Vitals practice questions

A nurse is assessing the respiratory rate of a sleeping infant. What would the nurse document as a normal finding? 12 to 20 breaths/min 30 to 60 breaths/min 60 to 80 breaths/min 80 to 100 breaths/min

30 to 60 breaths/min

Which term indicates a potentially serious client condition? pyrexia pulse pressure eupnea afebrile

pyrexia

The nurse has completed an assessment and notes that the client's blood pressure is 132/92 mmHg. What is this client's pulse pressure? 224 mmHg 132 mmHg 112 mmHg 40 mmHg

40

The nurse is attempting to assess a client's radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurse take next? Assess the apical pulse. Assess the carotid pulse. Get another nurse for validation. Document the findings.

Assess the apical pulse.

A client presents to the emergency department with profuse bleeding from a crushing injury while at work. Which set of vital signs does the nurse anticipate finding in such this client? Blood pressure 130/80 mm Hg, heart rate 74 beats/min, respiratory rate 14 breaths/min Blood pressure 80/50 mm Hg, heart rate 120 beats/min, respiratory rate 24 breaths/min Blood pressure 124/74 mm Hg, heart rate 90 beats/min, respiratory rate 14 breaths/min Blood pressure 140/90 mm Hg, heart rate 84 beats/min, respiratory rate 16 breaths/min

Blood pressure 80/50 mm Hg, heart rate 120 beats/min, respiratory rate 24 breaths/min

A nurse is assessing an adult client's blood pressure. How should the nurse estimate the client's systolic blood pressure (SBP)? Inflate the blood pressure cuff while palpating the client's brachial artery. Simultaneously compare the amplitude of the client's left and right radial pulses. Palpate the client's brachial pulse while having the client slowly raise his or her arm. Note the SBP that was documented during the client's last vital signs assessment.

Inflate the blood pressure cuff while palpating the client's brachial artery.

The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention? Provide privacy for the client. Position the client on the stomach. Insert the thermometer 0.5 in (1.25 cm) into the rectum. Maintain probe position in rectum for 2 minutes.

Provide privacy for the client.

The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation? Leave the thermometer in and notify the physician. Remove the thermometer and assess the blood pressure and heart rate. Remove the thermometer and assess the temperature via another method. Call for assistance and anticipate the need for CPR.

Remove the thermometer and assess the blood pressure and heart rate.

The nurse assesses a client admitted with multiple trauma including basilar skull fracture and rhinorrhea (drainage from nose), bilateral otorrhea (drainage from ear), and multiple fractures requiring a full body cast. The client is on a 40% Venturi oxygen mask. What is the best way to evaluate the client's temperature? Temporal artery Oral Tympanic Axillary

Temporal artery

The nurse teaches a client diagnosed with hypertension to self-measure blood pressure with an automated device. Which client behavior indicates the need for additional teaching? The client places the blood pressure cup on the upper arm just above the antecubital space. The client sits in the chair with feet flat on the floor and arm supported at the level of the heart. The client sits in the chair with feet flat on the floor and arm below the level of the heart. The client uses a blood pressure cuff width at least 40% of the circumference of the midpoint of the arm.

The client sits in the chair with feet flat on the floor and arm below the level of the heart.

A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse? The blood pressure is elevated. A baseline pulse rate is needed. The carotid pulse is bounding. The radial pulse is difficult to obtain.

The radial pulse is difficult to obtain.

The nurse is preparing to administer a medication that the client takes to treat a cardiac dysrhythmia. Which site should the nurse use to assess pulse in this client? brachial radial carotid apical

apical

The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mmHg. What is the priority nursing intervention? ask the client to demonstrate self-blood pressure assessment provide the client with a larger blood pressure cuff recommend lower sodium in the client's diet report readings to primary care provider

ask the client to demonstrate self-blood pressure assessment

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment? auscultate the client's apical pulse palpate the client's apical pulse arrange for cardiac monitoring auscultate the client's brachial artery

auscultate the client's apical pulse

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will: decrease the blood glucose. decrease the blood volume. decrease the apical pulse. decrease the respiratory rate.

decrease the apical pulse.

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem? peripheral vascular disease coronary artery disease pulmonary embolism chronic obstructive pulmonary disease (COPD)

peripheral vascular disease

A nurse received the following information about clients during shift report. Which client would the nurse assess first? An adult client with a blood pressure of 120/60 mm Hg who verbalizes anxiety about today's scheduled tests. An adult postoperative client with a temperature 99.9°F (37.7°C) who is due for a surgical dressing change. An adult client with a respiratory rate 26 breaths/min who slept in an upright position during the night. An adult client with a heart rate of 88 beats/min and a respiratory rate of 20 breaths/min.

An adult client with a respiratory rate 26 breaths/min who slept in an upright position during the night.

A nurse attempts to count the respiratory rate of 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? Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2. Palpate the posterior thorax excursion, count respirations for 30 seconds, and multiply by 2. Use a pulse oximeter to count the respirations for 1 minute. Monitor arterial blood gas results for 1 minute.

Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.

The nurse has palpated the client's radial artery and identified a heart rate of 88 beats per minute with an irregular rate. What is the nurse's most appropriate action? Reassess the client's radial pulse in 15 minutes. Page the client's primary care provider. Auscultate the client's apical heart rate. Palpate the radial pulse on the opposite wrist.

Auscultate the client's apical heart rate.

Which peripheral pulse site is generally used in emergency situations? Carotid Apical Radial Temporal

Carotid

Which statement describes diastolic blood pressure? During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. To assess diastolic pressure, the blood pressure measured during ventricular contraction. The pressure is highest when the ventricles of the heart eject blood into the aorta and pulmonary arteries. The flow of blood is produced by contractions of the heart and by the resistance to blood flow through the vessels.

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.

The nurse is caring for an adult postoperative client. Which physiologic response is related to pain? Heart rate of 110 beats/min 2500 milliliters of urine per 24 hours Oxygen saturation of 98% Constipation

Heart rate of 110 beats/min

The nurse consistently assesses an adult's blood pressure as 142/88 mm Hg after measuring it several times. Which is indicated by this blood pressure value? Hypertension stage 1 Blood pressure within normal limits Hypertension stage 2 Hypertensive crisis

Hypertension stage 1

A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff? Place cuff 8 cm above the elbow. Fully inflate cuff for about 1 minute. Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared. Elevate arm above heart level before inflating the cuff.

Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared.

A client monitoring his BP at home notices that his BP is higher in one arm than the other. He calls his health care provider for guidance. What is the most appropriate information for the nurse to give this client? It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results. It has been found that most people have differences in BP between arms and that he should use the arm that gives him the lowest reading for accurate results. This has no impact on BP readings and he should continue doing what he has been doing. This is unusual and he should be seen by the physician as soon as possible.

It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results.

The nurse needs to assess the carotid arteries of the client. Which assessment technique would be appropriate for the nurse to use? Palpate both arteries at the same time. Palpate one artery at a time. Measure the rate for 1 full minute. Measure the rate for 30 seconds and multiply by 2.

Palpate one artery at a time.

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse? Pulse is strong, and light pressure causes it to disappear. Pulse is felt with difficulty and disappears with slight pressure. Pulse is felt easily, and moderate pressure causes it to disappear. Pulse is strong and remains strong despite moderate pressure.

Pulse is felt with difficulty and disappears with slight pressure.

A client who has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong? She needs to press harder until she feels a pulse. She needs to take her pulse after her medication so that her pulse is stronger. She should stand when taking her pulse to increase blood flow. She should place her three fingers just below the wrist on the outside of the arm with the palm up.

She should place her three fingers just below the wrist on the outside of the arm with the palm up.

A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify? Preferred site for temperature assessment The client's nutritional status The client's most recent temperature The client's wellness goals

The client's most recent temperature

A nurse is assessing a client's blood pressure manually. The nurse should identify the client's systolic blood pressure (SBP) when which event occurs? The first audible sounds begin to decrease in intensity. The first audible sounds cease to be distinct. The initial Korotkoff sounds peak in intensity. The first faint, but clear, sound appears.

The first faint, but clear, sound appears.

A 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client? Not to worry and to take double the dose of BP medication To call her health care provider To take the medication that she missed and retake her BP To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns.

To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns.

A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which action should the nurse perform to obtain the accurate temperature of the client? Ask the client to drink a glass of cold water before measuring the oral temperature Wait for 15 to 20 minutes before measuring the oral temperature Obtain the client's temperature rectally after lubricating the rectum Use the axillary site for an alternate measurement site

Wait for 15 to 20 minutes before measuring the oral temperature

A client informs the nurse that a mercury thermometer is used at home to take the temperature of her children when they are sick. What health education by the nurse is most appropriate? educate the client about safety related to accidental breakage of the thermometer encourage the client to dispose of the thermometer in the trash and buy a new type encourage the client to use an alternative type of thermometer to assess temperature in the home instruct the client that mercury thermometers should be used only in a hospital setting with appropriate safeguards

encourage the client to use an alternative type of thermometer to assess temperature in the home

The nurse knows that a client who is being taught to perform home blood pressure monitoring (HBPM) understands the teaching plan when he makes which statement about the size of the BP cuff? The cuff should: fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow. fit snug around the upper arm with room to slip a fingertip under the cuff and should be touching the crease of the elbow. fit snug around the upper arm with room to slip three fingertips under the cuff and should be 1 in (2.5 cm) above the crease of the elbow. fit snug around the upper arm with no room to slip a fingertip under the cuff and should be 2 in (5 cm) above the crease of the elbow.

fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow.

The nurse understands that accurate blood pressure taking is dependent on several factors. Which example will most likely render an accurate blood pressure reading? the client reporting moderate pain for the past 4 hours using a medium size cuff for a 10-year-old, average weight client the ear tip of the stethoscope pointing backwards while taking blood pressure placing the client's arm at heart level

placing the client's arm at heart level