in a 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

When assessing the quality of a client's pedal pulses, what is the nurse assessing? Select all that apply. 1) Rhythm of the pulses 2) Strength of the pulses 3) Bilateral equality of pulses 4) Rate compared with apical pulse 5) Location of the pulse

2) Strength of the pulses 3) Bilateral equality of pulses

A client's radial pulse is full and bounding. Which nursing diagnosis should the nurse select to address this clinical finding? 1) Excess fluid volume 2) Deficient fluid volume 3) Decreased cardiac output 4) Ineffective tissue perfusion

1) Excess fluid volume

Which assessment data best supports 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

When measuring a blood pressure, which step is correct? Select 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. 5) Roll up a sleeve before applying the cuff.

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

For which patient would it be most important to obtain an apical-radial pulse and calculate the pulse deficit? 1) Recovering from abdominal surgery 2 hours ago 2) Experienced a fractured hip yesterday 3) Dehydrated from vomiting 4) History of heart and lung disease

4) History of heart and lung disease

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.

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."

A client's average normal temperature is 98°F. Which temperature would be expected during the night in a 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

The nurse is teaching a client how to use a portable blood pressure device to monitor blood pressure at home. What is the most important action for the nurse to take? 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.

At last measurement, the client's vital signs were: 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 were: 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 whether 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 whether he is feeling chilled. 4) Take the temperature by a different route.

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

The nurse is assessing vital signs for a client after a surgical procedure on the left leg. IV fluids are infusing. Which action is the most important for the nurse at this time? 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.

Which procedure technique 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

The nurse assesses 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

Which findings are specific indicators of hypoxia? Select all that apply. 1) Feelings of anxiety 2) Crackles in the lung bases 3) Increased heart rate 4) Improved breathing in upright position 5) Cyanosis of the tongue

1) Feelings of anxiety 3) Increased heart rate 5) Cyanosis of the tongue

A client experiences acute shortness of breath. Which noninvasive technique should the nurse use to assess this client's arterial oxygen saturation? 1) Pulse oximetry 2) Auscultate breath sounds 3) Count the respiratory rate 4) Arterial blood gas sampling

1) Pulse oximetry

Which intervention would be appropriate for a client who has a fever? Select 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) Measure the temperature using a tympanic thermometer. 5) Lower the head of the bed.

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

For which adult client should the nurse make follow-up observations and monitor the vital signs closely? 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.

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, what should the nurse anticipate the client's respiratory rate to be? 1) 16 2) 18 3) 20 4) 22

2) 18

Which set of vital signs is within normal limits for a client 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

The nurse prepares a teaching session on blood pressure for a group of nursing students. What should the nurse explain can falsely elevate the blood pressure measurement? Select all that apply. 1) Cuff that is too wide 2) Cuff that is too narrow 3) Mild to moderate pain present 4) Measuring after the client smokes 5) Measuring after a client ambulates

2) Cuff that is too narrow 3) Mild to moderate pain present 4) Measuring after the client smokes 5) Measuring after a client ambulates

Which client would probably have a higher than normal respiratory rate? 1) Recovering from surgery and receiving a narcotic analgesic 2) Recovering from surgery and lost a unit of blood intraoperatively 3) Lived at a high altitude and then moved to sea level 4) Exposed to the cold and is now hypothermic

2) Recovering from 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.

. The nurse provides client education regarding hypertension prevention and management. Which statement 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 of milk and other dairy products I consume."

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

The nurse is instructing a client how to appropriately dress an infant in cold weather. Which instruction 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 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." What would be the nurse's best response? 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."

A client's vital signs at the beginning of the shift are 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

3) 102

Which blood pressure has a pulse pressure within normal limits? Select all that apply. 1) 104/50 mm Hg 2) 120/62 mm Hg 3) 120/80 mm Hg 4) 130/86 mm Hg 5) 140/98 mm Hg

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

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. 5) Body temperature increases with aging

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

The nurse notes that a client's respiratory rate is 30 and irregular. Which nursing diagnosis should be identified to help guide this client's care? 1) Anxiety 2) Altered oxygenation level 3) Risk for poor oxygenation 4) Ineffective breathing pattern

4) Ineffective breathing pattern

During a clinic interview, a client states 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, what is the most important action for the nurse to take? 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.

The client has had a fever, ranging from 99.8°F orally to 103°F orally, over the past 24 hours. How should the nurse classify this fever? 1) Constant 2) Intermittent 3) Relapsing 4) Remittent

4) Remittent

When caring for a client with a fever, what should the nurse expect to be increased? 1) Urine output 2) Sensitivity to pain 3) Blood pressure 4) Respiratory rate

4) Respiratory rate