Vital Signs Ch. 15
A patient undergoes intentional hypothermia following a cardiac arrest. Which vital signs would the nurse expect to be altered? (Select all that apply.) 1. Blood pressure 2. Apical heart rate 3. Tympanic temperature 4. Oxygen saturation 5. Respiratory rate
1, 2, 3, and 5
A patient attends the hypertension clinic monthly for checkups. The patient's usual blood pressure range is 114/64 to 120/72 mm Hg. This month the patient's blood pressure is 132/80 mm Hg. She reports taking her medications regularly. What factor should the nurse consider when counseling the patient? 1. Caffeine can cause false elevations in blood pressure. 2. The warm environment can cause false elevations in blood pressure. 3. The medications she is taking for her blood pressure are not being effective. 4. Yoga classes may reduce her stress.
1. Caffeine can cause false elevations in blood pressure.
The nursing assistive personnel (NAP) reports that a patient is complaining of nausea, cramping, and abdominal pain of 6 on a 1-to-10 scale. Which assessment data support the patient's statements? 1. HR 114 2. RR 14 and deep 3. SpO2 95% 4. BP 92/60 mm Hg on right arm, 100/60 mm Hg on left arm
1. HR 114
Prehypertension BP
120-139/80-89
Normal BP
120/80 mmHg or less
Stage 1 HTN
140-159/90-99
A patient with a body mass index of 45 is being admitted for bariatric surgery. The nursing assistive personnel (NAP) obtains the admission vital signs and reports that she had to use a thigh cuff to obtain the patient's blood pressure on the left arm. The blood pressure was 180/100 mm Hg. What action should the nurse take? 1. Instruct the NAP to obtain a blood pressure on the right arm for comparison 2. Obtain a blood pressure using a large adult cuff on the forearm 3. Instruct the NAP to use the thigh cuff to obtain a popliteal blood pressure 4. Notify the nurse in charge or health care provider
2. Obtain a blood pressure using a large adult cuff on the forearm
The cuff should be deflated at a rate of
2 to 3 mmHg per second
An elderly woman calls the nurse at the outpatient clinic and reports that her home blood pressure machine, which she uses faithfully every day, is reading higher than her usual value of 128/72 mm Hg. This morning her measurement was 173/76 mm Hg. Which of the following could account for this difference? (Select all that apply.) 1. Blood pressure cuff was wrapped too tightly. 2. Arm was below the heart level. 3. Machine requires calibration. 4. Measurements were repeated too quickly. 5. Cuff was placed over several layers of clothing.
2, 3, and 4
A 16-year-old girl with a history of poorly controlled asthma is admitted with dyspnea and fatigue. Her vital signs on admission are HR 118, BP 108/82 mm Hg, RR 28, tympanic temperature 37°C (98.6°F), and oxygen saturation 92%. She is receiving oxygen via nasal cannula at 2 L. Which of the following vital signs indicate the patient is improving following treatment for her asthma? (Select all that apply.) 1. Temperature 36.8°C (98.2°F) 2. Radial pulse of 124 3. Respiratory rate of 22 4. Oxygen saturation 94% 5. Blood pressure 112/80 mm Hg
3 and 4
A nursing assistive personnel (NAP) reports to the charge nurse that a patient's pulse oximeter machine continues to alarm with a reading of 88%. The charge nurse enters the room and assesses for signs and symptoms of alterations in oxygen saturation and finds none. What action does the nurse take next? 1. Remove the current machine from service and ask the NAP to use another pulse oximeter device 2. Verify that the patient's oxygen device and flow are correct 3. Verify that the oximeter sensor is intact and the skin under the sensor is dry 4. Notify the health care provider immediately
3. Verify that the oximeter sensor is intact and the skin under the sensor is dry
The cuff should be inflated _________ mmHg above the point where the pulse disappears
30 mmHg
The nurse is explaining to a student nurse how to use the two-step method of blood pressure assessment to obtain accurate measurements. Place the steps in correct order: 1. Place stethoscope in ears. 2. Palpate brachial artery while inflating the blood pressure cuff 30 mm Hg over the pulse disappearance. 3. Note point where you hear first Korotkoff sound. 4. Wait 30 seconds. 5. Apply blood pressure cuff 1 inch above the brachial artery. 6. Continue to de ate cuff until sound disappears
5, 2, 4, 1, 3, and 6.
The pulse pressure for the BP of 150/90
60
Average Temperature Range
96.8° to 100.4°F
Stage 2 HTN
>160/>100
A nurse observes nursing assistive personnel (NAP) obtaining a blood pressure on a patient. The patient's blood pressure range over the past 2 hours has been 118/72 to 112/68 mm Hg. Which of the following blood pressure readings obtained by the NAP is most likely caused by the NAP deflating the cuff too fast? 1. 132/52 mm Hg 2. 124/88 mm Hg 3. 106/48 mm Hg 4. 102/80 mm Hg
4. 102/80 mm Hg
A young mother asks about the best type of thermometer to have at home to measure the temperature of her toddler (age 3 years) and infant (age 4 months). What is the nurse's best response? 1. A tympanic thermometer is easy to place in all children. 2. Children tolerate axillary thermometers the best. 3. Oral thermometers are the most accurate of the surface thermometers. 4. Temporal artery thermometers are good for fast screening of temperatures.
4. Temporal artery thermometers are good for fast screening of temperatures.
Hemoglobin
Boy: 14 to 18 g/100 mL Girl: 12 to 16 g/100 mL
Gurgles
Bubbling sounds usually during expiration
The patient has a fever that spikes and then shows acceptable temperature levels. The temperature returns to acceptable levels two or three times within a 24 hour period. This is documented by the nurse as: a. sustained b. remittent c. relapsing d. intermittent
d. intermittent
For a patient who is experiencing a febrile blood state, the nurse should: a. ambulate the patient frequently b. restrict fluid intake c. keep the patients warm d. provide oxygen as ordered
d. provide oxygen as ordered
The most accurate temperature measurement for an adult patient experiencing tachypnea and dyspnea is: a. oral b. forehead c. axillary d. tympanic
d. tympanic
The danger of an increased temperature in young children is the potential for
dehydration and febrile seizures
Relapsing Fever
fever has periods of febrile episodes mixed with acceptable temperature values; febrile episodes and periods of normothermia that are sometimes longer than 24 hours.
Remittent Fever
fever spikes & falls without a return to acceptable temperature levels.
intermittent fever
fever spikes of high temperature, mixed with usual temperature levels; temperature returns to acceptable value at least once in 24 hours.
Bell of stethoscope used for
heart and vascular sounds low pitched sounds
What can lead to hypotension?
hemorrhage fluid deficit
Decreasing hemoglobin levels will increase
RR
Which type of fever pattern demonstrates fever spikes of high temperature mixed with usual temperature levels. The temperature levels return to acceptable values at least once in 24 hours? a. Sustained b. Intermittent c. Remittent d. Relapsing
b. Intermittent
A 34-year-old patient has gone to a physician's office for an annual physical examination. The nurse is completing the vital signs before the patient is seen by the physician is seen by the physician. The nurse alerts the physician to a finding of: a. Temp: 37.6 b. P: 120 bpm c. R: 18 breaths per min d. BP: 116/78 mmHg
b. P: 120 bpm
True or False: apical pulse measurements may not be delegated to unlicensed assistive personnel
True
A nurse is assigned to the well-child center that is affiliated with the acute care center. A mother takes her 1.5-year-old son to the center for his immunizations. The nurse assesses the child's pulse rate checking the: a. radial pulse b. apical pulse c. popliteal artery d. femoral artery
b. apical pulse
Which sign or symptom is indicative of high blood pressure? a. dizziness b. headache c. restlessness d. cool skin over the extremities
b. headache
A nurse anticipates that bradycardia will be evident if a patient is: a. exercising b. hypothermic c. asthmatic d. extremely anxious
b. hypothermic
While working in an emergency department, a nurse is carefully monitoring the vital signs of the patients who have been admitted. The nurse is alert to the potential decrease in a patients pulse rate as a result of: a. hemorrhage b. hypothyroidism c. respiratory difficulty d. epinephrine administration
b. hypothyroidism
A nurse anticipates an increased in blood pressure for the patient who is: a. sleeping b. overweight c. talking narcotics d. hemorrhage
b. overweight
Substances that trigger immune system
bacteria or viruses, stimulate the release of hormones in an effort to promote bodily defense against infection. These hormones also trigger the hypothalamus to raise the set point, inducing a febrile episode.
Diaphragm of stethoscope is used for
bowel, lung, and heart sounds high pitched sounds
While working in an extended care facility, a nurse expects the vital signs of an older adult patient to be: a. BP: 98/70, P: 60, R: 12 b. BP: 120/60, P: 110, R: 30 c. BP: 140/90, P: 74, R: 14 d. BP: 150/100, P: 90, R: 25
c. BP: 140/90, P: 74, R: 14
Vital signs measurements have been completed on all assigned patients. The nurse will need to immediately report a finding of: a. pulse pressure of 40 mmHg b. apical pressure of 78, 80, 76 bpm c. apical pulse of 82 bpm radial pulse of 70 bpm d. BP of 140/80 mmHg left arm, 136/74 mmHg right arm
c. apical pulse of 82 bpm radial pulse of 70 bpm
A nurse determines that a patient's pulse rate is significantly lower than it has been during the past week. The nurse reassesses and finds that the pulse rate is still 46 bpm. The nurse should first: a. document the measurements b. administration a stimulant medication c. inform the charge nurse or physician d. apply 100% oxygen at maximum flow rate
c. inform the charge nurse or physician
A student nurse is taking vital signs for her assigned patients on the surgical unit. The student is aware that a patient's body temperature may be reduced after: a. exercise b. emotional stress c. periods of sleep d. cigarette use
c. periods of sleep
An electronic BP measurement is acceptable for a patient who: a. is shivering b. has had fluctuations in readings c. requires frequent monitoring d. has an irregular heart beat
c. requires frequent monitoring
False high BP readings occur when
cuff too narrow or short arm below heart level cuff wrapped too loosely repeating assessments too quickly
An adolescent patient is expected to have a respiratory rate that is: a. 35- 40 min b. 30- 50 min c. 25- 32 min d. 16- 20 min
d. 16- 20 min
When checking the temperature of a patient, a nurse notes that he is febrile. A nonsteroidal antipyretic medication is ordered. The nurse prepares to administer: a. digoxin b. prednisone c. theophylline d. acetaminophen
d. acetaminophen
The nurse is the ERD assesses that the patient's respirations are below the expected amount. The nurse recognizes that slow respirations can be an indication of: a. pneumonia b. hemorrhage c. hypoglycemia d. brain stem trauma
d. brain stem trauma
A patient is being treated for hyperthermia. The nurse anticipates that the patient's response to this condition will be: a. generalized pallor b. bradycardia c. reduced thirst d. diaphoresis
d. diaphoresis
To determine the arterial blood flow to a patient's feet, the nurse should assess the: a. radial pulse b. brachial pulse c. popliteal pulse d. dorsalis pedis artery
d. dorsalis pedis artery
Which of the following is a correct technique for BP monitoring? a. placing the cuff over rolled up or thick clothing b. putting the cuff firmly on the antecubital space c. inflating the cuff to 60 mmHg over patient's usual systolic pressures d. having the patient rest for 5 min before measurement
d. having the patient rest for 5 min before measurement
Sustained Fever
a body temperature continuously above 38° C (100.4° F) that demonstrates little fluctuation
The thermometer of choice for a patient in isolation is
a disposable chemical dot thermometer
The nurse assesses the patient's pulse is diminished and barely palpable. This is documented as: a. + 1 b. +2 c. +3 d. +4
a. + 1
Which of the following values indicates the correct pulse pressure for a patient which a blood pressure of 170/90? a. 80 b. 170 c. 260 d. value not known based on the information given
a. 80
A nurse is working on a pediatric unit and assessing the vital signs of an infant admitted for gastroenteritis. The nurse expects that the vital signs are normally the following: a. BP: 90/50, P: 122, R: 46 b. BP: 90/60, P: 80, R: 20 c. BP: 100/60, P: 140, R: 32 d. BP: 110/50, P: 98, R: 40
a. BP: 90/50, P: 122, R: 46
A nurse is preparing to take vital signs for the patients in the acute care center. A tympanic temperature assessment is indicated for the patient: a. after rectal surgery b. wearing a hearing aid c. experiencing otitis meatus d. after an exercise session
a. after rectal surgery
A nurse has been assigned a number of patients in the long-term care unit. When taking vital signs the nurse is alert to the greater possibility of tachycardia for the patients with: a, anemia b. hypothyroidism c. a temperature of 98 F d. PCA pump with a morphine drip
a. anemia
A nurse anticipates that a patient with hypertension will be receiving: a. diuretics b. antipyretics c. narcotic analgesics d. anticholinergics
a. diuretics
Which of the following observations of the newly hired nurse requires intervention by the nurse manager? a. fabric covering the stethoscope b. use of 12 inch long tubing c. use of the belt to auscultate heart sounds d. cleansing the stethoscope with alcohol in between patients
a. fabric covering the stethoscope
The most important sign of heat stroke is a. hot, dry skin b. nausea c. excessive thirst d. muscle cramping
a. hot, dry skin
While reviewing the vital signs taken by the air this morning, a nurse notes that one of the patients is hypotensive. The nurse will be checking to see if the patient is experiencing: a. lightheadedness b. a decreased heart rate c. an increased urinary output d. increased warmth to the skin
a. lightheadedness
Several friends have gone on a ski trip and have been exposed to very cold temperatures. One of the individuals appears to be slightly hypothermic. The best initial response by the nurse in the ski lodge is to give this individual: a. soup b. coffee c. brandy d. warm clothes
a. soup
HTN risk factors
age, frailty and physical deconditioning, automatic neuropathy, multiple system atrophy, volume depletion, medications that impair sympathetic tone
A patient's pulse is expected to be increased in the presence of which of the following factors?
anxiety presence of asthma administration of beta blockers
A nurse should insert a rectal thermometer into the adult patient: a. 1/4 to 1/2 inch b. 1 to 1.5 inch c. 1.5 to 2 inch d. 2 to 2.5 inch
b. 1 to 1.5 inch
Core temperature readings are measured through
invasive means
auscultary gap
korotokoff sounds disappear during auscultation
RBC count
male: 4.7 to 6.1 million/mm female: 4.2 to 5.4 million/mm
Hematocrit
males: 42% to 52% females; 37% to 47%
Normal Lung Sounds
no pauses no extra noises
Risk factors of hypertension
obesity smoking alcohol abuse high cholesteral
Children Fevers
often caused by viruses, their immature immune systems mean that their temperatures can rise quickly to dangerous levels.
Crackles
popping sounds primarily during inspiration
Fever Pattern
present when a febrile episode recurs. Patterns may be sustained, intermittent, remittent, or relapsing.
Sites for core temperatures include
pulmonary arteries esophagus bladder
orthostatic HTN
reduction of systolic b/p by 20mmHg or diastolic by 10mmHg within 1-3 minutes of standing
True Fever
results from an alteration in the hypothalamic set point.
Pyrogens
substances that cause fever (Bacteria, Virus)
Onset of kickoff sounds
systolic pressure
A patient in the OR having surgery
temp decreases
a well person at 6:30 am
temp decreases
older adult
temp decreases
Ovulating female
temp increases
an individual under stress
temp increases
an individual who has exercised
temp increases
Wheezes
whistling or squeaking musical sounds