Chapter 20. Measuring Vital Signs

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? a)97.2°F b)98.0°F c)98.6°F d)99.2°F

A

A postsurgical patient has just returned from the recovery room to the surgical unit. After the first hour on the unit, what is the likely schedule for measuring the patient's vital signs? a)Every 4 hours for 24 hours b)Every 8 hours for 24 hours c)Once per shift d)Every 2 hours for 24 hours

A

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 the nurse's first intervention be at this time? a)Ask the client whether he has had a warm drink in the last 30 minutes. b)Notify the primary care provider of the client's temperature. c)Ask the client whether he is feeling chilled. d)Take the temperature by a different route.

A

For which of the following adult clients should the nurse make follow-up observations and monitor the vital signs closely? A client whose: a)Resting morning blood pressure is 136/86, whereas the afternoon BP is 128/84 mm Hg b)Oral temperature is 97.9°F in the morning and 99.8°F in the evening c)Heart rate was 76 beats/min before eating and 88 beats/min after eating d)Respiratory rate is 16 breaths/min when standing and 18 when lying down

A

The nurse assesses the following changes in a client's vital signs. Which client situation should be reported to the primary care provider? a)Decreased blood pressure (BP) after standing up b)Decreased temperature after a period of diaphoresis c)Increased heart rate after walking down the hall d)Increased respiratory rate when the heart rate increases

A

The nurse is assessing vital signs for a client after a surgical procedure on the left leg. IV fluids are infusing. It would be most important for the nurse to: a)Compare the left pedal pulse with the right pedal pulse b)Count the client's respiratory rate for 1 full minute c)Take the blood pressure in the arm without an IV d)Take an oral temperature with an electronic thermometer

A

The nurse is caring for a critically ill patient with a severe midbrain injury involving the hypothalamus. Which vital sign is most critical for the nurse to monitor closely for this patient? a)Temperature b)Pulse c)Respiration d)Blood pressure

A

The nurse is caring for a patient with a history of postural hypotension. She obtains a blood pressure reading on her patient of 130/80 lying and 100/60 standing. What is the most appropriate nursing diagnosis for this patient? a)Risk for falls b)Risk for fatigue c)Risk for dizziness d)Risk for activity intolerance

A

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: a)Ask the client to demonstrate the use of the blood pressure device b)Explain the importance of frequent calibration of the device c)Give the client a chart to record his blood pressure readings d)Provide written instructions of the information taught

A

Which of the following procedure techniques has the most effect on the accuracy of an apical pulse count? a)Counting the rate for 1 full minute b)Exposing only the left side of the chest c)Determining why assessment of apical pulse is indicated d)Using your ring finger to palpate the intercostal spaces

A

Which nursing interventions are appropriate for a 38-year-old patient admitted with a diagnosis of Dehydration who has a temperature of 101.5°F (38.6°C)? Select all that apply. a)Provide oral and/or IV fluids. b)Take vital signs every 2 hours. c)Contact the provider for respirations of 18 breaths/min. d)Keep the patient on a "nothing by mouth" (NPO) diet until defervescence occurs. e)Apply a cooling blanket every 2 hours.

A, B

A 70-year-old homeless man is admitted to the emergency department with heat stroke following 3 days of overexposure to outside temperatures. The nurse is most alerted to which signs and symptoms associated with heat stroke? Select all that apply. a)Temperature of 103.8°F b)Throbbing headache c)Diaphoresis d)Confusion

A, B, D

Which of the following interventions would be appropriate for a client who has a fever? Select all that apply. a)Put an ice pack on the client's neck and axillae. b)Provide the client a blanket when he is shivering. c)Offer the client fluids to drink every 1 to 2 hours. d)Take the temperature using a tympanic thermometer.

A, C

A 1-day postoperative client has a temperature of 36.8°C. What is the nurse's next best action? a)Contact the primary care provider for guidance. b)Document the temperature and continue with his care. c)Administer the prescribed antipyretic medication. d)Instruct the client to drink more fluids.

B

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: a)16 b)18 c)20 d)22

B

After obtaining a full set of vital signs, the nurse assesses the client's fifth vital sign as a 7 on a scale of 1 to 10 (or 7/10). Which action by the nurse is most appropriate? a)Document the pulse pressure as normal and continue the client's assessment. b)Review the client's records to determine the last time he received pain medication. c)Assess the client's pulse on the opposite side for comparison. d)Wait 2 minutes and retake the client's blood pressure.

B

The nurse administers two blood pressure (BP) medications to a patient and asks the certified nurse assistant (CNA) to obtain a BP reading in 30 minutes. The CNA states, "I just took his BP." What is the most appropriate response by the nurse? a)"Take it again so we can be sure nothing else is wrong with him." b)"I need to check the patient's response to the BP medications." c)"If his BP drops too much, I'll need to discontinue one of the medications" d)"If you just took his BP, then recheck it in 2 hours instead."

B

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? a)Have the client take several deep breaths. b)Request the client take a deep breath and cough. c)Take the client's blood pressure and apical pulse readings. d)Count the client's respiratory rate for 1 minute.

B

The nurse is obtaining vital signs on a newborn infant and notes respirations at 56 breaths/min. What is the most appropriate action by the nurse? a) Apply oxygen immediately. b) Document the finding and continue the assessment. c) Contact the obstetrician for orders. d) Compare the finding with other infants in the nursery.

B

The nurse on a medical-surgical unit palpates a patient's carotid pulse for 30 seconds and obtains a rate of 80 beats/min. The nurse knows in obtaining a patient's carotid pulse she must be careful that her technique does not cause a/an: a)Increase in heart rate b)Decrease in heart rate c)Increase in blood pressure d)Irregular heart rhythm

B

Which assessment data best support a report of severe pain in an adult client whose baseline vital signs are within an average normal range? a)Oral temperature 100°F (37.8°C) b)Respiratory rate 26 breaths/min and shallow c)Apical heart rate 56 beats/min d)Blood pressure 124/82 mm Hg

B

Which of the following sets of vital signs are all within normal limits for patients at rest? a)Infant: T 98.8°F (rectal), HR 160, RR 16, BP 120/54 b)Adolescent: T 98.2°F (oral), HR 80, RR 18, BP 108/68 c)Adult: T 99.6°F (oral), HR 48, RR 22, BP 130/84 d)Older adult: T 98.6°F (oral), HR 110, RR 28, BP 170/95

B

Which one of the following clients would probably have a higher than normal respiratory rate? A client who has: a)Had surgery and is receiving a narcotic analgesic b)Had surgery and lost a unit of blood intraoperatively c)Lived at a high altitude and then moved to sea level d)Been exposed to the cold and is now hypothermic.

B

When assessing the quality of a client's pedal pulses, what is the nurse assessing? Select all that apply. a)Rhythm of the pulses b)Strength of the pulses c)Bilateral equality of pulses d)Rate compared with apical pulse

B, C

Which of these steps in taking a blood pressure is/are correct? Select all that apply. a)Use a bladder that encircles 40% of the arm. b)Wrap the cuff snugly around the client's arm. c)Ask the client to hold the arm at heart level. d)Have the client sit with feet flat on the floor.

B, D

1. 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 102.3°F (39.1°C). Based on the temperature change, the nurse should anticipate the client's heart rate would be how many beats/min? a)62 b)82 c)102 d)122

C

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? a)"Your vital signs confirm that your infection is resolved; how do you feel?" b)"I'll let your healthcare provider know so you can be discharged." c)"Your vital signs are stable, but there are other things to assess." d)"We still need to keep monitoring your temperature for a while."

C

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? a)Add 1°F to 100.8°F to obtain an oral equivalent. b)Add 2°F to 100.8°F to obtain a rectal equivalent. c)Obtain a rectal temperature reading. d)Obtain a tympanic membrane reading.

C

The client has an order for the drug digitalis, which has the effect of decreasing the heart rate. Which site should the nurse use to obtain a pulse rate prior to administering the medication? a)Radial b)Temporal c)Apical d)Brachial

C

The nurse documents a patient's radial pulse rate as 120 beats/min and regular. One hour later, the nurse rechecks the pulse and it is irregular at 120 beats/min. What is the most appropriate nursing action? a)Ask another nurse to check the pulse. b)Place the patient on bedrest and administer fluids. c)Place the patient on a cardiac monitor. d)Check the pulse in the opposite arm.

C

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? a)Be sure to put on mittens. b)Layer the infant's clothing. c)Place a cap on the head. d)Put on warm booties.

C

The nurse obtains the following vital signs on an adult patient: T. 100.6°F BP 100/60, HR 110, respirations 36. What is the first action by the nurse? a)Offer oral fluids. b)Begin an IV infusion. c)Obtain a pulse oximetry reading. d)Administer oxygen.

C

The nurse palpates a radial pulse on her 80-year-old patient and notes that it feels irregular. What is the most appropriate method to count this patient's pulse? a)Count for 15 seconds, multiply by 4. b)Count for 30 seconds, multiply by 2. c)Count for 1 full minute. d)Count for 10 seconds multiply by 6.

C

The nurse provides client education regarding hypertension prevention and management. Which of these statements indicates that the client understands the instructions? a)"I don't have to worry if my blood pressure is high once in a while." b)"I guess I will have to make sure I don't drink too much water." c)"I can lose some weight to help lower my blood pressure." d)"I will need to reduce the amount milk and other dairy products I use."

C

Comparing the changes in vital signs as a person ages, which statement(s) is/are correct? Select all that apply. a)Blood pressure decreases, but less than heart rate and respiratory rate. b)Respiratory rate remains fairly stable throughout a person's life. c)Blood pressure increases; heart rate and respiratory rate decline. d)Men have higher blood pressure than women until after menopause.

C, D

Which blood pressure reading has a pulse pressure within normal limits? Select all that apply. a)104/50 mm Hg b)120/62 mm Hg c)120/80 mm Hg d)130/86 mm Hg

C, D

A 42-year-old client has a rectal temperature reading of 39.2°C (102.6°F). Her blood pressure has decreased from 124/76 to 118/70 since taken 4 hours earlier. Her pulse rate has increased from 68 to 78. The nurse's initial best action is to: a)Document the vital signs and continue with her assessment b)Contact the provider immediately due to the alarming changes in the vital signs c)Obtain a pulmonary artery temperature reading before initiating any type of treatment d)Ask the NAP to obtain another set of vital signs in 4 hours

D

During a clinic interview, a client states he has been experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement? a)Ask the client when in the day dizziness occurs. b)Help the client to assume a recumbent position. c)Measure both heart rate and blood pressure with the client standing. d)Measure vital signs with the client supine, sitting, and standing.

D

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: a)Had abdominal surgery 2 hours ago b)Suffered a fractured hip yesterday c)Is dehydrated from vomiting d)Has a heart or lung disease

D

In evaluating a client's blood pressure for hypertension, it would be most important to: a)Use the same type of manometer each time b)Auscultate all five Korotkoff sounds c)Measure the blood pressure in both arms d)Monitor the blood pressure for a pattern

D

The nurse caring for a postsurgical patient obtains an oral temperature reading of 103°F. She contacts the surgeon, obtains an order, and administers acetaminophen 650 mg orally. Which clinical information should the nurse document? Select all that apply. a)Oral temperature reading of 102°F b)The call to the surgeon to obtain the order c)Administering acetaminophen 650 mg orally d)All of the above

D

The nurse enters the client's room and before he can take vital signs, he hears a piercing, high-pitched sound coming from the client when he breathes. The nurse's initial next best action is to: a)Document the finding and continue with the assessment b)Ask the client to take several deep breaths over the next 24 hours c)Give the client extra fluids to loosen the secretions of mucus d)Assess the client's airway patency

D

The nurse obtains a blood pressure reading of 160/90 from a cardiac patient. What is the first action by the nurse? a)Obtain the blood in lying, sitting, and standing positions. b)Contact the primary care provider for medication orders. c)Recheck the blood pressure in 30 minutes. d)Check the patient's pattern of blood pressures over the past 3 days.

D

The nurse volunteers to work at the annual summer 20-mile marathon in her community. In planning for the event, the nurse knows that which of the following nursing diagnoses is most important to include in the plan? a)Risk for Fatigue b)Risk for Elevated Heart Rate c)Risk for Alterations in Blood Pressure d)Risk for Imbalanced Body Temperature

D