chapter 24 end of chapter questions and the point questions
it si important to have the appropriate cuff size when taking the bp what error may result from a cuff that is too large or too small a an incorrect reading b injury to the patient c prolonged pressure on the arm d loss of korotkoff sounds
a an incorrect reading
a patient has intravenous fluids infusing in the right arm when taking a bp on this patient what would the nurse do in this situation a take the bp in the right arm b take the bp in the left arm c use the smallest possible cuff d report inability to take the patients bp
b take the bp in the left arm
You are preparing to measure an adult's orthostatic blood pressure. Place the following steps of the procedure in the correct order. 1. Assist the client into a supine position 2. Assist the client to a standing position. 3. Assist the client to the sitting position with legs dangling. 4. Wait one to three minutes, then measure the client's blood pressure. 5. Wait 2 to 3 minutes, then measure the patient's blood pressure. 6. Wait three to 10 minutes, then measure the client's blood pressure.
1. Assist the client into a supine position 6. Wait three to 10 minutes, then measure the client's blood pressure. 3. Assist the client to the sitting position with legs dangling. 4. Wait one to three minutes, then measure the client's blood pressure. 2. Assist the client to a standing position. 5. Wait 2 to 3 minutes, then measure the patient's blood pressure.
a patient complains of severe abdominal pain. when assessing the vital signs the nurse would not be surprised to find what assessments select all that apply a an increase in the pulse rate b a decrease in body temperature c a decrease in bp d an increase in respiratory depth e an increase in respiratory rate f an increase in body temperature
a an increase in the pulse rate e an increase in respiratory rate
a patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic what would the nurse recommend to the patient? a follow up measurement of blood pressure b immediate treatment by a physician c no action, because the nurse considers this reading due to anxiety d a change in dietary intake
a follow up measurement of bp
two nurses are taking an apical radial pulse and not a difference in pulse rate of 8 beats per minute. the nurse would document this difference as which of the following? a pulse deficit b pulse amplitude c ventricular rhythm d heart arrhythmia
a pulse deficit
The nurse has just measured an adult client's oral temperature and obtained a result of 102.4ºF (39.1ºC). The client states, "I just finished my coffee right before you came in. Can I have another cup?" Which of the following responses by the nurse is most appropriate? a) "I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return." b) "You will need to remain NPO until I notify your primary health care provider about your increased temperature." c) "I'll be right back with your coffee and a different thermometer. I'm not sure this one measured your temperature correctly." d) "Before you drink another hot beverage, drink some cool water so I can obtain an accurate oral temperature."
a) "I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return."
While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute. How will the nurse interpret this finding? a) Bradypnea is a response to IICP. b) Bradypnea is uncommon in a client with IICP. c) This is a normal respiratory rate. d) IICP most commonly results in tachypnea.
a) Bradypnea is a response to IICP.
the rectal temperature, a core temperature, is considered to be one of the most accurate routes. in which cases would taking a rectal temperature be contraindicated? select all that apply a a newborn who has hypothermia b a child who has pneumonia c an older patient who is post myocardial infarction (heart attack) d a teenager who has leukemia e a patient receiving erythropoietin to replace red blood cells f an adult patient who is newly diagnosed with pancreatitis
a, c, d, e a a newborn who has hypothermia c an older patient who is post myocardial infarction (heart attack) d a teenager who has leukemia e a patient receiving erythropoietin to replace red blood cells
A nursing is assessing the vital signs of a patients who presented at the emergency department. based on the knowledge of age related variations in normal vital signs which patients would the nurse document as having a normal vital sign? a a 4 month old infant whose temperature is 38.1 c (100.5f) b a 3 year old whose bp is 118/80 c a year old whose temperature is 39c (102.2f) d an adolescent whose pulse rate is 70 bpm e an adult whose respiratory rate is 20 bpm f a 72 year old whose pulse rate is 42 bpm
a, d, e, f a a 4 month old infant whose temperature is 38.1 c (100.5f) d an adolescent whose pulse rate is 70 bpm e an adult whose respiratory rate is 20 bpm f a 72 year old whose pulse rate is 42 bpm
the nurse instructor is teaching student nurses about the factors that may affect a patients blood pressure which statements accurately describe these factors? select all that apply a blood pressure decreases with age b blood pressure is usually lowest on arising in the morning c women usually have lower bp than men until menopause d blood pressure decreases after eating food e blood pressure tends to be lower in the prone or supine position f increased bp is more prevalent in African Americans
b blood pressure is usually lowest on arising in the morning c women usually have lower bp than men until menopause e blood pressure tends to be lower in the prone or supine position f increased bp is more prevalent in African Americans
a patient is having dyspnea what would the nurse do first? a remove pillows from under the head b elevate the head of the bed c elevate the foot of the bed d take the bp
b elevate the head of the bed
a student nurse is learning to access blood pressure. what does the blood pressure measure? a flow of blood through the circulation b force of blood against the arterial walls c force of blood against the venous walls d flow of blood through the heart
b force of blood against the arterial walls
A nurse is assigned to take vital signs in a pediatric unit. Which of the following sites would be most appropriate for taking the blood pressure of children? a) Temporal b) Popliteal c) Brachial d) Radial
b) Popliteal
Which of the following statements accurately describes the types of equipment that are used to assess temperature? Select all that apply. a) Nonmercury glass thermometers used for oral readings commonly have blunt bulbs to prevent injury. b) Rectal temperatures are generally about one degree higher than other temperatures. c) The nurse should wait five minutes before taking an oral temperature on a client who was drinking iced tea. d) A dirty probe lens and cone on the temporal artery thermometer can cause a falsely high reading. e) Nasal oxygen is not thought to affect oral temperature readings, but oxygen by mask does. f) Axillary temperatures are generally about one degree less than oral temperatures.
b) Rectal temperatures are generally about one degree higher than other temperatures. e) Nasal oxygen is not thought to affect oral temperature readings, but oxygen by mask does. f) Axillary temperatures are generally about one degree less than oral temperatures.
A nurse who provides care on a hospital unit has taken a client's temperature this morning, yielding a reading of 37.6C (99.7F). How should the nurse best interpret this assessment finding? a) The client is at risk of experiencing seizure activity. b) This body temperature may temporarily enhance the client's immune function. c) The client is experiencing dysfunction of the thermoregulatory center. d) This is likely a reflection of normal circadian variations in body temperature.
b) This body temperature may temporarily enhance the client's immune function.
A pulse deficit is the difference between ... a) palpated and auscultated blood pressure readings b) the apical pulse and the radial pulse rate c) the radial pulse and the ulnar pulse rates d) the systolic and diastolic blood pressure readings
b) the apical pulse and the radial pulse rate
The nursing student is selecting a blood pressure cuff prior to obtaining a client's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading? a) 60% of the circumference of the limb to be used b) 70% of the circumference of the limb to be used c) 40% of the circumference of the limb to be used d) 50% of the circumference of the limb to be used
c) 40% of the circumference of the limb to be used
Which peripheral pulse site is generally used in emergency situations? a) Apical b) Temporal c) Carotid d) Radial
c) Carotid
The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as which of the following? a) Tachypnea b) Bradypnea c) Orthopnea d) Apnea
c) Orthopnea
Assessment of the pulse amplitude is accomplished by which of the following? a) Palpating the area of the left ventricle b) Auscultating the area of the left ventricle c) Palpating the flow of blood through an artery d) Auscultating the flow of blood through an artery
c) Palpating the flow of blood through an artery
Clients demonstrating apnea have what? a) Increased rate and depth of respirations b) Normal respiratory rate of 20 c) Usually have a temporary cessation of breathing d) Decreased rate and depth of respirations
c) Usually have a temporary cessation of breathing
prioritization place the following descriptions of the phases of korotkoff sounds in order from phase I to Phase V a characterized by muffled or swishing sounds that may temporarily disappear, also known as the auscultatory gap b characterized by distinct loud sounds as the blood flows relatively freely through an increasingly open artery c the last sound heard before a period of continuous silence known as the second diastolic pressure d characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity known as the systolic pressure e characterized by a distinct abrupt muffling sound with a soft blowing quality considered to be the first diastolic pressure
d a b e c (this order is correct switch bottoms two) d characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity known as the systolic pressure a characterized by muffled or swishing sounds that may temporarily disappear, also known as the auscultatory gap b characterized by distinct loud sounds as the blood flows relatively freely through an increasingly open artery c the last sound heard before a period of continuous silence known as the second diastolic pressure e characterized by a distinct abrupt muffling sound with a soft blowing quality considered to be the first diastolic pressure
During a routine vital sign assessment, you note the client's blood pressure is 212/110. Why is this finding particularly significant? a) It allows the nurse to have a baseline value. b) It is due to the fact the client is fearful. c) It is related to a tumor of the adrenal. d) It deviates from normal and is significant.
d) It deviates from normal and is significant.
A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which of the following health problems should the nurse consider when client falls occur? a) Secondary hypertension b) Dyspnea c) Primary hypertension d) Orthostatic hypotension
d) Orthostatic hypotension
A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure? a) Radial artery b) Over the lower arm c) Brachial artery d) Over the client's thigh
d) Over the client's thigh
a patient who is febrile may lose body heat through perspiration. the nurse recognizes that this is an example of what mechanism of heat loss? a Evaporation b convection c radiation d conduction
a Evaporation
A nurse is assessing a newborn at the health care facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be most appropriate? a) "It is because of the immature ability to regulate temperature in general." b) "It is common for newborns to have body temperatures less than 36.4C" c) "The baby is showing how it is adapting to the environmental temperature. d) "It is because of the closely woven, dark fabric wrapped around the baby"
a) "It is because of the immature ability to regulate temperature in general."
What is the pulse pressure of a client whose blood pressure is 132/82 mm Hg? a) 50 b) 1.6 c) 100 d) 214
a) 50
A nurse is caring for a client with orthostatic hypotension. Which of the following are symptoms of orthostatic hypotension? Select all that apply. a) Weakness b) Syncope c) Headache d) Dizziness e) Skin rash
a) Weakness b) Syncope d) Dizziness
Which of the following is an accurate guideline to follow when assessing blood pressure using a Doppler ultrasound? a) If using a mercury manometer, check to see that the manometer is in the horizontal position and that the mercury is within the zero level. b) Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery itself. c) Using your nondominant hand, place the Doppler tip in the gel and adjust the volume as needed; move the Doppler tip around until you hear the pulse. d) Take the measurement with the client in a standing position with the appropriate limb exposed.
b) Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery itself
A nurse is assessing the blood pressure of an adult client using the Korotkoff sounds technique to document the measurement. Which phase of Korotkoff sounds will the nurse use to document blood pressure measurements in her client? a) Phase II b) Phase IV c) Phase I d) Phase III
b) Phase IV
a nurse is documenting a bp of 120/80 mm Hg the nurse interprets the 120 to represent a the rhythmic distention of the arterial walls as a result of increased pressure due to surges of blood with ventricular contraction b the lowest pressure present on arterial walls while the ventricle is relax c the highest pressure present on arterial walls while the ventricle is contract d the difference between the pressure on arterial walls with ventricular contraction and relaxation
c the highest pressure present on arterial walls while the ventricle is contract
a nurse assesses an oral temperature for an adult patient. the patients temperature is 37.5c (99.5) what term would the nurse use to report this temperature? a febrile b hypothermia c hypertension d Afebrile
d afebrile
while taking an adult patients pulse, a nurse finds the rate to be 140 bpm what should the nurse do next? a check the pulse again in 2 hours b check the blood pressure c record the information d report the rate to the primary care provider
d report the rate to the primary care provider
A client is taking medications to treat a heart dysrhythmia. Which site should be used to assess pulse in this client? a) Brachial b) Radial c) Dorsalis pedis d) Apical
d) Apical
A nurse attempts to count the respiratory rate for a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this client? a) Use a pulse oximeter to count the respirations for one minute. b) Palpate the posterior thorax excursion, count respirations for 30 seconds, and multiply by 2. c) Monitor arterial blood gas results for one minute. d) Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.
d) Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.
Which of the following terms describes a heart rate that is below the expected norm? a) Apnea b) Tachycardia c) Hypotension d) Bradycardia
d) Bradycardia
Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs? a) Decreased pulse rate b) Increased temperature c) Decreased temperature d) Increased pulse
d) Increased pulse
A nurse records a pulse rate of 170 beats/minute on a client's flow chart. For which of the following age groups would this be considered a normal reading? a) Child age 10 years b) Adult c) Adolescent d) Newborn
d) Newborn
