Measuring Vital Signs

24. A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly: a. listens to the apical pulse for 1 full minute. b. takes the pulse for 30 seconds on the other wrist. c. records the findings on the graphic sheet. d. takes the pulse for 1 full minute on the other wrist.

ANS: A An apical pulse is measured whenever the radial pulse is irregular or when the patient has a cardiac disease history.

12. A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding: a.a breathing pattern of dyspnea followed by a short period of apnea. b.rapid wheezing respirations for two or three breaths with short periods of apnea. c.quick shallow respirations with long periods of apnea. d.respirations gradually decreasing in rate and depth.

ANS: A Cheyne-Stokes respirations are faster and deeper rather than slower and are followed by a period of no breathing.

18. Elderly patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to: a. continue to listen until the cuff is deflated. b. pump up the cuff until no sound is heard and then let the air out. c. make sure the bell of the stethoscope is placed firmly over the artery. d. stop midway and begin to inflate again.

ANS: A Many older adults with hypertension have an auscultatory gap in their Korotkoff sounds, making it important to listen until the cuff is deflated to avoid mistaking the auscultatory gap as the Korotkoff sound.

31. The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.) a. dizziness upon rising to a standing position. b. a drop of 15 to 20 mm Hg from baseline when changing position. c. nausea. d. syncope. e. blurred vision.

ANS: A, B, D, E Assessment of dizziness, drop in up to 20 mm Hg from baseline BP, syncope, and blurred vision are all indicative of orthostatic hypotension.

29. Standards of the Joint Commission state that pain is the fifth vital sign and should be documented by assessments of: (Select all that apply.) a. location. b. duration. c. usual methods of relief. d. character. e. intensity.

ANS: A, B, D, E Pain should be monitored when vital signs are monitored, to closely assess for any cardiac changes. Pain is documented by assessments relative to location, intensity, character, frequency, and duration.

30. The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a: (Select all that apply.) a. previous mastectomy. b. patent IV line. c. injured hand. d. 2-year-old hand amputation. e. dialysis shunt.

ANS: A, B, E Arms affected by previous mastectomies, patent IVs, or dialysis shunts should not be used to assess the blood pressure using an inflatable cuff.

9. The nurse anticipates that if the stroke volume of a patient is reduced, the pulse will be: a.stronger. b.weaker. c.bradycardic. d.irregular.

ANS: B A weak pulse will result if the stroke volume is reduced, because this decreases circulating volume.

10. When caring for a victim with a gunshot wound to the abdomen who has lost a significant amount of blood, the nurse would anticipate the vital signs to reflect: a.increase in temperature. b.decrease in blood pressure. c.decrease in pulse. d.decrease in respirations.

ANS: B If blood volume decreases, as with bleeding, blood pressure decreases.

2. The nurse documents vital signs on a newly admitted patient as: "blood pressure is 148/94 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min." The nurse would record the pulse pressure as _____ mm Hg. a. 14 b. 54 c. 64 d. 80

ANS: B In calculating pulse pressure, take the difference between the systolic and diastolic pressures (i.e., 148 - 94 = 54).

27. The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction is warranted when the caregiver states, "I will: a. offer warm fluids to the patient, if permitted." b. instruct the patient to remain on strict bed rest." c. provide the patient with additional blankets." d. encourage the patient to increase his muscle activity."

ANS: B Nursing activities for treating the patient with a below-normal body temperature should focus on reducing heat loss and supplying additional warmth. These activities may include (1) providing additional clothing or blankets for warmth (an electric blanket is most effective for raising temperature); (2) giving warm fluids, if permitted; (3) adjusting the temperature of the room to 72° F or higher; (4) eliminating drafts; and (5) increasing the patient's muscle activity.

21. The nurse is caring for a patient who had a cardiac catheterization 2 hours ago and has a pressure dressing to his left groin. In addition to taking routine vital signs, the nurse should also check the: a. strength of the femoral pulse. b. presence of the pedal pulse. c. temperature of the right foot. d. ability to move the left toes.

ANS: B Pedal pulses are checked to determine whether there is any blockage in the artery following a cardiac catheterization.

14. Because the elderly have non-elastic blood vessels, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to: a. keep the patient in bed in a high Fowler's position. b. allow the patient to sit on the side of the bed for a minute before standing. c. instruct the patient to use the wheelchair for all mobility activity. d. help the patient to rise quickly and support the patient for a minute.

ANS: B The elderly often experience orthostatic hypotension and are at risk for falls and should be encouraged to sit on the side of the bed a minute before standing. These patients also benefit from the use of elastic stockings.

1. The nurse would anticipate a patient diagnosed with damage to the hypothalamus after suffering a head injury from a fall to exhibit: a. a blood pressure elevation. b. a temperature abnormality. c. a decrease in pulse rate. d. depressed respirations.

ANS: B The hypothalamus, which is located between the cerebral hemispheres, controls body temperature. Any damage to the hypothalamus prevents the body from regulating its temperature.

8. The nurse is aware that the use of an oral glass thermometer would be contraindicated in a: a.5-year-old with a facial laceration. b.12-year-old patient with a recent seizure. c.15-year-old with an abscessed tooth. d.20-year-old with severe dehydration.

ANS: B The rectal method is best for patients who have seizure activity so as not to put them at risk for biting and breaking the thermometer.

22. The accuracy in measuring the apical pulse is enhanced when the nurse: a. counts the radial pulse at the same time. b. counts the beats for one minute. c. keeps the patient warm. d. uses the bell of the stethoscope.

ANS: B Using the diaphragm of the stethoscope, the nurse counts the beats for 1 full minute.

19. Regarding the blood pressure in children, the diastolic pressure is assessed by the auscultation of a: a. clear tapping that gradually grows louder. b. murmur or swishing sound that increases with depression of the cuff. c. sudden change or muffling of the sound. d. louder knocking sound that occurs with each heartbeat.

ANS: C A sudden change or muffling sound (Phase IV) indicates the diastolic pressure in children and in some adults.

16. The nurse using either a regular or an electronic sphygmomanometer would ensure that the cuff is the correct size by: a. using a narrow cuff for an obese patient. b. making sure the width of the bladder is at least 3 inches. c. confirming that the bladder goes around three fourths of the arm. d. always using a wide cuff.

ANS: C For accuracy in a BP reading, the cuff of the sphygmomanometer should have a bladder that goes around three fourths of the arm

26. The nurse explains that one method of environmental heat loss is convection, which is exemplified by body heat being reduced by: a. being transferred to ice packs. b. production of sweat. c. being removed by fast air currents from a fan. d. exposure to a cool environment.

ANS: C Heat loss through convection can be accomplished by the use of a fan, which produces fast air currents.

11. When a frail 83-year-old patient whose temperature was 96.8° F at 8:00 AM shows a temperature of 98.6° F at 4:00 PM, the nurse is: a. pleased that the temperature has come up to normal. b.satisfied that the patient is warm enough. c.concerned about the evidence of fever. d.relieved that the patient is improving.

ANS: C In older patients who have a frail frame, the normal temperature is often 97.2° F. An elevation of 2° F is indicative of fever

20. The nurse covers a newborn baby's head with a cap, because the head: a. is wet and needs to be dried. b. has large fontanels. c. allows loss of body heat. d. can be reshaped more quickly.

ANS: C Infants lose considerable body heat through the scalp; therefore a cap helps prevent heat loss

15. An elderly patient has a tympanic temperature of 96.2° F (35.7° C). What nursing intervention would best meet this patient's need? a. Take the patient's vital signs every 4 hours, including temperature. b. Provide fluids to increase circulation. c. Increase room temperature to 72° F (22.2° C) and add blankets to the bed. d. Check the temperature orally to confirm the accuracy of the reading.

ANS: C Nursing interventions for treating hypothermia should focus on reducing heat loss and supplying additional warmth, such as increasing the room temperature and adding blankets to the bed.

5. To ensure an accurate reading when using a glass oral thermometer, it is necessary to: a.rinse the thermometer with water. b.wipe the thermometer with alcohol. c.shake down the galinstan alloy to below normal. d.dry the thermometer with a dry cotton ball.

ANS: C Oral thermometers remain at the last reading until they are shaken down; therefore, for accuracy, the thermometer must be below normal range before using.

25. The nurse caring for a 30-year-old postsurgical patient would assess that the patient is in pain as indicated by: a. a temperature of 102° F. b. respirations of 16 breaths/min. c. a pulse rate of 120 beats/min. d. blood pressure of 128/86 mm Hg

ANS: C Pain increases the pulse rate.

13. The nurse explains to a patient that the pulse oximeter can measure the arterial oxygen by: a.assessing the amount of blood passing through the sensor. b.assessing the relative warmth of the skin on the monitored part. c.measuring the oxygenated hemoglobin through a capillary bed. d.measuring the respirations to the blood pressure via infrared rays.

ANS: C The pulse oximeter measures oxygen saturation by means of a sensor/probe attached to peripheral digits, an earlobe, the nose, or the forehead as it passes through the capillary bed. Oxygenated blood absorbs more infrared than red light.

4. The nurse would document a patient as being febrile if the patient's temperature was over _____° F. a. 99.5 b. 99.8 c. 100 d. 100.5

ANS: D A patient with a temperature above the normal range (100.2° F) is called febrile.

7. The nurse would record a pulse as bradycardic if the rate were _____ beats/min. a.64 b.62 c.60 d.59

ANS: D Bradycardia indicates a slow pulse that is less than 60 beats/min

23. A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to: a. notify the charge nurse of the hypotension. b. notify the doctor of the bradycardia. c. check medications that might be the cause of the irregularity. d. check the patient's record to determine his baseline blood pressure.

ANS: D Check to see what the patient's baseline vital signs indicate regarding the cardiac arrhythmia.

6. The nurse taking an apical pulse would place the stethoscope at: a.the left of the sternum at the third intercostal space. b.directly below the sternum. c.slightly above the left nipple. d.the left midclavicular line at the fifth intercostal space.

ANS: D The apical pulse is determined by placing a stethoscope on a point midway between the imaginary line running from the midclavicle through the left nipple in the fifth intercostal space.

17. For the nurse to assess the most accurate respiration count, the nurse should: a. inform the patient about his respirations and ask him to breathe normally. b. count each inhalation and expiration for 1 full minute. c. watch the patient's chest rise and fall from a distance. d. continue to hold the patient's radial pulse, and count the respirations for 30 seconds and multiply them by 2.

ANS: D The respirations should be counted for 30 seconds and multiplied by 2 if they are regular. If the patient knows the nurse is assessing the respiration, he or she may alter breathing.

3. A patient has been admitted with hypothermia after lying unconscious overnight in an unheated apartment. The most appropriate route to assess the patient's core temperature would be: a.rectal. b.tympanic arterial thermometer. c.axillary. d.tympanic.

ANS: D The same blood vessels serve the hypothalamus and the tympanic membrane, so the tympanic temperature is an excellent indicator of core body temperature, although it can be affected by ear wax.

28. The nurse clarifies the average cardiac output in the adult is about _____ L/minute.

five The average cardiac output of the normal adult is about 5 L/minute