Chapter 15: Vital Signs

When getting a postoperative patient out of bed for the first time, the patient immediately feels light-headed and then faints. What are the appropriate actions of the nurse? (Select all that apply.) A. Have the patient lie down. B. Report findings to the health care provider. C. Instruct the patient not to get out of bed without assistance. D. Have the nursing assistant check the patient's orthostatic blood pressure. E. Take the BP in each arm and use the arm with the lowest systolic reading.

A,B,C

The nurse is caring for a patient with an elevated blood pressure. Which factors may account for the high measurement? (Select all that apply.) A. The patient's BMI is 42. B. The patient is in acute renal failure. C. The patient is extremely dehydrated. D. The patient refuses to take antihypertensive medications. E. The cuff was not wrapped snugly around the patient's arm.

A,B,D,E

The nurse is caring for an unconscious, intubated patient in the intensive care unit. Which methods may be used to check the patient's temperature? (Select all that apply.) A. Axillary B. Rectal C. Oral D. Tympanic E. Pulmonary artery

A,B,D,E

Which characteristics place the patient at high risk for development of hypothermia? (Select all that apply.) A. Lack of funds to pay utility bills B. Lifelong member of Mormon Church C. History of poorly managed schizophrenia D. 25-year history of alcohol abuse E. Occasional incontinence of urine

A,C,D

Which medications may be administered to reduce the patient's fever without masking signs of infection? (Select all that apply.) A. Acetaminophen B. Prednisone C. Ibuprofen D. Indomethacin E. Ketorolac

A,C,D,E

Which characteristics put the patient at risk for developing orthostatic hypotension? (Select all that apply.) A. Dehydration B. Obesity C. Recent blood loss D. Cigarette smoking E. Prolonged bed rest

A,C,E

The nurse notes that the patient's temperature varies significantly throughout the day and night. Which are possible reasons for this variation? (Select all that apply.) A. The patient's diagnosis of pneumonia B. The patient's gluten-free, low sodium diet C. The patient's history of hypertension D. The patient's frequent trips outside to smoke E. The patient's allergies to penicillin and shellfish

A,D

The nurse is caring for a patient who suffered a traumatic head injury. The patient's temperature rises to 104.5° F but there is no evidence of infection. Which statement will the nurse make to the patient's family member who verbalizes concern over the patient's fever? A. "The area of the brain that controls body temperature was damaged." B. "The body is compensating for losing too much body heat in the accident." C. "I will contact the physician now to obtain an order for antibiotics." D. "The hospital room must be too warm so I will turn down the thermostat."

A. "The area of the brain that controls body temperature was damaged."

The nurse is caring for a hypotensive patient whose peripheral pulses are very weak. Which grade will the nurse use to document this finding? A. +1 B. +2 C. +3 D. +4

A. +1

The nurse is caring for a patient with a highly contagious infection. Which is the appropriate type of blood pressure cuff to use when caring for this patient? A. A disposable vinyl blood pressure cuff B. An electronic vital signs monitor C. A soft cloth blood pressure cuff D. A Doppler ultrasound device

A. A disposable vinyl blood pressure cuff

Which site will the nurse use to measure the patient's pulse rate before administering the cardiac medication digoxin? A. Apical B. Radial C. Brachial D. Carotid

A. Apical

The patient has a history of orthostatic hypotension. What is the priority action of the nurse? A. Assist the patient to sit and stand slowly when getting out of bed. B. Monitor the patient's neurological status carefully for symptoms of a stroke. C. Always take the patient's blood pressure manually using a sphygmomanometer. D. Check the patient's blood pressure on a lower extremity using a thigh-sized cuff.

A. Assist the patient to sit and stand slowly when getting out of bed.

The nurse is unable to hear the blood pressure for a patient who is in septic shock. What is the best option of the nurse? A. Determine the diastolic blood pressure by palpation and notify the health care provider immediately. B. Elevate the head of the patient's bed and obtain the patient's blood pressure with an electronic vital sign machine. C. Assess the patient's blood pressure using a lower extremity and a thigh-sized blood pressure cuff. D. Raise the patient's arm above the level of the heart and apply the stethoscope more firmly against the antecubital fossa.

A. Determine the diastolic blood pressure by palpation and notify the health care provider immediately.

The nurse is caring for a patient who collapsed after working outside on a hot day. The patient is disoriented with hot, dry skin and heart rate of 140 beats/minute. What is the priority action of the nurse? A. Remove the clothes and cover the patient's body with ice-water soaked towels. B. Insert an indwelling urinary catheter to monitor hourly urine output. C. Insert a nasogastric tube to prevent the patient from vomiting. D. Obtain a 12-lead EKG and draw blood to check the patient's electrolyte levels.

A. Remove the clothes and cover the patient's body with ice-water soaked towels.

A patient's blood pressure suddenly drops from 132/82 to 104/52. The nurse notes that the patient's skin is pale and the patient appears ready to faint. What is the priority action of the nurse? A. Report the findings to the health care provider immediately. B. Check the patient's apical rate to check for a pulse deficit. C. Elevate the head of the patient's bed to at least 45 degrees. D. Immediately check the patient for orthostatic hypotension.

A. Report the findings to the health care provider immediately.

Why will the nurse draw a blood culture before giving an antipyretic medication? A. The causative organism is most prevalent during a spike in temperature. B. Elevated temperatures slow metabolic rate and improve blood oxygenation. C. The antipyretic medication will inhibit bacteria growth within the culture tubes. D. Venous distention is greater because of fluid retention from hyperthermia.

A. The causative organism is most prevalent during a spike in temperature.

The nurse is caring for a patient who was just pulled from a freezing lake. The patient's pulse oximetry reads 68% although the patient is not in respiratory distress. What is the correct interpretation of these assessment findings? A. The pulse oximeter will not give an accurate reading until the patient's extremities have warmed to near normal temperature. B. The pulse oximeter adhesive was left on too long and no longer stuck to the patient's finger adequately. C. The pulse oximeter became overheated when it was placed underneath the patient's warming blanket. D. The pulse oximeter displayed a falsely low reading because the patient was receiving supplemental oxygen via nasal cannula.

A. The pulse oximeter will not give an accurate reading until the patient's extremities have warmed to near normal temperature.

The nurse is caring for an extremely anxious patient. Which assessment findings would be expected as a result of the patient's emotional state? (Select all that apply.) A. Temperature 96.8° F B. Pulse 124 C. Respiratory rate 32 D. Blood pressure 188/88 E. Pulse oximetry 84%

B,C,D

Which factors may lead to inaccurate pulse oximetry readings? (Select all that apply.) A. The patient drinks four to six beers every night. B. The patient has thick gel polish on the fingernails. C. The patient was admitted with heatstroke. D. The patient's hemoglobin level is dangerously low. E. The patient has a generalized mild sunburn.

B,D

The nurse is caring for an adult patient with a temperature of 101.2° F. Which statement will the nurse make to the patient's family member who verbalizes concern over the patient's fever? A. "Fevers this high can cause permanent neurological damage." B. "Fevers under 102° F help the body's immune system fight infections." C. "The fever may cause the patient to have a febrile seizure." D. "I will call the physician now to obtain an order for antibiotics."

B. "Fevers under 102° F help the body's immune system fight infections."

Which patient should have the temperature taken orally rather than using a tympanic thermometer? A. An unconscious, intubated patient B. A patient with bilateral middle ear infections C. A patient with gastroenteritis who is vomiting D. An agitated patient who cannot follow directions

B. A patient with bilateral middle ear infections

The nurse is caring for a patient with a bacterial infection. After antibiotic treatment is started, the patient develops a generalized itchy rash. What is the most likely reason for the rash? A. Vasodilation to lower the body temperature B. An allergic response to the prescribed medication C. Overloaded temperature release mechanism D. Development of infectious heat exhaustion

B. An allergic response to the prescribed medication

An infant born prematurely has irregular breathing patterns and short periods when breathing stops altogether. Which device will be utilized to facilitate respiratory status assessment for this patient after discharge? A. Oxygen flowmeter B. Apnea monitor C. End-tidal CO2 monitor D. Incentive spirometer

B. Apnea monitor

The adult patient's heart rate is 48 beats/minute. Which term will the nurse use when documenting the finding in the patient's medical record? A. Tachycardia B. Bradycardia C. Pulse deficit D. Bradypnea

B. Bradycardia

The nurse is concerned that the outside of the stethoscope is becoming dirty and unsightly. Which is the appropriate action of the nurse? A. Obtain a soft cloth cover for the stethoscope tubing. B. Clean the stethoscope tubing throughout each shift with isopropyl alcohol. C. Send the entire stethoscope to central supply for disinfection. D. Clean the stethoscope tubing weekly with a solution of mild dish soap.

B. Clean the stethoscope tubing throughout each shift with isopropyl alcohol.

The nurse notes that the patient's radial pulse is irregular. What is the most appropriate first action of the nurse? A. Document the finding in the patient's medical record. B. Count the patient's apical pulse for 1 full minute. C. Assess the brachial pulse for a pulse deficit. D. Notify the health care provider immediately.

B. Count the patient's apical pulse for 1 full minute.

The nurse notes that the patient is utilizing accessory and intercostal muscles to breathe. What is the priority action of the nurse? A. Document this normal assessment finding in the patient's medical record. B. Elevate the head of the bed and listen to the patient's lung sounds. C. Direct the nursing assistant to obtain the patient's temperature and blood pressure. D. Instruct the patient about the importance of smoking cessation.

B. Elevate the head of the bed and listen to the patient's lung sounds.

The nurse assistant is preparing to take the patient's oral temperature with a red-tipped electronic thermometer probe. What is the priority action of the nurse? A. Remind the nurse assistant to enter the result into the patient's medical record. B. Give the nurse assistant a blue-tipped probe to take the patient's oral temperature. C. Inform the patient that temperatures are most accurate when taken orally. D. Direct the nurse assistant to change the thermometer probe cover daily.

B. Give the nurse assistant a blue-tipped probe to take the patient's oral temperature.

The nurse is having difficulty hearing his patient's apical pulse with his stethoscope. Which action will help the nurse hear the heartbeat more clearly? A. Positioning the bell very lightly over the patient's sternum B. Placing the diaphragm firmly against the patient's skin C. Making sure that the earpieces fit loosely in the nurse's ear canals D. Utilizing a stethoscope with the longest possible tubing

B. Placing the diaphragm firmly against the patient's skin

Which vital signs are most important for a patient who is experiencing shortness of breath? A. Temperature, pulse, respirations B. Pulse, respirations, oxygen saturation C. Temperature, pulse, blood pressure D. Respirations, blood pressure, pain

B. Pulse, respirations, oxygen saturation

Which technique will provide the most accurate measurement of the patient's core temperature? A. Orally B. Rectally C. Axillary D. Forehead

B. Rectally

The nurse is caring for an adult patient with a respiratory rate of 32 breaths/minute. Which term will the nurse use to document this finding in the patient's chart? A. Eupnea B. Tachypnea C. Bradypnea D. Apnea

B. Tachypnea

The nurse is caring for a patient who is very anemic. Which assessment finding will the nurse expect to note in the patient's medical record? A. Irregular breaths with periods of apnea B. Tachypnea with rapid, deep breaths C. Bradypnea with shallow regular breaths D. Eupnea with even, unlabored breaths

B. Tachypnea with rapid, deep breaths

The nurse is caring for a patient who came to the emergency department with confusion and muscle cramps after working outside on a hot day. What is the priority action of the nurse? A. Place the patient in a tub of iced water. B. Take the patient's temperature and vital signs. C. Remove fans to prevent premature chilling. D. Apply a hyperthermia blanket to lower temperature slowly.

B. Take the patient's temperature and vital signs.

The patient's blood pressure is 152/92 but the primary health care provider does not diagnose the patient with hypertension. What is the rationale for this decision? A. The patient's primary health care provider must consult with a cardiologist in order to make a diagnosis of hypertension. B. The patient's blood pressure must remain elevated during several separate assessments in order to make a diagnosis of hypertension. C. The patient's blood pressure must be at least 180/100 during a single assessment in order for a diagnosis of hypertension to be made. D. The patient appeared extremely stressed and the health care provider decided not to inform the patient of the diagnosis at that appointment.

B. The patient's blood pressure must remain elevated during several separate assessments in order to make a diagnosis of hypertension.

The nurse is caring for an unconscious patient who was just pulled from a freezing lake. What is the priority action of the nurse? A. Have the patient drink hot liquids. B. Wrap the patient in warmed blankets. C. Bathe the patient to promote shivering. D. Remove restrictive items of clothing.

B. Wrap the patient in warmed blankets.

The nurse is shown the mercury thermometer which was used to take the patient's temperature before coming to the hospital. What is the appropriate statement of the nurse? A. "Mercury thermometers are more accurate than electronic ones." B. "Hospitals use mercury thermometers for patients with very high fevers" C. "Electronic thermometers are much safer than mercury thermometers" D. "Mercury thermometers can be used to take rectal or oral temperatures"

C. "Electronic thermometers are much safer than mercury thermometers"

The nurse is caring for a patient with the following vital signs: Temperature: 98.9°F Pulse: 94 Respirations: 20 Blood pressure: 144/94 Pulse oximetry: 94% What is the priority action of the nurse? A. Apply a cool washcloth to the patient's forehead. B. Administer oxygen at 2 L/minute via nasal cannula. C. Ask the patient about his usual blood pressure results. D. Document the findings in the patient's medical record.

C. Ask the patient about his usual blood pressure results.

The nurse is caring for a patient who lost consciousness and collapsed. Which site will be used to determine if the patient has a pulse? A. Apical artery B. Radial artery C. Carotid artery D. Brachial artery

C. Carotid artery

The nurse applies a warmed blanket to a chilled patient. Which term is used to describe the process by which the blanket increases the patient's temperature? A. Convection B. Radiation C. Conduction D. Emission

C. Conduction

The nurse is caring for a patient who has just been admitted with a fever of 102.6° F. Which intervention will the nurse perform first for the patient? A. Administer the prescribed antibiotic. B. Administer the prescribed antipyretic. C. Draw blood cultures for laboratory testing. D. Apply a cool washcloth to the patient's forehead.

C. Draw blood cultures for laboratory testing.

The nurse is assessing a patient with shortness of breath. Which is the optimal technique to auscultate the patient's lung sounds? A. Place the binaurals firmly in both ears and utilize the diaphragm of the stethoscope. B. Place the earpieces loosely in both ears and utilize the bell of the stethoscope. C. Place the diaphragm of the stethoscope firmly on the skin of the patient's chest. D. Place the bell of the stethoscope firmly on the skin of the patient's chest.

C. Place the diaphragm of the stethoscope firmly on the skin of the patient's chest.

The nurse is to take the patient's temperature right after the patient drank a glass of ice water. What is the most appropriate action of the nurse? A. Wait 10 minutes before taking the temperature orally. B. Document that the patient refused the assessment. C. Take the patient's axillary temperature instead. D. Obtain a core temperature measurement instead.

C. Take the patient's axillary temperature instead.

The nurse delegates vital signs for a patient to the nurse assistant. What is the nurse's responsibility regarding delegation of this task? A. The nurse assistant should not be responsible for obtaining vital signs. B. The nurse assistant should determine if the patient's vital signs are abnormal. C. The nurse should review the patient's vital signs as soon as they are done. D. The nurse is not responsible if the nurse assistant fails to obtain the vital signs.

C. The nurse should review the patient's vital signs as soon as they are done.

The nurse is caring for a patient whose temperature has dropped from 102.4° F to 99.4° F. The nurse notes that the patient's face is flushed. What is the reason for this assessment finding? A. The patient is exhausted from shivering. B. The patient's infection has spread to the bloodstream. C. Vasodilation is working to lower the body temperature. D. The patient's core temperature has dropped too low.

C. Vasodilation is working to lower the body temperature

The patient calls the health care provider's office after obtaining a reading of 170/88 with a home wrist blood pressure monitor. What is the appropriate recommendation of the nurse? A. "Take the blood pressure again now using the other wrist." B. "Take the blood pressure again now with the cuff on your upper arm." C. "Take the blood pressure again tomorrow and call the office with the result." D. "Come to the office today to have your blood pressure checked manually."

D. "Come to the office today to have your blood pressure checked manually."

The nurse is caring for a patient who collapsed after working outside on a hot day. The patient is disoriented with hot, dry skin and heart rate of 140 beats/minute. Which temperature will the nurse expect the patient to have? A. 99.2° F B. 100.8° F C. 102.2° F D. 104.4° F

D. 104.4° F

The nurse applies a cooling blanket to a patient with a dangerously high fever. Which is the most accurate method to monitor the patient's temperature? A. Taping a digital thermometer probe to the skin of the patient's axilla to download the temperature readings directly to the patient's chart B. Checking the patient's oral temperature every 15 minutes while the cooling blanket is in place until the patient is afebrile C. Applying a temperature-sensitive patch to the patient's forehead to monitor the temperature of the patient's skin surface D. Inserting a small rectal thermometer probe for continuous core temperature measurement

D. Inserting a small rectal thermometer probe for continuous core temperature measurement

The nursing assistant informs the nurse that the patient's blood pressure is 220/102 using the electronic monitor. What is the priority action of the nurse? A. Perform a neurological assessment to determine if the patient is stressed, in pain, or having a stroke. B. Inform the patient's health care provider immediately to obtain an order for antihypertensive medication. C. Instruct the nursing assistant to take the patient's blood pressure again and inform the nurse of the results immediately. D. Take the patient's blood pressure manually with a sphygmomanometer and stethoscope.

D. Take the patient's blood pressure manually with a sphygmomanometer and stethoscope.

The nurse is caring for a patient with a temperature of 100.3° F. Why will the nurse refrain from administering an antipyretic at this time? A. A temperature of 100.3° F is within the normal range for the patient. B. The patient's shivering will lower the temperature more quickly than an antipyretic. C. Antipyretics should not be administered until the temperature is at over 104° F. D. The patient is diaphoretic after the temperature was 101.3° F 1 hour ago.

D. The patient is diaphoretic after the temperature was 101.3° F 1 hour ago.