VITAL SIGN: Overview of Vital Sign Assessment

Which actions are required for proper documentation of vital signs? Select all that apply. Recording duplicate entries Documenting in a standardized format Documenting at the end of the day Recording on a specified form Recording just expected values

Documenting in a standardized format Documenting in a standardized format allows for easy communication to all members of the health care team. Recording on a specified form Recording on the specified form where multiple sets of vital signs are easily visible at one time allows health care staff to identify trends for the patient. WRONG: Documenting at the end of the day Results are documented promptly rather than waiting until the end of the day. Recording duplicate entries Recording duplicate entries is not necessary when documenting vital signs as it can produce inconsistencies in the record. Recording just expected values Expected and unexpected results are recorded, not just expected values.

How frequently would the nurse take vital sign measurements for a stable hospitalized patient? Every 5 minutes Every 15 to 60 minutes Every hour Every 4 to 8 hours

Every 4 to 8 hours A vital sign measurement for a stable hospitalized patient occurs every 4 to 8 hours to monitor any changes. WRONG: Every 5 minutes A vital sign measurement every 5 minutes is for a critical or unstable patient. Every 15 to 60 minutes A vital sign measurement every 15 to 60 minutes is for postprocedure or postoperative patients, not for a stable patient. Every hour A stable patient's vital signs remain in the established expected range throughout the day and would not need hourly monitoring.

How frequently would the nurse assess vital signs for a patient with a head injury who suddenly reports a severe headache and whose blood pressure rises from 118/62 to 170/94? Every 5 minutes Every 30 minutes Every 4 hours Every 8 hours

Every 5 minutes The nurse would monitor the patient's vital signs every 5 minutes because this patient has experienced a sudden, severe change in condition as evidenced by the severe headache and blood pressure changes. These findings would be reported to the health care provider. WRONG: Every 30 minutes Monitoring vital signs every 15 to 60 minutes is for a postprocedure or postoperative patient; this patient is not stable because of sudden, severe changes in condition, and there is no indication of a recent medical procedure. Every 4 hours Monitoring vital signs every 4 hours is for a stable patient, and this patient is not stable because of the severe change in blood pressure. Every 8 hours Monitoring vital signs every 8 hours is for a stable patient, and this patient is not stable because of the sudden changes in health status.

Which finding is unexpected for a 15-year-old patient? Pain level 0 Pulse rate 88 Respirations 30 O2 sat 97%

Respirations 30 This is an unexpected (abnormal) finding; respirations within expected ranges are 14 to 20. WRONG: Pain level 0 This is an expected pain level. A pain level of 0 indicates the patient is having no pain; the higher the number, the worse the pain. Pulse rate 88 This is an expected pulse rate; the pulse rate for a 15-year-old is 50 to 90. O2 sat 97% This is an expected finding; O2 sat above 95% is within the expected range.

Which response indicates a nurse has a correct understanding about the components of a vital sign assessment? "Oxygen saturation is the measurable intake of oxygen and release of carbon dioxide." "Pulse is the detectable rhythmic expansion of an artery from the pumping action of the heart." "Respiration is the measurable amount of oxygen available to the tissues." "Blood pressure is the measurable pressure of blood within the systemic veins."

"Pulse is the detectable rhythmic expansion of an artery from the pumping action of the heart." This is a correct statement because pulse is the detectable rhythmic expansion of an artery from the pumping action of the heart and is measured as the number of beats per minute. WRONG: "Oxygen saturation is the measurable intake of oxygen and release of carbon dioxide." Respiration is the intake of oxygen and release of carbon dioxide (inhalation and exhalation); oxygen saturation is the measurable amount of oxygen available to tissue. "Respiration is the measurable amount of oxygen available to the tissues." Oxygen saturation, not respiration, is the measurable amount of oxygen available to the tissues. Respiration is the intake of oxygen and release of carbon dioxide (inhalation and exhalation). "Blood pressure is the measurable pressure of blood within the systemic veins." Blood pressure is the measurable pressure of blood within the systemic arteries, not veins.

Which actions are strictly a nurse's responsibility? Select all that apply. Assess patients to determine if medically stable. Interpret vital sign measurements. Report significant vital sign findings to the health care provider. Reassess any unexpected vital sign values. Measure vital signs for stable patients.

Assess patients to determine if medically stable. Patients must be assessed by the nurse and determined to be medically stable, making this a responsibility of the nurse. Interpret vital sign measurements. Interpretation of vital sign data is strictly a nursing function because it requires clinical judgment. Report significant vital sign findings to the health care provider. To report unexpected values and other significant assessment findings to the appropriate health care provider is strictly a nursing responsibility because it requires clinical judgment. Reassess any unexpected vital sign values. To reassess any unexpected vital sign values is strictly a nurse's responsibility because it requires clinical judgment. WRONG: Measure vital signs for stable patients. The unlicensed assistive personnel may measure, record, and report vital signs for a stable patient; therefore it may be delegated by the nurse.

Which action would the nurse take before notifying the health care provider about a patient's vital signs? Compare the findings to the patient's baseline Follow only the expected ranges for the patient Observe for slight changes in results Review for just increases in measurements

Compare the findings to the patient's baseline The nurse would compare the findings to the patient's baseline before notifying the health care provider to determine if a true change has occurred. WRONG: Follow only the expected ranges for the patient The nurse does not follow only the expected ranges for the patient; the nurse uses the patient's baseline. Observe for slight changes in results The nurse observes for significant changes in results, not slight changes. Review for just increases in measurements The nurse reviews for both increases and decreases in measurements rather than just increases.

Which entries would the nurse include when documenting vital signs? Select all that apply. Date of assessment Time of assessment Names of visitors in the room Numeric results of the assessment Expected values for vital signs

Date of assessment Date of assessment is documented to follow vital sign trends over several days. Time of assessment Time of assessment is documented to follow vital sign trends over time. Numeric results of the assessment Recording the specific numeric data is documented to accurately note changes. WRONG: Names of visitors in the room Names of visitors in the room are not necessary for vital sign assessment. Expected values for vital signs Expected values for vital signs are not entries for documenting because the documentation focuses on the patient's actual results.

Which actions are responsibilities of the nurse when assigning vital signs to the unlicensed assistive personnel (UAP)? Select all that apply. Ensure that the UAP uses the proper technique for measuring vital signs. Validate that the UAP knows what values need to be reported immediately for each patient. Determine that the UAP knows to report unexpected values to the health care provider. Ensure that the UAP is competent to perform vital sign assessments. Validate that the UAP uses appropriate equipment.

Ensure that the UAP uses the proper technique for measuring vital signs. Since the task of vital sign measurement can be delegated, the nurse ensures accurate procedures are followed to obtain valid results. Validate that the UAP knows what values need to be reported immediately for each patient. The nurse validates that the UAP knows which values for each patient are immediately reported to the nurse to provide safe care. Ensure that the UAP is competent to perform vital sign assessments. The nurse ensures that the UAP is competent to perform a vital sign assessment to obtain accurate, valid results. Validate that the UAP uses appropriate equipment. Since the task of vital sign measurement can be delegated, the nurse ensures appropriate equipment is used to obtain accurate readings. WRONG: Determine that the UAP knows to report unexpected values to the health care provider. It is the nurse's responsibility (not the UAP's) to notify the health care provider of unexpected values.

Which measurements are included as cardinal vital signs? Select all that apply. Pain Pulse Respirations Blood pressure Oxygen saturation

Pulse A cardinal vital sign is pulse, the detectable rhythmic expansion of an artery in the pumping action of the heart. Respirations A cardinal vital sign is respirations, the act of breathing. Blood pressure A cardinal vital sign is blood pressure, the measurable pressure of blood within the systemic arteries. WRONG: Pain Pain, a subjective experience, is not a cardinal vital sign but is usually assessed at the same time as vital signs. Oxygen saturation Although oxygen saturation is a component of vital signs, it is not a cardinal vital sign because not all facilities have the capability to measure the percentage of oxygen in the blood.

Which action would the nurse take when the unlicensed assistive personnel (UAP) reports the patient's pulse increased from 74 beats/min to 100 beats/min and the temperature increased from 99° to 101.8°F (37.2° to 38.8°C)? Advise the UAP to wait 1 hour and repeat vital signs. Compare the findings to the expected values. Reassess the patient. Tell the UAP to give fluids to the patient.

Reassess the patient. The nurse verifies the vital signs since this is a significant change and notifies the health care provider. WRONG: Advise the UAP to wait 1 hour and repeat vital signs. This patient is no longer stable, and waiting to take vital signs in 1 hour is too long; the vital signs are taken more frequently. Compare the findings to the expected values. Comparing the findings to the expected values is not indicated because the nurse uses the patient's baseline. Tell the UAP to give fluids to the patient. The nurse would not tell the UAP to give fluids to the patient; the nurse needs to gather more data before telling the UAP what to do.

Which vital sign measurements of adult patients would require the nurse to immediately notify the health care provider? Select all that apply. 158 pulse rate 8 respirations 99.5°F (37.5°C) temperature 98% oxygen saturation 50/30 blood pressure

158 pulse rate This is an extremely elevated pulse rate and would require the nurse to immediately notify the health care provider; the expected rate is 60 to 100. 8 respirations This is an extremely low respiratory rate and would require the nurse to immediately notify the health care provider; the expected rate is 12 to 20. 50/30 blood pressure This is an extremely low blood pressure and would require the nurse to immediately notify the health care provider; expected is 90 to <120/60 to <80. WRONG: 99.5°F (37.5°C) temperature Although this is a high value, it is expected and does not require the nurse to immediately notify the health care provider. 98% oxygen saturation Oxygen saturation above 95% is expected and does not require notification of the health care provider.

Which vital sign measurements are unexpected? Select all that apply. 99.5°F (37.5°C) temperature for a newborn 60 pulse rate for a 1-year-old 35 respirations for a 6-year-old SpO2 90% for a 15-year-old 110/68 blood pressure for an older adult

60 pulse rate for a 1-year-old 80 to 150 (awake) or 70 to 120 (asleep) pulse rate is expected for a 1-year-old; thus this pulse rate is unexpected. 35 respirations for a 6-year-old 20 to 24 respirations are expected for a 6-year-old; thus this patient's respirations are unexpected. SpO2 90% for a 15-year-old Greater than 95% is expected for a 15-year-old; thus this patient's SpO2 is unexpected. WRONG: 99.5°F (37.5°C) temperature for a newborn 96° to 99.5°F (35.5° to 37.5°C) is an expected temperature for a newborn; thus this newborn's temperature is expected, not unexpected. 110/68 blood pressure for an older adult 90 to <120 systolic and 60 to <80 diastolic are expected for an older adult; thus this patient's blood pressure is expected, not unexpected.

What is the expected pulse range for an adult patient? Record your answer as whole numbers separated by a hyphen. Use numbers only.

60-100 The expected pulse range for an adult patient is 60 to 100 beats/min.

Which situations require vital sign assessment? Select all that apply. After discharge In ongoing care During an inpatient stay Before and after surgery As part of a physical assessment

In ongoing care Ongoing care requires a vital sign assessment to detect changes in a patient's condition. During an inpatient stay An inpatient stay requires a vital sign assessment to establish the patient is stable. Before and after surgery Before and after surgery requires a vital sign assessment to monitor and establish when a patient has recovered and returns to a stable status. As part of a physical assessment A physical assessment must include a vital sign assessment because this is one way to monitor the patient's physical status. WRONG: After discharge Before (not after) discharge requires a vital sign assessment.

Which information about a patient's pain is accurate? It is a subjective experience. A high score on the rating scale indicates little pain. The nurse is the expert on the patient's pain. A measurement of 0 to 10 mm Hg is expected.

It is a subjective experience. Pain is a subjective experience of discomfort as described by a patient. WRONG: A high score on the rating scale indicates little pain. A high score on the rating scale indicates a high level of pain; in fact, the higher the number, the worse the pain. The nurse is the expert on the patient's pain. Pain is described by the patient, not the nurse; pain is a subjective experience. A measurement of 0 to 10 mm Hg is expected. A measurement of mm Hg is used for blood pressure, not pain. A pain scale of 0 to 10 measures the pain level.

Which tasks would the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. Interpret vital sign data collected. Record vital signs for any patient. Report vital signs for a stable patient. Measure vital signs for a stable patient. Measure vital signs before the nurse has assessed the patient.

Measure vital signs for a stable patient. The nurse may delegate the UAP to measure vital signs once a patient's condition has been assessed stable. Report vital signs for a stable patient. The UAP can report vital signs for a stable patient because it is a responsibility the UAP can fulfill. WRONG: Record vital signs for any patient. The UAP may only be delegated to record vital signs for a stable patient, not any patient. Interpret vital sign data collected. Interpretation of vital sign data is a critical nursing function and cannot be delegated to the UAP. Measure vital signs before the nurse has assessed the patient. The nurse must assess any patient before delegating vital sign measurements to the UAP.

Which factors influence the interpretation of a patient's vital signs? Select all that apply. Patient status Length of time the nurse is on duty Consideration of patient's baseline vital signs Standard range for vital sign values Patient's unique medical condition

Patient status Interpretation of vital signs depends on patient status being stable,improving, or worsening. Consideration of patient's baseline vital signs Consideration of the patient's baseline vital signs assists in identifying trends. Standard range for vital sign values The standard range is a guide the nurse uses to interpret vital sign measurements. Patient's unique medical condition The patient's unique medical condition may explain vital signs being higher or lower (e.g., increased blood pressure in hypertension diagnosis). WRONG: Length of time the nurse is on duty The length of time the nurse is on duty is irrelevant to the interpretation of vital signs.

Which finding takes precedence when interpreting a patient's vital sign values? Expected result Normal result Patient's averaged result Patient's baseline result

Patient's baseline result The patient baseline result takes precedence because interpretation is dependent upon the patient's previous readings. WRONG: Expected result The expected result is used as a guide and does not take precedence. Normal result The expected (normal) result is used as a guide and does not take precedence. Patient's averaged result The results are not averaged when interpreting a patient's vital signs.

Which vital sign finding indicates the adult patient is improving? Blood pressure changes from 120/78 to 80/60. Pulse rate increases from 85 to 110. Oxygen saturation changes from 90% to 85%. Respiratory rate decreases from 36 to 20.

Respiratory rate decreases from 36 to 20. Respiratory rate was elevated and decreased to expected range, indicating the patient is improving. WRONG: Blood pressure changes from 120/78 to 80/60. A drop in blood pressure indicates the patient is deteriorating, not improving. Pulse rate increases from 85 to 110. The pulse rate was in an expected range and increased to an unexpected range, indicating the patient is worsening, not improving. Oxygen saturation changes from 90% to 85%. This patient's oxygen saturation level was lower than expected and decreased even further, indicating the patient is deteriorating, not improving.

Which action would the nurse take for a stable patient who is scheduled for a transfer to the rehabilitation unit later in the afternoon? Take vital signs before the transfer. Require every 2-hour monitoring until the transfer. Monitor the pulse rate once a day after the transfer. Delay vital signs monitoring since the patient is being transferred.

Take vital signs before the transfer. Vital signs need to be taken before the transfer to confirm that the patient maintains a stable status and is suitable for transfer. WRONG: Require every 2-hour monitoring until the transfer. The patient is stable and does not require 2-hour monitoring. Monitor the pulse rate once a day after the transfer. All vital signs, not just the pulse rate, would be monitored before the transfer and upon admission to the rehabilitation unit. Delay vital signs monitoring since the patient is being transferred. Although the patient is being transferred, the nurse would not delay vital signs monitoring. All stable hospitalized patients should have vital signs monitored every 4 to 8 hours to observe for early signs of any alteration in condition.

Which patient trend does the vital sign graphic indicate? Mon 8 am: 142/87 Mon 8:30 am: 140/86 __________________145/90 Mon 9:00 am:136/86 Mon 9:30am: 144/88 __________________150/90 The diastolic blood pressure is slowly increasing while the systolic pressure is remaining constant. The systolic blood pressure is rising slightly while the diastolic pressure is steady. The diastolic blood pressure is more varied than the systolic blood pressure. Both systolic and diastolic blood pressure readings require the nurse to immediately notify the health care provider

he systolic blood pressure is rising slightly while the diastolic pressure is steady. The image depicts a systolic blood pressure that is rising slightly (from 142 mm Hg to 150 mm Hg) while the diastolic pressure is remaining constant and steady (around 86 mm Hg to 90 mm Hg). WRONG: The diastolic blood pressure is slowly increasing while the systolic pressure is remaining constant. This statement is the opposite of what the image is depicting: the systolic blood pressure is slowly increasing while the diastolic blood pressure is relatively stable. The diastolic blood pressure is more varied than the systolic blood pressure. This statement is the opposite of what the image is depicting: there is more variation in the systolic blood pressure than the diastolic blood pressure. Both systolic and diastolic blood pressure readings require the nurse to immediately notify the health care provider. While both systolic and diastolic blood pressures are high, all are within the patient's baseline and do not require the nurse to immediately notify the health care provider. However, if the systolic blood pressure continues to rise, the nurse may have to notify the health care provider.