Vital signs (posttest)

A nurse is preparing an in-service about peripheral pulses for a group of staff nurses. Which of the following information should the nurse include?

A pulse strength of +1 indicates that the pulse is weak or diminished upon palpation.

A nurse is caring for a group of clients. Which of the following clients is experiencing an alteration in their respiratory rate that requires intervention?

A school-age child who has a respiratory rate of 14/min.

A nurse is discussing oxygen saturation with a client. Which of the following information should the nurse include?

Oxygen saturation reflects the amount of oxygen being delivered to body tissues.

A nurse is reviewing blood flow through the heart with a group of assistive personnel. The nurse should identify that blood flows to which of the following parts of the heart as it leave the right ventricle?

Pulmonary artery

A charge nurse is providing an in-service for a group of nurses about cardiac output. Which of the following statements should the nurse include?

"Cardiac output is the amount of blood flow through the heart in 1 minute. "

A nurse is evaluating the effectiveness of interventions used for clients who had alterations in vital signs. Which of the following clients vital signs indicate that interventions were effective? (select all that apply)

*A preschooler who was exhibiting tachypnea 2 hours postoperative and now has a respiratory rate of 26/min. *An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min. *A young adult who had hypotension after receiving an opioid analgesic and now has a blood pressure of 98/68 mm Hg.

A nurse is planning care for a client who has hypertension. Which of the following interventions should the nurse include in the plan?

*Provide the client with low-sodium meals and snacks. *Encourage the client to participate in physical activity each day. *Instruct the client in the use of relaxation techniques. *Inform the client of the importance of abstaining from using products that contain nicotine.

A charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. Identify the order of the steps the nurse should include.

1. Select the site for obtaining the measurement. 2. Apply the sensor probe on the chosen site. 3. Confirm the pulse rate displayed on the oximeter by palpating the radial pulse. 4. Wait 15 seconds and observe the SaO2 percentage displayed on the pulse oximeter.

A nurse is planning care for a group of clients and is reviewing the recent vital signs obtained by an assistive personnel. Which of the following clients should the nurse assess and recheck the vital signs prior to notifying the provider?

8-year-old male: respiratory rate 34/min, SaO2 97%

A nurse is reviewing the vital signs of four clients. The nurse should identify that which of the following clients has a vital sign outside of the expected reference range?

A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg.

A nurse on a pediatric unit is reviewing the medical records for a group of clients. Which of the following clients has a vital sign outside the expected reference range and requires intervention?

A 3-year-old preschooler who has an apical pulse rate of 144/min **The nurse should identify that an apical pulse rate of 144/min is above the expected reference range of 75 to 129/min for a preschooler. This finding requires intervention by the nurse.

A nurse is review the recent vital signs of a group of clients. Which of the following clients should the nurse see first?

A 52-year-old client who has an SaO2 of 92%

A nurse is caring for a client who is experiencing tachypnea due to an exacerbation of asthma. Which of the following medications should the nurse anticipate administering?

A broncholilator

A nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings for vital signs. Which of the following findings requires follow up?

A client has a radial pulse of +4 bilateral. **A peripheral pulse strength of +4 is described as bounding and is considered an unexpected finding. The nurse should check further and report the findings to the provider. A pulse strength of +2 is considered an expected finding.

A charge nurse in a clinic is preparing an in-service about blood pressure measurements for a group of staff members. Which of the following information should the nurse include?

A client who has a blood pressure of 162/102 mm Hg has stage 2 hypertension.

A nurse working on a med-surg unit is caring for a group of clients. Which of the following clients vital signs should the nurse identify is outside the expected reference range and notify the provider?

A client who has an apical pulse rate of 120/min.

A nurse is teaching a group of assistive personnel (AP) about techniques used to obtain BP. For which of the following clients should the nurse use to instruct the AP to obtain an electronic BP measurment?

A client who has stabilized BP measurements.

A nurse is planning care for a group of clients. For which of the following clients should the nurse direct an assistive personnel (AP) to obtain a rectal temperature?

A client who is diaphoretic and frequently chewing ice to relieve dry mouth.

A nurse is planning care for a group of clients and is delegating to the assistive personnel (AP) to take the clients' vital signs. For which of the following clients should the nurse obtain the vital signs rather than the AP?

A client who was recently admitted and reports chest pain.

A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. Which of the following statements should the charge nurse make?

A decrease of 20 millimeters of mercury in the diastolic pressure with a position change indicates orthostatic hypotension.

A nurse is preparing an in-service for a group of newly hired assistive personnel (AP) about body temperature. Which of the following information should the nurse include?

A temporal probe thermometer uses infrared scanning to determine a client's temperature.

A nurse is reviewing the vital signs for a group of clients obtained by an assistive personnel. The nurse should identify that which of the following clients requires a follow-up assessment due to bradycardia?

A young adult who has a radial pulse rate of 56/min.

A nurse is reviewing the vital signs for a group of clients. Which of the following clients should the nurse identify as exhibiting tachycardia?

A young adult who has an apical pulse rate of 104/min

A nurse is evaluating the effectiveness of interventions used to address a clients' vital signs that were outside of the expected reference ranges. Which of the following findings indicates the intervention was effective?

A young adult who is experiencing an asthma attack and has blood pressure of 116/72 mmHg after using an inhaler.

A nurse is planning care for a client who is experiencing tachycardia. Which of the following interventions should the nurse plan to include?

Encourage the client to practice relaxation techniques each day.

A nurse is caring for a client who has a heart rate of 118/min. Which of the following actions should the nurse take to improve the client's heart rate?

Encourage the client to reduce intake of caffeinated soft drinks.

A nurse is preparing an in-service about factors affecting respiratory rate for a group of assistive personnel. Which of the following information should the nurse include?

Fever can increase a client's respiratory rate.

A charge nurse is reviewing the expected reference range of blood pressure in adult clients with a newly licensed nurse. Which of the following statements should the charge nurse include?

Hypertension is diagnosed with two elevated measurements on two seperate occasions.

A nurse is caring for a client who has an increase in cardiac afterload. Which of the following findings should the nurse expect?

Increase in blood pressure

A nurse is caring for a client who has an increase in cardiac output. Which of the following findings should the nurse expect?

Increase in blood pressure

A nurse is providing care to a client who has an apical pulse rate of 54/min and is experiencing dizziness. Which of the following is the nurse's priority action?

Inform the client to ask for assistance with getting out of bed. **Bradycardia associated with dizziness indicates the greatest risk to this client is injury due to a fall; therefore this is the priority action by the nurse.

A nurse is caring for a client who has a heart rate of 120/min. Which of the following actions should the nurse take?

Instruct the client to bear down like they are having bowel movement. **The Valsalva maneuver can be used to regulate heart rate. To elicit this, the nurse should instruct the client to "bear down" like they are having a bowel movement. This action produces a vasovagal response in the client's body which lowers the client's heart rate.

A nurse is evaluating the effectiveness of interventions provided to a client who was admitted for decreased circulation. Which of the following findings requires further intervention by the nurse?

Left radial pulse is nonpalpable.

A nurse obtains a client's electronic blood pressure reading of 188/96 mm Hg. Which of the following actions should the nurse take next?

Obtain a manual blood pressure reading from the client.

A nurse is preparing an in-service about vital signs for a group of newly hired assistive personnel. Which of the following information should the nurse include about measuring body temperature?

Oral temperature is easily accessible despite a client's position.

A nurse is assessing a 3-month-old infant during a well-child visit. Which of the following actions should the nurse take when assessing the apical pulse?

Place the stethoscope over the 4th intercostal space to the left of the sternum.

A nurse is caring for a recently admitted client and as part of the plan of care, two nurses obtained simultaneous pulse rates. The client's auscultated apical pulse was 106/min and the palpated radial pulse was 93/min. The nurse should document the findings as which of the following?

Pulse deficit of 13/min.

A nurse is reviewing documentation of vital signs by a newly licensed nurse for an assigned client. Which of the following entries in the chart requires follow up by the nurse?

Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall. **This client's pulse rate is higher than the expected reference range. While the notation of the client ambulating in the hall can be a factor in the tachycardia, the nurse does not indicate they will re-evaluate the pulse rate after the client has rested. The nurse should use clinical judgment when evaluating vital signs and wait 15 to 30 min following exercise.

A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. Which of the following statements should the nurse include?

Radiation is the loss of body heat when a client is in close proximity to a cooler surface. **The nurse should include that radiation is the loss of body heat that occurs when a client is in close proximity to a cooler surface. For example, radiative heat loss can occur when a client sits near a window when it is cold outside.

A charge nurse is teaching a group of assistive personnel (AP) about the importance of documenting accurate vital signs. Which of the following information should the charge nurse include in the teaching?

Recording vital signs provides critical information regarding a client's condition.

A charge nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct?

SaO2 97% right index finger, room air.

A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart?

Sinatrial (SA) node

A nurse is caring for a client who asks about factors that could cause their pulse rate to increase. Which of the following factors should the nurse include in their response?

Smoking

A nurse is obtaining vital signs for a group of clients. Which of the following findings requires intervention?

An 11-year-old child who has a respiratory rate of 34/min.

A nurse is reviewing the vital signs for a group of clients to determine the effectiveness of interventions. which of the following findings indicates an intervention was effective?

An adult client who received medication for pain 30 min ago now has respiratory rate of 18/min.

A nurse is preparing to obtain a young adult client's apical pulse. In which of the following locations should the nurse place their stethoscope to auscultate the client's pulse?

Apex of the heart

A charge nurse is evaluating a newly licensed nurse's documentation of vital signs for several clients. Which of the following documentation should the charge nurse identify as being incomplete?

BP 124/82 mm Hg, lying in bed. (does not include site from where the blood pressure was obtained.

A nurse is discussing the physiology of blood pressure with a group of assistive personnel. Which of the following information should the nurse include?

Blood pressure is measured and documented in millimeters of mercury.

A nurse is teaching a group of newly licensed nurses about vital sign measurements. Which of the following factors should the nurse include in the teaching?

Body temperature is typically lower in older adults.

A charge nurse is discussing a client's respiratory data with a newly licensed nurse. Which of the following statements should the nurse include?

Count the respiratory rate for 1 minute for clients who have a respiratory infection.

A nurse is caring for a client who has hypotension. Which of the following factors should the nurse identify as a contributing factor to the client's condition?

Decrease in contractility. **The nurse should identify that a decrease in contractility of the client's heart is a contributing factor to hypotension. Contractility is the ability of the heart muscle to contract effectively.

A nurse is evaluating the effectiveness of interventions provided to a client who has an SaO2 below the expected reference range. Which of the following manifestations requires follow up by the nurse?

Dyspnea

A nurse is assessing a client who has orthostatic hypotension. Which of the following actions should the nurse take?

Encourage the client to change positions slowly.

A nurse is observing an assistive personnel (AP) obtain vital signs from an adult client. Which of the following actions by the AP requires follow up by the nurse?

The AP informs the client when they are counting the respirations

A nurse is observing an assistive personnel (AP) who is obtaining a blood pressure reading from a client. Which of the following actions by the AP requires follow up by the nurse?

The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second.

A nurse is providing teaching about thermoregulation to a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching?

The body lowers body temperature through sweating.

A nurse is reviewing the vital signs obtained by an assistive personnel at 1200. For which of the following clients should the nurse plan to intervene?

Toddler who has a respiratory rate of 44/min.

A nurse is discussing the use of a client's thigh for blood pressure measurements with an assistive personnel (AP). Which of the following information should the nurse include?

Use the thigh to obtain blood pressure when a client has severe edema in their arms.