Vital Signs and Lab Reference Practice Test
While assessing a patient, the nurse finds that the radial pulse is abnormal. Which pulse would the nurse assess next in this situation? Temporal Carotid Apical Brachial
Because radial and apical locations are most common sites for pulse rate measurement, if the radial pulse is abnormal or intermittent because of dysrhythmias or if it is inaccessible because of a dressing or cast, the patient's apical pulse should be assessed. The carotid site is recommended for quickly finding and assessing the pulse when other sites are not palpable. Therefore, carotid pulse is not the most appropriate option if the radial pulse is abnormal or intermittent. The brachial pulse is the best site for assessing the pulse of an infant or young child. However, obtaining brachial pulse is unnecessary when routinely obtaining the vital signs. The temporal site is an easily accessible site, which is used to assess pulse in children. However, the apical site is more commonly used.
A nurse is teaching a student about the assessment of vital signs in older adults. Which statement by a student indicates the need for further teaching? "Assess the skin while frequently monitoring the blood pressure." "Rotate the sites for measurement of blood pressure for frequent monitoring of blood pressure." "Instruct the patient to slowly change their position." "Use a large cuff to measure blood pressure."
Older adults usually lose upper arm mass and require a smaller blood pressure cuff. Changing the patient's position will help reduce the risk of postural hypotension. The skin of older adults is more fragile and susceptible to cuff pressure during frequent measurements. Therefore, it is advisable to frequently assess the skin under the cuff and rotate blood pressure sites.
The nurse is reviewing the laboratory results of a client scheduled for surgery. Which laboratory result would indicate to the nurse that the surgery might be postponed? Platelets, 200,000 mm3 Hemoglobin, 8.4 g/dL Sodium, 140 mEq/L Serum creatinine, 0.9 mg/dL
Routine screening tests include a complete blood cell count, serum electrolyte analysis, coagulation studies, and serum creatinine tests. The complete blood count includes the hemoglobin analysis. All these values are within normal range except the hemoglobin. If a client has a low hemoglobin level, the surgery may be postponed.
Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory results warrant a call to the primary health care provider (PHCP)? Select all that apply. Blood urea nitrogen (BUN), 10 mg/dL Magnesium, 1 mg/dL Thyroid-stimulating hormone (TSH), 0.4 microunits/mL Calcium, 7 mg/dL White blood cells (WBC), 3000 mm3 Serum creatinine, 1 mg/dL
The PHCP would be notified of significantly abnormal laboratory results that are helpful with diagnosing the medical problem, warrant further testing, and/or may put the client at risk for complications. The blood calcium is 7mg/dL, which is significantly low (normal calcium is 9 to 10.5 mg/dL). The blood magnesium is 1 mg/dL, which is also significantly low (normal magnesium is 1.8 to 2.6 mg/dL). The WBC count is somewhat decreased at 3000 cells/mm3 (normal WBC is 5,000 to 10,000 mm3). These laboratory results should be called to the PHCP. The TSH of 0.4 microunits/mL is normal (2 to 10 microunits/mL). The BUN of 10 mg/dL is normal (10 to 20 mg/dL). The serum creatinine of 1 mg/dL is normal (0.6 to 1.1 mg/dL). These values should be noted.
The nurse volunteering at the health screening clinic reinforces instructions to a 22-year-old client that diet and exercise would be used as tools to keep the total cholesterol level under at least which level? 250 mg/dL 300 mg/dL 130 mg/dL 200 mg/dL
The cholesterol level should be at least less than 199 mg/dL. The client should be counseled to keep the total cholesterol level under 200 mg/dL. This will aid in prevention of atherosclerosis, which can lead to a number of cardiovascular disorders later in life. The option of 130 mg/dL is abnormally low, and the options of 250 mg/dL and 300 mg/dL are too high.
The nurse caring for a male client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's laboratory results and notes a hematocrit level of 30%. Which action would the nurse take? Inform the client that the laboratory result is normal. Report the abnormally low level. Place the normal report in the client's medical record. Report the abnormally high level.
The normal hematocrit level in a male client ranges from 42% to 52%, depending on age. A hematocrit level of 30% is a low level and should be reported to the registered nurse and primary health care provider because it indicates blood loss. This laboratory result is neither elevated nor normal.
In which situation would the nurse measure the vitals signs? Select all that apply. While the patient is sleeping On admission to the hospital Before and after the patient receives a respiratory treatment Before and after the patient complains of distress According to the needs of the patient
Vital signs should be taken as often as the patient's condition warrants and according to the needs of the patient. It is important to measure the vital signs of the patient on admission to the hospital to determine the baseline vital signs. Vitals signs should also be checked anytime the patient complains of any distress. Vital signs are always taken and recorded before and after any medication that could affect the patient's pulmonary or respiratory function, or other vital signs. There is no major change in vital signs during sleep, so recording at that time is not required.
After assessment, the nurse immediately reports an unstable vital sign to the registered nurse. Which finding alerts the nurse to a deviation from the normal range? Oxygen saturation of 95% Pulse rate of 62 beats per minute Respiratory rate of 11 breaths per min Rectal temperature of 99.5 F
The normal acceptable range of respiratory rate is between 12 and 20 breaths per minute; hence the patient has a reduced respiratory rate (bradypnea). The normal range of pulse oximetry is 95% or higher. The average rectal temperature is 99.5 F. The pulse rate of a normal patient should be in the range of 60 to 100 beats per minute.
The nurse is monitoring the laboratory results of a client preparing to receive chemotherapy. The nurse determines that the white blood cell count (WBC) is normal if which result is present? 2000 mm3 (2 × 109/L) 5000 mm3 (5 × 109/L) 15,000 mm3 (15 × 109/L) 3000 mm3 (3 × 109/L)
The normal WBC count ranges from 5000 to 10,000 mm3 (5 to 10 × 109/L). Options 1 and 2 identify values lower than normal. Option 4 identifies a value higher than normal.
The nurse in an ambulatory care clinic takes a client's blood pressure (BP) in the left arm; it is 200/118 mm Hg. Which action would the nurse take next? Notify the primary health care provider. Inquire about the presence of kidney disorders. Recheck the pressure in the same arm within 30 seconds. Check the client's blood pressure in the right arm.
When a high BP reading is noted, the nurse takes the pressure in the opposite arm to see if the blood pressure is elevated in one extremity only. The nurse would also recheck the blood pressure in the same arm but would wait at least 2 minutes between readings. The nurse would inquire about the presence of kidney disorders that could contribute to the elevated blood pressure. The nurse would notify the primary health care provider because immediate treatment may be required, but this would not be done without obtaining verification of the elevation.
