Chapter 19 - Vitals

A patient presents as follows: able to only speak in short phrases, blood pressure (BP) 152/90 mm Hg, respiratory rate 28 bpm. Which priority intervention should be instituted by the nurse? A. Suctioning B. Retake vital signs C. Focused assessment D. Immediate oxygenation

D. Immediate oxygenation Immediate oxygenation is the first step, as the goal is to relieve the patient's shortness of breath.

A student nurse is describing the process of taking a patient's temperature to the charge nurse. Which statement made by the student nurse indicates teaching has been effective? A. "I must determine the patient's baseline temperature." B. "I will be alert to evaluate emotional changes in the patient." C. "Patients usually cannot maintain normal body temperature." D. "It does not matter whether the patient has taken medication."

A. "I must determine the patient's baseline temperature."

In which patients would pulse oximetry most likely be utilized? A. An older adult with hypoxemia B. A patient with community-acquired pneumonia C. A pediatric patient whose oxygen saturation is 95% on room air D. A teenager having an asthma attack with oxygen saturations of less than 92% in air E. An adult patient in the outpatient clinic who has a history of chronic obstructive pulmonary disease (COPD)

A. An older adult with hypoxemia B. A patient with community-acquired pneumonia D. A teenager having an asthma attack with oxygen saturations of less than 92% in air E. An adult patient in the outpatient clinic who has a history of chronic obstructive pulmonary disease (COPD)

While taking the temperature of a patient the nurse learns that the patient exercised before arriving at the appointment. Which explanation describes why the nurse assumes the temperature reading will not reflect an accurate body temperature? A. Body temperature increases with exercise. B. Body temperature fluctuates with exercise. C. The energy used during exercise will cause the patient to experience vasodilation, which cools the body. D. The energy used during exercise will cause the patient to experience vasoconstriction, which cools the body.

A. Body temperature increases with exercise.

Which questions are appropriate for a nurse to ask during a pulse assessment? Select all that apply A. Do you smoke? B. What medications do you take? C. Are your hands or feet swollen? D. Do you experience shortness of breath? E. Have you engaged in any type of exercise in the past 60 minutes?

A. Do you smoke? B. What medications do you take? C. Are your hands or feet swollen? D. Do you experience shortness of breath? **EXERCISE IS WITHIN HALF HOUR**

Which features are signs of hypothermia? Select all that apply A. Drowsiness B. Muscle cramps C. Pale and cool skin D. Loss of sensation E. Decreased urinary output

A. Drowsiness C. Pale and cool skin E. Decreased urinary output

A 56-year-old patient was admitted to the emergency department with sudden chest pain. The patient is stable and the nurse has already inquired about the patient's current pain factors. Which question related to pain history is most important for the nurse to ask next? A. Have you ever experienced pain like this before?" B. "Has anyone else in your family ever experienced chest pain?" C. "How has the pain been affecting your activities of daily living?" D. "Which coping strategies have you been using to deal with the pain?"

A. Have you ever experienced pain like this before?"

Which diagnostic measures are taken to define a specific dysrhythmia? Select all that apply A. Holter monitor B. Electrocardiogram C. Telemetry monitoring D. Palpation of the pulse wave E. Auscultation of heart sounds

A. Holter monitor B. Electrocardiogram C. Telemetry monitoring

The nurse is making the daily assignment on the unit. There is an unlicensed assistive personnel (UAP) available to assist with patient care. Which action is the responsibility of the nurse? Select all that apply A. Interpret vital sign data collected. B. Reassess any abnormal values measured by the UAP. C. Ensure the UAP uses the proper technique for measuring vital signs. D. Ensure the UAP knows what values need to be reported immediately for each patient. E. Instruct the UAP to report abnormal values and other significant assessment findings to the appropriate health care provider.

A. Interpret vital sign data collected. B. Reassess any abnormal values measured by the UAP. C. Ensure the UAP uses the proper technique for measuring vital signs. D. Ensure the UAP knows what values need to be reported immediately for each patient.

A 6-year-old child is carried into the emergency department (ED) by the mother. The child has a history of asthma and is gasping for breath and wheezing. The child's vital signs are respirations 30 bpm, pulse 120 bpm, SpO292%, and BP 90/50 mm Hg. The nurse takes which actions? Select all that apply A. Obtain oxygen saturation measurement. B. Call for the appropriate care provider to quickly evaluate. C. Ask the mother for a medical history, including any medications. D. Initiate standing protocols for childhood asthma until the appropriate care provider arrives. E. Explain to the mother that the ED is very busy and to have a seat in the waiting room with the child.

A. Obtain oxygen saturation measurement. B. Call for the appropriate care provider to quickly evaluate. C. Ask the mother for a medical history, including any medications. D. Initiate standing protocols for childhood asthma until the appropriate care provider arrives.

Which factors influence the interpretation of vital signs? Select all that apply A. Patient status B. Patient's unique medical condition C. Length of time the nurse is on duty D. Standard range for vital sign values E. Consideration of patient's baseline vital signs

A. Patient status B. Patient's unique medical condition D. Standard range for vital sign values E. Consideration of patient's baseline vital signs

Which nursing intervention will help a patient with low cardiac output and a pulse rate of 120 bpm? Select all that apply A. Promoting rest B. Assessing peripheral pulses C. Elevating the patient's legs while at rest D. Administering supplemental oxygen as prescribed E. Writing an order for furosemide 40 mg IV twice daily for this patient

A. Promoting rest B. Assessing peripheral pulses C. Elevating the patient's legs while at rest D. Administering supplemental oxygen as prescribed

The nurse is caring for a patient with a temperature of 38.5°C. (100.4) What symptoms might he or she observe? Select all that apply A. Shivering B. Hot, dry skin C. Slow heart rate D. Cool, clammy skin E. Decreased urinary output

A. Shivering B. Hot, dry skin E. Decreased urinary output

Nursing diagnoses and realistic goals for an alteration in pulse are selected after carefully reviewing which pieces of information? Select all that apply A. Subjective information B. Patient's knowledge level C. Laboratory data and test results D. Orders that were placed by the health care provider E. Objective data gathered during the pulse assessment by the nurse

A. Subjective information B. Patient's knowledge level C. Laboratory data and test results E. Objective data gathered during the pulse assessment by the nurse

Which range reflects a person's normal core body temperature? A. 38.6°C to 39.6°C B. 36.5°C to 37.5°C C. 38.0°C to 38.5°C D. 37.8°C to 38.6°C

B. 36.5°C to 37.5°C A person's core body temperature is within the range of 36.5°C to 37.5°C. The average normal body temperature is 37°C.

Why would the nurse use a Doppler unit to assess pulse? Select all that apply A. Measure blood pressure. B. Assess peripheral circulation. C. Listen to blood flow in arteries. D. Amplify the sound of each pulse wave. E. Assess pulses that are difficult to palpate.

B. Assess peripheral circulation. D. Amplify the sound of each pulse wave. E. Assess pulses that are difficult to palpate.

The nurse is caring for an 88-year-old patient who is currently in cardiac arrest. A Code Blue has been called and staff is performing cardiopulmonary resuscitation (CPR). When the nurse checks for a pulse, which areas of the body would be most appropriate if resuscitative measures are successful? Select all that apply A. Radial pulse B. Carotid pulse C. Femoral pulse D. Dorsalis pedis pulse E. Temporal artery pulse

B. Carotid pulse (A palpable carotid is the current pulse point for rapidly deciding if external chest compressions are indicated. In the absence of a carotid pulse, CPR is indicated.) C. Femoral pulse (Femoral pulse is central to the body and very accessible in a code situation.)

The nurse is assessing a patient's pain. In addition to inquiring about pain factors, the nurse should ask which additional questions? Select all that apply A. Do you have a personal history of hypertension? B. Do you do anything to help lessen your pain experience? C. What medications have you tried taking to relieve your pain? D. How does your pain affect your ability to get dressed in the morning? E. Have you or any of your family members ever seen a cardiologist?

B. Do you do anything to help lessen your pain experience? C. What medications have you tried taking to relieve your pain? D. How does your pain affect your ability to get dressed in the morning?

The nurse is caring for an adult patient, post laparoscopic cholecystectomy 1 day prior. The patient's heart rate is 132 bpm and temperature is 102°F. The nurse is having a difficult time obtaining a blood pressure reading. Which statements are true of tachycardia in this situation? Select all that apply A. Due to exercise B. Indicative of anemia C. Causes a drop in blood pressure D. Related to hypothermia E. Due to hyperthermia

B. Indicative of anemia C. Causes a drop in blood pressure E. Due to hyperthermia

Antipyretic medications such as aspirin (ASA) and other nonsteroidal antiinflammatory drugs (NSAIDs) are given to patients that are experiencing fever. Which statement describes the mechanism of action? A. Reduce the peroxidase enzymes. B. Lower the hypothalamus set-point. C. Transfer of heat through direct contact. D. Transfer of heat as waves or particles of energy.

B. Lower the hypothalamus set-point. NSAIDs and ASA reduce the production of prostaglandins, which in turn lower the hypothalamus set-point, thereby reducing fever.

The novice nurse treats a patient using heat therapy for a back injury. Afterward, the nurse takes the patient's temperature using the oral method and notices that it is high. Which action made by the novice nurse indicates the need for additional training? A. Did not measure the temperature using the axillary method B. Should have measured the temperature before providing heat application C. Did not apply cold application after the heat application, before measuring temperature D. Should have provided cold application for an injury, followed by temperature measurement

B. Should have measured the temperature before providing heat application

The nurse is ready to give a 60-year-old patient the daily cardiac medication. The certified nursing assistant (CNA) reports that the patient's vital signs are pulse 42 bpm, blood pressure 148/86 mm Hg, and respirations 20 bpm. What interpretation will the nurse make? Select all that apply A. Call a code for this patient. B. Withhold the cardiac medication. C. Recheck the patient's vital signs. D. Administer the cardiac medication to the patient. E. Compare the current vital signs with this patient's baseline data.

B. Withhold the cardiac medication. C. Recheck the patient's vital signs. E. Compare the current vital signs with this patient's baseline data.

How is blood pressure measured?

Blood pressure is measured in millimeters of mercury (mm Hg) and is recorded as a fraction. Consider a BP of 120/80 mm Hg: The numerator 120 is the systolic pressure, or the maximum pressure the heart exerts while beating. The denominator 80 is the diastolic pressure, or the amount of pressure in the arteries in between beats. Pulse pressure is the numeric difference between the diastolic and systolic pressures, which in this case is 40.

What is blood pressure?

Blood pressure refers to the force of blood exerted against arterial walls. The left ventricle pushes blood through the aortic valve and into the aorta. Pressure rises as the ventricle contracts and falls as the heart relaxes. This rise and fall creates a pressure wave throughout the arterial system.

A student nurse is taking the temperature of a patient at 6 p.m. and realizes that the temperature is higher than it was only an hour ago. Which statement made by the student nurse indicates effective learning? A. "It is normal for temperatures to fluctuate from one hour to the next." B. "I should let the patient tell me whether the patient feels worse from an hour ago." C. "The temperature of most people is lowest around 3 a.m. and highest around 6 p.m." D. "This is alarming and should be reported immediately to the health care provider."

C. "The temperature of most people is lowest around 3 a.m. and highest around 6 p.m."

A nurse working in the pulmonary step-down unit realizes that the primary goal for altered respirations in patients is to improve oxygenation. How would evaluation of interventions be measured to assess how successful the interventions have been? A. Monitor the pulse oximetry reading pre- and postintervention. B. Interview the patient and ask how his or her breathing pattern is. C. Compare preintervention baseline data with postintervention data. D. Compare preintervention blood pressure and postintervention blood pressure.

C. Compare preintervention baseline data with postintervention data.

A 21-year-old college football player has been in the hospital 24 hours for observation following a concussion. His blood pressure (BP) has been stable at 118/62 mm Hg, but suddenly he complains of a severe headache and his BP is 170/94 mm Hg. The nurse orders vital sign monitoring with what frequency? A. Every 4 hours B. Every 8 hours C. Every 5 minutes D. Once per shift

C. Every 5 Minutes This patient has experienced a sudden severe change in condition as evidenced by his severe headache and vital sign changes. He should have vital signs monitored every 5 minutes and reported to the appropriate health care provider.

Under which conditions is an apical pulse considered a better alternative to a radial pulse? Select all that apply A. Before surgical procedures B. Before giving a patient thyroid medication C. If the nurse is unable to accurately palpate a radial pulse D. When there is need for a more accurate pulse assessment E. When a patient is on a medication that could affect cardiac function

C. If the nurse is unable to accurately palpate a radial pulse D. When there is need for a more accurate pulse assessment E. When a patient is on a medication that could affect cardiac function

A patient with swollen feet from heart failure might have which one of these nursing diagnoses? A. Deficient Fluid Volume related to fluid volume loss, as evidenced by increased temperature, decreased blood pressure, and change in mental status B. Decreased Cardiac Output related to altered contractility of the heart as evidenced by shortness of breath and tachycardia C. Ineffective Peripheral Tissue Perfusion related to decreased peripheral circulation, as evidenced by pedal edema and the need for Doppler ultrasound to detect pedal pulses D. Activity Intolerance related to immobility, as evidenced by shortness of breath with ambulation

C. Ineffective Peripheral Tissue Perfusion related to decreased peripheral circulation, as evidenced by pedal edema and the need for Doppler ultrasound to detect pedal pulses

Which rationale supports the restriction on administering aspirin to children under the age of 2 years? A. Is not an antipyretic. B. Might cause allergies. C. Might cause Reye syndrome. D. Does not come in appropriate doses for children.

C. Might cause Reye syndrome.

The nurse is unable to assess an indirect blood pressure in using the patient's brachial arteries due to bilateral upper extremity injuries. Which alternate artery should the nurse use to assess the patient's blood pressure? A. Carotid artery B. Femoral artery C. Popliteal artery D. Temporal artery

C. Popliteal artery

A patient is recovering from hip replacement surgery. The nurse assessed the patient's blood pressure (BP) lying down, and it registered 126/82 mm Hg. Immediately after sitting, the BP dropped to 96/64 mm Hg. The nurse assessed the BP a third time while the patient was standing. The BP was 100/70 mm Hg. Which statement reflects an appropriate nursing diagnosis for this patient? A. Impaired Physical Mobility related to pain, as evidenced by recent surgery B. Excess Fluid Volume related to renal compromise, as evidenced by increased blood pressure C. Risk for Falls related to changes in BP when lying, sitting, and standing reflecting orthostatic hypotension D. Decreased Cardiac Output related to altered stroke volume, as evidenced by estimated blood loss of 500 mL during surgery

C. Risk for Falls related to changes in BP when lying, sitting, and standing reflecting orthostatic hypotension

Which situations require assessment of a person's temperature? Select all that apply A. Immobility B. Constipation C. Spinal cord injury D. Cognitive impairment E. Altered level of consciousness

C. Spinal cord injury D. Cognitive impairment E. Altered level of consciousness

The nurse is teaching a student nurse about vital signs. Which patient response shows teaching has been effective? A. "Pain is generally included as a vital sign." B. "Oxygen saturation level refers to the act of breathing." C. "Respiration is the measurable amount of oxygen available to the tissues." D. "Blood pressure is the measurable pressure of blood within the systemic arteries."

D. "Blood pressure is the measurable pressure of blood within the systemic arteries."

The nurse is educating a patient about the differences between chronic and acute pain. Which statement by the patient indicates further teaching is needed? A. "If my heart rate increases, my pain must be acute." B. "When my pain is acute, my respiratory rate increases." C. "When I experience chronic pain, my blood pressure sometimes decreases." D. "Since my pulse rate is above my normal baseline, I must be experiencing chronic pain."

D. "Since my pulse rate is above my normal baseline, I must be experiencing chronic pain." This statement reflects a lack of understanding. When pain is chronic, the pulse rate will fall below the normal baseline.

A 95-year-old patient was admitted to the hospital with a hip fracture. The patient has a medical history of hypertension and advanced dementia. The patient does not respond appropriately and is disoriented. Which approach is appropriate for assessing the patient's pain? A. Ask if the patient's hip hurts. B. Encourage the patient to rate the pain on a scale of 0 to 10. C. Tell the patient to point to the face on the Wong-Baker scale that best describes the pain. D. Closely monitor the patient's vital signs, as well as level of agitation, irritation, and restlessness.

D. Closely monitor the patient's vital signs, as well as level of agitation, irritation, and restlessness.

The nurse is completing a pain assessment on a 45-year-old patient with a history of rheumatoid arthritis. Which pain response observed by the nurse would indicate the chronic nature of the patient's pain? A. Irritability due to pain B. Rubbing the painful area C. Elevated respiratory rate D. Decrease in blood pressure

D. Decrease in blood pressure Decrease in blood pressure is a physiological response that indicates chronic pain.

Which part of the human brain maintains a consistent internal body temperature despite environmental extremes? A. Pons B. Medulla C. Cerebellum D. Hypothalamus

D. Hypothalamus The hypothalamus is a section of the brain responsible for hormone production. It acts as the thermostat for the human body. Even minor changes in body temperature are transmitted by thermal receptors located throughout the body to the hypothalamus via the spinal cord.

The nurse must assess the patient's indirect blood pressure using the popliteal artery due to bilateral injuries to the upper extremities. Which nursing action is accurate when assessing the indirect blood pressure using this artery? A. Apply the cuff to the patient's calf B. Apply the cuff 2.5 cm below the popliteal artery C. Ensure the bladder of the cuff is located on the front of the thigh D. Inflate the cuff 30 mm Hg above the palpable pulsation of the popliteal artery

D. Inflate the cuff 30 mm Hg above the palpable pulsation of the popliteal artery

The nurse receives a 50-year-old patient back from the endoscopic department. The patient had conscious sedation for an esophageal biopsy. When should the nurse take vital signs? A. Monitor vital signs every hour. B. Assess vital signs once per shift because the patient is awake. C. Take vital signs every 4 hours once the patient is fully awake back on the regular floor. D. Monitor vital signs every 15 minutes for 1 hour; then if stable, every hour for 2 hours.

D. Monitor vital signs every 15 minutes for 1 hour; then if stable, every hour for 2 hours. Monitor vital signs every 15 minutes for 1 hour; then if stable, every hour for 2 hours. This is a typical protocol for postprocedure patients to assess their return to a stable status.

A registered nurse is assessing a patient with decreased respirations, cool skin, and decreased muscle coordination. Which action made by the nurse supports the nursing diagnosis of hypothermia? A. Asks the patient about feeling feverish B. Requests laboratory work to check the patient's iron levels C. Checks the patient's urinary output, which is increased D. Takes the patient's blood pressure, which shows hypotension

D. Takes the patient's blood pressure, which shows hypotension

An 82-year-old patient is 2 days postoperative with right hip replacement. The patient has comorbidities of hypertension, atrial fibrillation, and type 2 diabetes. The patient is scheduled for transfer to a rehab unit later today. Vital signs have been stable since surgery. How often should the patient's vital signs be monitored? A. This patient only requires a pulse check once a day. B. All postoperative patients require monitoring every 2 hours until discharge. C. The patient is stable and no longer needs any vital sign monitoring. D. Vital signs need to be monitored at the time of morning care and again 1 hour before transfer.

D. Vital signs need to be monitored at the time of morning care and again 1 hour before transfer. Vital signs need to be monitored at the time of morning care and again 1 hour before transfer to confirm that the patient maintains a stable status and is suitable for transfer.

The nurse is caring for an older adult patient with heart failure (HF) and atrial fibrillation with rapid ventricular response. The patient's blood pressure is 88/56 mm Hg with a heart rate of 156 beats per minute. The nurse contacts the health care provider to prescribe medication to slow down the patient's heart rate. Why is this important? A. The patient can feel the rapid heart rate and is uncomfortable. B. When the heart rate increases, it increases the contractility of the heart. C. A rapid heart rate will raise the blood pressure, placing the patient at risk for stroke. D. With an increased heart rate, there is less time available for the heart to contract and fill with blood, leading to decreased cardiac output.

D. With an increased heart rate, there is less time available for the heart to contract and fill with blood, leading to decreased cardiac output.

How often are vital signs taken?

Every 4 to 8 hours for a stable patient Every 15 to 60 minutes for postprocedure or postoperative patients Every 5 minutes or continuously for critical or unstable patients