Lesson 09 Vital Signs HESI RN FLMIR 1904COHORT PDF

Lesson 09 - Vital Signs: HESI RN FLMIR 1904COHORT 4/8/20, 5)50 PM
Lesson 09 - Vital Signs

Due Apr 8 at 11:59pm Points 37 Questions 37
Available Mar 18 at 12am - Apr 8 at 11:59pm 22 days Time Limit None
Instructions
This is your Virtual Clinical Excursion. Each VCE is 4 hours and you will be assigned 3 VCE's per 12
hour clinical. This is to be completed on the day of clinical scheduled. This assignment will be
reviewed and graded by your clinical instructors. Do not utilize copy and paste from the internet-type
the answers in your own words utilizing available resources.
Attempt History
Attempt Time Score
LATEST Attempt 1 159 minutes 17.2 out of 37 *
* Some questions not yet graded
Score for this quiz: 17.2 out of 37 *

Submitted Apr 8 at 4:10pm
This attempt took 159 minutes.
Question 1 Not yet graded / 1 pts
Exercise 1 - Writing Activity
This exercise will take approximately 30 minutes to complete.
Exercise 1 - Question 1
What guidelines should be taken into consideration when incorporating

vital signs into nursing practice?
https://concorde.instructure.com/courses/18808/quizzes/142974?module_item_id=2323795 Page 1 of 29
Your Answer:
measuring vital signs is your responsibility
assess equipment to ensure that it is working correctly and provides

accurate findings
select equipment on the basis of. the patients condition and

characteristics
know the patients usual range of vital signs
know your patients medical history, therapies and prescribed

medications
control or minimize environmental factors that affect vital signs
use an organized, systemic approach when taking vital signs
collaborate with healthcare providers to decide the frequency of vital

sign assessment
use vital sign measurements to determine indications for medication

administration
analyze the results of vital sign measurement on the basis of patients

condition and past medical history
verify and communicate significant changes in vital signs
instruct the patient of family caregiver in vital sign assessment and the
significance of findings
The nurse caring for the patient is responsible for measurement

of vital signs.
Ensure that equipment is functional and appropriate for the size

and age of the patient.
Select equipment based on the patient's condition and

characteristics.
Determine the patient's medical history, therapies, and

prescribed medications.
Control or minimize environmental factors.
Use organized, systematic approach.
Based on the patient's condition, collaborate with health care

providers to determine frequency of vital sign assessment.
Use vital sign measurements to determine indications for

medication administration.
Analyze the results of vital sign measurement in conjunction with

physical signs and symptoms and patient's ongoing health
status.
Instruct the patient or family caregiver in vital sign assessment

and the significance of findings.
Question 2 1 / 1 pts
The process by which the body regulates between heat lost and heat
produced is known as thermoregulation .
Answer 1:
Correct! thermoregulation
For each of the vital signs listed below, record the acceptable range for
adults.
Temperature
Pulse
Respirations
Blood pressure
Your Answer:
temp:97.8 F-99.0 F
pulse: 60-100
respirations:12-20
blood pressure:120/80
Temperature: 36 to 38° C (96.8 to 100.4° F)
Pulse: 60 to 100 beats per minute
Respirations: 12 to 20 breaths per minute
Blood pressure: Less than 120/ Less than 80 mm Hg
You are providing care for a 9-year-old patient. When assessing the
heart rate, you know that which of the following findings is within normal
limits?
60 to 90 beats per minute
Correct!
You are taking the vital signs of a 10-year-old boy for a sports physical.
During the assessment, you notice that the child's heartbeat speeds up
with inspiration and slows down with expiration. Which of the following
actions should be taken next?
Contact the physician.
Obtain orders for an electrocardiogram (ECG).
Correct Answer
Instruct the child to hold his breath to further assess the phenomenon.
You Answered Document the presence of a heart murmur.
Which part of the brain is responsible for control of body temperature?
Correct! Hypothalamus
Anterior pituitary gland
Medulla
Pons
Cerebellum
The nurse is assessing a patient's respirations. The nurse notes that

the patient's respiratory rate is 7 breaths per minute and that the depth
of ventilation is depressed. Which of the following terms best describes
the respiratory pattern being observed?
Biot's respirations
Cheyne-Stokes respirations
Correct!
Hypoventilation
Kussmaul's respirations
A nurse has been advised to take a patient's temperature once daily.

The nurse wants to take the temperature at the time when the patient
would most likely have an elevation in reading. Based on your
knowledge, you recognize the best time for the nurse to take the
temperature would be:
You Answered upon waking.
midmorning.
Correct Answer
late afternoon.
late evening.
A patient has an elevated temperature. Which of the following terms

may be used to describe the patient's condition? Select all that apply.
Afebrile
Hypothermia
Correct! Febrile
Correct!
Pyrexia
A heart rate less than 60 beats per minute is known as

bradycardia .
Answer 1:
Correct! bradycardia
List at least six factors that may influence pulse rate.
Your Answer:
Obesity
Medications
Body temperature
age
Exercise
gender.
Exercise
Temperature
Emotions
Drugs
Hemorrhage
Postural changes
Pulmonary conditions
Acceptable pulse oximetry ranges from 95 % to
100 %. A value less than 90 % is
considered hypoxemia. A value below 90 % is
acceptable for some conditions.
Answer 1:
Correct! 95
Answer 2:
Correct! 100
Answer 3:
Correct! 90
Answer 4:
Correct! 90
Question 13 0.6 / 1 pts
A nurse is assessing a patient's pulse oxygen saturation readings. The

nurse recognizes that which of the following factors may affect the
results? Select all that apply.
Correct Answer Patient motion
Correct Answer Skin color
Correct!
Nail polish
Correct! Fit of assessing probe
Correct!
Temperature at assessment site
Indicate whether the following statement is true or false.
A potential site for pulse saturation level readings can be assessed for
appropriateness by reviewing capillary refill.
Correct! True
False
Exercise 2 - Virtual Hospital Activity

Sign in to work at Pacific View Regional Hospital on the Medical-
Surgical Floor for Period of Care 2. (Note: If you are already in the
virtual hospital from a previous exercise, click on Leave the Floor
and then on Restart the Program to get to the sign-in window.)
From the Patient List, select Clarence Hughes (Room 404).
Click on Get Report.
Click on Go to Nurses' Station.
Click on Chart and then on 404.
Click on and review the Physician's Orders, Physician's Notes,
Admission Assessment, and History and Physical.
Why has Clarence Hughes been admitted to the hospital?
Your Answer:
to have knee replacement surgery
Clarence Hughes has been admitted to the hospital to have

knee replacement surgery.
Identify any significant factors in Clarence Hughes' medical history.
Your Answer:
Clarence Hughes has a history of degenerative joint disease and

osteoarthritis
Clarence Hughes has a history of degenerative joint disease and

osteoarthritis.
Click on Return to Nurses' Station.

Click on 404 at the bottom of the screen.
Review the Initial Observations.
Click on Take Vital Signs.
Click on and review the Clinical Alerts.
Record Clarence Hughes' vital signs below.
Your Answer:
temp:98.7
heart rate:114
respiratory rate:30
blood pressure:123/86
Answers will vary depending on the exact time vital signs are
assessed.
Temperature 98.7
Heart rate 114
Respiratory rate 30
Blood pressure 123/86
Clarence Hughes' heart rate is elevated. Which of the following is likely

to be the underlying cause of the elevation?
Fever
Recent exercise
Hypotension
Correct!
Decreased oxygenation
Based on his vital sign findings, what will be the best location for the
nurse to assess Clarence Hughes' heart rate?
Correct!
Apical
Brachial
Radial
Femoral
If irregularities are noted in Clarence Hughes' heart rate, subsequent

assessments should be counted for:
10 seconds.
15 seconds.
30 seconds.
Correct!
1 minute.
Develop a priority nursing diagnosis for Clarence Hughes that

incorporates the abnormalities noted with his vital signs.
Your Answer:
anxiety related to chest pain
fear related to change in condition
impaired gas exchange related to elevations in heart rate
Answers may vary but may include:
Anxiety related to chest pain
Fear related to change in condition
Impaired Gas Exchange related to elevations in heart rate
Question 22 0.6 / 1 pts
Click on EPR and then on Login.

Select 404 from the Patient drop-down menu and Vital Signs from
the Category drop-down menu.
Review the vital signs recorded for Clarence Hughes since his
admission.
When a nurse measures vital signs, technique may influence results.

Which of the factors below could cause a false high value in Clarence
Hughes' blood pressure. Select all that apply.
Correct!
Loose-fitting cuff
Correct Answer Blood pressure cuff too wide
Correct!
Inflation of blood pressure cuff too slow
Correct Answer Patient's arm above heart level
Correct!
Blood pressure cuff deflated too quickly
Click on Exit EPR.

Click on Patient Care and then on Physical Assessment.
You are preparing to complete a physical examination for Clarence
Hughes. As you review the body system categories detailed below (the
yellow buttons on your screen), identify which subcategories (the green
buttons) you believe are priorities for Clarence Hughes at this time?
(For example: Under Head & Neck, would the Sensory area be a
priority assessment?)
Head & Neck

Chest
Upper Extremities
Abdomen
Lower Extremities
Your Answer:
head and neck:mental
chest: respiratory and cardiovascular
upper extremities: integumentary
abdomen: none
lower extremities: vascular and integumentary
Head & Neck: Mental Status
Chest: Respiratory, Cardiovascular
Upper Extremities: Integumentary
Abdomen: None
Lower Extremities: Vascular, Integumentary
Complete a systems assessment by clicking on the body system categories (yellow

buttons) and body system subcategories (green buttons).
Using the findings from your assessment of Clarence Hughes, match each of the
following clinical manifestations with its probable cause.
(A) Anxious and agitated
(B) Tachypnea
(C) Patient sitting up
(D) Altered peripheral circulation
Correct! Color in lower extremities D

pale
Correct! Attempt to improve C

ventilation
Correct! Pulmonary condition B

affecting oxygenation
Correct! Reduced oxygen to brain A
When Clarence Hughes' pulse oximetry reading is measured, it will
normally take between 10 and 30
seconds for the reading to appear.
Answer 1:
Correct! 10
Answer 2:
Correct! 30
The nurse is preparing to obtain a pulse oximetry reading for Clarence

Hughes. Which of the following are the two preferred locations?
Tip of the nose
Correct!
Fingertip
Lip
Correct! Earlobe
Click on Chart.
Select the chart for Room 404.
Review the Physician's Orders. (Note: Click on Return to Nurses’
Station and use the fast-forward feature to advance the clock to
1121. Click on Chart and then on 404. Click on Physician’s Orders
to view the most recent orders.)
Explain the rationale for the arterial blood gas (ABG) orders.
Your Answer:
to determine the balance of the body pH, partial pressure of carbon

dioxide and oxygen, arterial oxyhemoglobin, and bicarbonate levels.
This helps to determine how well the lungs and kidneys are working
The ABG values will provide a more accurate measure of

oxygen saturation. These findings will assist the physician to
confirm diagnoses concerning the oxygenation problems.

Sign in to work at Pacific View Regional Hospital on the Medical-
Surgical Floor for Period of Care 1. (Note: If you are already in the
virtual hospital from a previous exercise, click on Leave the Floor
and then on Restart the Program to get to the sign-in window.)
From the Patient List, select Patricia Newman (Room 406).
Click on Get Report.
Click on Go to Nurses' Station.

Click on Chart and then on 406.
Click on and review the Nursing Admission and History and
Physical.
Why has Patricia Newman been admitted to the hospital?
Your Answer:
pneumonia , emphysema
Patricia Newman has been admitted to the hospital with

respiratory difficulty. A diagnosis of pneumonia was made.
What factors in Patricia Newman's health history may be associated

with her emphysema and hypertension?
Your Answer:
smoker 90 pack years, 12 years emphysema, hypertension, pneumonia

and osteoporosis
Patricia Newman has a long-standing history of smoking.
While assessing Patricia Newman, the nurse hears coarse crackles

throughout the lung fields. Below, identify the characteristics of
crackles. Select all that apply.
You Answered Heard over anterior lateral lung field
Correct Answer
Best heard in dependent lobes
Primarily heard over trachea and bronchi
You Answered Caused by high-velocity air flow
Result of inflamed pleura
Correct! Result of sudden reinflation of alveoli
Correct!
High-pitched, fine, short crackling sound
Dry grating sound
Low-pitched rumbling sound
Click on Return to Nurses' Station.
Click on 406 to go to Patricia Newman's room.

Review the Initial Observations.
Click on Take Vital Signs and review.
Record the vital signs for Patricia Newman below.
Your Answer:
BP: 178/89
O2: 91
Temp:102.1
RR: 27
Answers will vary depending on the exact time vital signs are
assessed.
Temperature 102.2
Heart rate 115
Respiratory rate 29
Blood pressure 175/89
Which of Patricia Newman's vital signs are abnormal?
Your Answer:
Blood pressure, temperature and respiratory rate
Her temperature, heart rate, and blood pressure are elevated.
Click on Patient Care and then on Nurse-Client Interactions.

Select and view the video titled 0730: Prioritizing Interventions.
(Note: Check the virtual clock to see whether enough time has
elapsed. You can use the fast-forward feature to advance the time
by 2-minute intervals if the video is not yet available. Then click
again on Patient Care and on Nurse-Client Interactions to refresh
the screen.)
After viewing the video, click on Physical Assessment.
Complete a focused assessment by clicking on Chest (yellow
buttons) and then on the available body system subcategories
(green buttons).
During the nurse-client interaction, the nurse indicates that she plans to
administer a prescribed antipyretic medication for Patricia Newman's
fever. What additional interventions can be implemented to manage the
febrile patient?
Your Answer:
Obtain blood cultures (before beginning antibiotics) if ordered.
Minimize heat production: reduce the frequency of activities that

increase oxygen demand such as excessive turning and
ambulation; allow rest periods; limit physical activity.
Maximize heat loss: reduce external covering on patient’s body

without causing shivering; keep clothing and bed linen dry.
Satisfy requirements for increased metabolic rate: provide

supplemental oxygen therapy as ordered to improve oxygen
delivery to body cells; provide measures to stimulate appetite
and offer well-balanced meals; provide fluids (at least 8 to 10
eight-ounce glasses for patients with normal cardiac and renal
function) to replace fluids lost through insensible water loss and
sweating.
Promote patient comfort: encourage oral hygiene because oral

mucous membranes dry easily from dehydration; control
temperature of the environment without inducing shivering; apply
damp cloth to patient’s forehead.
Identify onset and duration of febrile episode phases: examine

previous temperature measurements for trends.
Initiate health teaching as indicated.
Control environmental temperature to 21° to 27° C (70° to 80°

F).
Match the blood pressure types listed below with the corresponding
auscultatory sound. (Note: Not all of the auscultatory sounds will be
used.)
(A) First Korotkoff sound
(B) Second Korotkoff sound
(C) Third Korotkoff sound
(D) Fourth Korotkoff sound
(E) Fifth Korotkoff sound
Correct! Systolic A
Correct! Diastolic E
Other Incorrect Match Options:

D
C
B
Patricia Newman may exhibit an auscultatory gap during her

assessment. What factor in her health history/current diagnosis will
increase the incidence for the development of this phenomenon?
Elevated temperature
Increased heart rate
Correct! Elevated blood pressure
Reduced lung capability
Increased respirations
What is an auscultatory gap, and between which Korotkoff sounds does

is typically occur?
Your Answer:
a period of diminished or absent Korotkoff sounds during the manual

measurement of blood pressure. The improper interpretation of this gap
may lead to blood pressure monitoring errors; namely , an
underestimation of systolic blood pressure and or an overestimation of
diastolic blood pressure
An auscultatory gap is a temporary disappearance in

auscultatory sounds. It occurs between the first and second
Korotkoff sounds
What actions can you take to avoid having this happen?
Your Answer:
by always inflating a blood pressure cuff to 20-40 mmHg higher than

the pressure required to occlude the brachial pulse.
Inflate the cuff high enough to hear a true systolic pressure

before the gap. Palpation of the radial artery helps to determine
how high to inflate the cuff. Inflate the cuff 30 mm Hg above the
pressure at which the radial pulse is palpated.
Quiz Score: 17.2 out of 37

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Lesson 09 - Vital Signs: HESI RN FLMIR 1904COHORT 4/8/20, 5)50 PM

Lesson 09 - Vital Signs

* Some questions not yet graded

Score for this quiz: 17.2 out of 37 *

Question 1 Not yet graded / 1 pts

Exercise 1 - Writing Activity

This exercise will take approximately 30 minutes to complete.

What guidelines should be taken into consideration when incorporating

measuring vital signs is your responsibility

assess equipment to ensure that it is working correctly and provides

select equipment on the basis of. the patients condition and

know the patients usual range of vital signs

know your patients medical history, therapies and prescribed

control or minimize environmental factors that affect vital signs

use an organized, systemic approach when taking vital signs

collaborate with healthcare providers to decide the frequency of vital

use vital sign measurements to determine indications for medication

analyze the results of vital sign measurement on the basis of patients

verify and communicate significant changes in vital signs

The nurse caring for the patient is responsible for measurement

Ensure that equipment is functional and appropriate for the size

Select equipment based on the patient's condition and

Determine the patient's medical history, therapies, and

Control or minimize environmental factors.

Use organized, systematic approach.

Based on the patient's condition, collaborate with health care

Use vital sign measurements to determine indications for

Analyze the results of vital sign measurement in conjunction with

Instruct the patient or family caregiver in vital sign assessment

produced is known as thermoregulation .

Question 3 Not yet graded / 1 pts

Temperature: 36 to 38° C (96.8 to 100.4° F)

Pulse: 60 to 100 beats per minute

Respirations: 12 to 20 breaths per minute

Blood pressure: Less than 120/ Less than 80 mm Hg

60 to 90 beats per minute

90 to 140 beats per minute

120 to 160 beats per minute

Contact the physician.

Obtain orders for an electrocardiogram (ECG).

You Answered Document the presence of a heart murmur.

Which part of the brain is responsible for control of body temperature?

Anterior pituitary gland

The nurse is assessing a patient's respirations. The nurse notes that

A nurse has been advised to take a patient's temperature once daily.

You Answered upon waking.

A patient has an elevated temperature. Which of the following terms

A heart rate less than 60 beats per minute is known as

Question 11 Not yet graded / 1 pts

List at least six factors that may influence pulse rate.

Acceptable pulse oximetry ranges from 95 % to

100 %. A value less than 90 % is

considered hypoxemia. A value below 90 % is

acceptable for some conditions.

Question 13 0.6 / 1 pts

A nurse is assessing a patient's pulse oxygen saturation readings. The

Correct Answer Patient motion

Correct Answer Skin color

Correct! Fit of assessing probe

Indicate whether the following statement is true or false.

Question 15 Not yet graded / 1 pts

Exercise 2 - Virtual Hospital Activity

This exercise will take approximately 45 minutes to complete.