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1. A client's vital signs at the beginning of the shift are: temperature (oral) 99.3oF (37.oC), heart rate 82, respiratory rate 14, and blood pressure 118/76. Four hours later the client's oral temperature is 102.2o F (39oC). Based on the temperature change, the nurse should anticipate the client's heart rate would be: A) 62. B) 82. C) 102. D) 122. 2. Which blood pressure (BP) has a pulse pressure within normal limits? Choose all that apply. A) 104/50. B) 120/62. C) 120/80. D) 130/86. 3. The nurse is assessing vital signs for a client who has had surgery on his left leg and has an IV running. It would be most important for the nurse to: A) Compare the left pedal pulse with the right pedal pulse. B) Count the client's respiratory rate for 1 full minute. C) Take the blood pressure in the arm without an IV. D) Take the client's temperature orally with an electronic thermometer. 4. The nurse hears rhonchi when auscultating a client's lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds? A) Have the client take several deep breaths. B) Have the client take a deep breath and cough. C) Take the client's blood pressure and apical pulse. D) Count the client's respiratory rate for 1 minute. 5. Which of the following sets of vital signs (VS) are all within normal limits? A) 2-year-old: T 98.6°F (rectal), HR 140, RR 18, BP 100/54. B) Teenager: T 98.6°F (oral), HR 100, RR 18, BP 108/68. C) Adult: T 98.9°F (oral), HR 54, RR 22, BP 130/84. D) Older adult: T 98.6°F (oral), HR 110, RR 22, BP 170/95.
Monday, October 29, 2007
ranging from 99.6. B) Offer the client a blanket when he is shivering. C) Offer the client fluids to drink every 1-2 hours. over the last 24 hours. B) 38.8oF orally to 103oF orally.8°C. 10. Based on the temperature change. A) Put a cold ice pack on the client's neck and axillae.0°C.4°C. 8. The nurse assesses the following changes in a client's vital signs. B) A decrease in temperature after a period of diaphoresis. Which of the following interventions would be appropriate for a client who has a fever? Choose all that apply. the nurse might best anticipate the client's respiratory rate to be: A) 16. The temperature is now 99. The client's temperature is 101. 7. heart rate 110.1oF. D) An increase in respiratory rate when the heart rate increases. C) 20. C) 38. D) Take the client's temperature hourly with a tympanic thermometer. The client has had a fever.6oC). The client's fever would be classified as: A) Constant. and blood pressure 124/78. C) Relapsing. B) 18. 9. Which is the correct conversion to centigrade? A) 38. . respiratory rate 26. D) Remittent. C) An increase in heart rate after walking down the hall. D) 22. D) 39.4oF (38. B) Intermittent. Which client situation should be reported to the primary care provider? A) A decrease in blood pressure (BP) after standing up. A client's vital signs 4 hours ago were: temperature (oral) 101.4oC).4oF (37.2°C.
” D) “We still need to keep monitoring your temperature for a while. C) Lived at a high altitude and has moved to sea level.Chapter 17: Measuring Vital Signs 11. that means I'm cured. “The nursing assistant told me my vital signs are all within normal limits.4oF orally. The nursing instructor asks his students how they would assess the fifth vital sign.” 15. Monday. Which of the following clients should have further evaluation? A client whose: A) Resting morning blood pressure was 136/86 and the afternoon BP was 128/84. 13. 2007 Page 3 . D) 100. B) 99. B) Had surgery and lost a unit of blood.4oF rectally.8oF in the evening. Which of the following clients would probably have a higher than normal respiratory rate? A client who has: A) Had surgery and is taking a narcotic. but there are other things to assess. 12.” D) Ask the client about her smoking history. C) 98. October 29.9oF in the morning and 99.” The nurse's best response would be: A) “Your vital signs do confirm your infection is gone. B) Oral temperature is 97.” B) Ask the client when she had her last bowel movement.” C) “Your vitals signs are stable. This is equivalent to: A) 98. C) Heart rate was 76 before eating and 88 after eating. A client who has been hospitalized for an infection states. how do you feel?” B) “I'll let your health care provider know so you can be discharged. D) Been exposed to the cold and is hypothermic.4oF.2oF rectally.9oF orally.” C) Take the client's pulse oximetry reading. Which student would be correct? “I would: A) Have the client rate her pain on a scale of 0-10. A client's axillary temperature is 98.” 14. D) Respiratory rate is 16 when standing and 18 when lying down.
The client's vital signs are temperature (oral) 101. 20. . 19. C) Blood pressure. B) Respiratory rate remains fairly stable throughout a person's life. D) Men have higher blood pressure than women until after menopause. C) Give the client a chart to record his blood pressure readings. Comparing the changes in vital signs as a person ages. C) Ask the client if he is feeling chilled. 17. In caring for a client who has a fever.2oF. D) 99.16.5oC). The nurse is teaching a client how to use a portable blood pressure device to monitor his blood pressure at home. B) Explain the importance of frequent calibration of the device. B) 98oF.2oF. respiratory rate 16. A) Blood pressure decreases less than heart rate and respiratory rate. which statement(s) is/are correct? Select all that apply. 18. C) Blood pressure increases. It would be most important for the nurse to: A) Have the client demonstrate the use of the blood pressure device. and blood pressure 128/80. C) 98. it would be important for the nurse to monitor for increased: A) Urine output. B) Sensitivity to pain. heart rate 80. B) Notify the primary care provider of the client's temperature. D) Give the client written instructions of what was taught. Which of the following temperatures would the nurse anticipate in the middle of the night in a client who does not have a fever? A) 97. D) Take the temperature by a different route.2oF (38.6oF. heart rate and respiratory rate decline. D) Respiratory rate. Which intervention would be most appropriate at this time? A) Ask the client if he has had a hot drink in the last few minutes.
25. the nurse is assessing: A) Rhythm of the pulses. The nurse is instructing a client how to appropriately dress an infant in cold weather. Which of these steps in taking a blood pressure is correct? Choose all that apply. D) Have the client sit with feet flat on the floor. C) Inflate the cuff rapidly 30 mm Hg above the palpated BP. C) Has a family history of kidney disease. D) Monitor the blood pressure for a pattern. 22. Which of the following instructions would be most important for the nurse to include? A) Be sure to put mittens on. 23. B) Wrap the cuff snugly around the client's arm. B) Auscultate all five Korotkoff sounds. When assessing the quality of a client's pedal pulses. 24. B) Drinks three to four beers every day. D) Rate compared with the apical pulse rate. D) Does not participate in any physical activity.Chapter 17: Measuring Vital Signs 21. Monday. it would be most important to: A) Use the same type of manometer each time. B) Layer the infant's clothing. Which of the following information given by a client would indicate a risk for primary hypertension? A) Eats a high-protein diet. D) Put warm booties on. C) Ask the client to hold the arm at heart level. C) Put a cap on the head. C) How loud the pulses are on auscultation. A) Use a bladder that encircles 40% of the arm. B) Strength of the pulses. 2007 Page 5 . October 29. In evaluating a client's blood pressure for hypertension.
Which of the following may indicate inadequate oxygenation (choose all that apply)? A client: A) Complains of feeling anxious. Which of these statements by the client indicates that he understands the instructions? A) “I don't have to worry if my BP is high once in a while.” . D) Breathes easier sitting up.” D) “I will need to reduce the amount milk and milk products I use.26.” B) “I guess I will have to make sure I don't drink too much water. C) Has an increased heart rate.” C) “I can lose some weight to help lower my blood pressure. A client has been given instructions about hypertension prevention and management. 27. B) Has crackles in the lung bases.
snoring sound Monday. Match the breath sound with the appropriate description. High-pitched. October 29.Chapter 17: Measuring Vital Signs 28. Labored. 2007 Page 7 . High-pitched popping or low-pitched bubbling sounds _____ Wheezes D. continuous musical sound _____ Stridor C. High-pitched sound heard on inspiration in infants _____ Rhonchi B. _____ Crackles A. Low-pitched continuous sounds that clear with coughing E.
Describe where to auscultate the apical pulse on an adult client. .29. calculate the cardiac output for a client with a heart rate of 75. Using the average stroke volume. 30.
Chapter 17: Measuring Vital Signs 31. How will each of the errors affect a client's blood pressure reading? _____ A. October 29. Assessing immediately after exercise Monday. Assessing immediately after eating _____ E. Assessing when the client is in mild-to-moderate pain _____ F. Assessing when the client is in severe pain _____ G. Blood pressure cuff too wide _____ C. Assessing immediately after smoking _____ D. 2007 Page 9 . Blood pressure cuff too narrow _____ B.
306) 6. and the BP is high for the age. entire chapter. (D) The temperature is high. neck or axillae. 204) 4. and the BP is high for the age. (120 – 80 = 40.Answer Key 1. This can only be done by comparing one side with the other. A. the RR is low. The pulse pressure is usually approximately 1/3 of the systolic pressure. p. the HR is high. the HR is low. BP on p. This is how you differentiate between rhonchi and other adventitious sounds. 40 = 1/3 of 120) (130 – 86 = 44. it is important to assess whether the circulation has been compromised because of the surgery. the HR is high. D Response: The pulse pressure is the systolic blood pressure minus the diastolic BP. 333. 318) 2. C Response: Heart rate increases 10 bpm for each degree of temperature to meet increased metabolic needs and compensate for peripheral dilation. C. (B) This would . (V1. (V1. the RR is high. and the cause should be investigated. B Response: All of the teenager's VS are within normal parameters for the age. the RR is high. (C) The temperature is high. p. but should read content about all of the vital signs) 7. A Response: All answers are correct. specific information about pulses in V1. (A) The temperature is below normal. (V1. (V1. B Response: Rhonchi are caused by secretions in the large airways and may clear with coughing. C Response: (A) If ice packs are used. 325) 5. and the BP is high for the age. 327) 3. 1/3 of 130 = 43. (V1. The changes in the other answers are normal changes for the situations. p. p. 321 and V2. p. pp. 202.3) (V1. so fluids are necessary to prevent dehydration. but option A is the most important because after surgery on an extremity. they are applied to the groin. The other interventions will not help to clear rhonchi. A Response: A drop in the client's BP when standing indicates orthostatic hypotension. (C) A fever increases metabolic needs.
B Response: To convert Fahrenheit to centigrade. (V1. C Response: Vital signs are one indicator of a client's physiological status. (V1. The client's temperature has fallen 2 degrees. (D) Hypothermia decreases the metabolic rate. The decision to be discharged is not based on vital signs alone (B). (C) Relapsing fevers alternate between periods of fever and periods of normal temperature. (B) Body temperature normally increases during the course of a day. p. more than just the temperature will Monday. (D) Respiratory depth decreases when lying down. (C) Heart rate increases for several hours after eating. (A) Constant fevers stay above normal with only slight fluctuations. p. (C) Going from lower altitudes to higher altitudes inhibits oxygen binding. 325) 12. (V1. so the respiratory rate would decrease. p. subtract 32 from the temperature. p. multiplied by 4. but they are not an absolute indicator of well-being. Although D is true. 327) 13. B Response: For every degree Fahrenheit (0. p. D Response: Remittent fevers fluctuate widely over a 24-hour period. October 29. 314) 10. (D) A tympanic thermometer is not appropriate when an accurate temperature is needed. therefore C is the correct answer. (B) Intermittent fevers alternate between normal or subnormal temperatures with periods of fever. pp. (A) Narcotics and hypothermia slow the respiratory rate. the respiratory rate may decrease up to 4 breaths per minute. 2007 Page 11 . each phase lasting 1-2 days. and multiply by 5/9.6oC) the temperature falls. (V1. A Response: Both the blood pressures would be classified as prehypertension according to the JNC 7 Express guidelines.Chapter 17: Measuring Vital Signs increase the client's temperature. B Response: A reduction in hemoglobin from blood loss would increase the respiratory rate. Stating that the vital signs indicate the infection is gone (A) may not be accurate. so going to a lower altitude would decrease the respiratory rate or have no effect. (V1. so the rate would increase. 315-316) 8. It was 26/min. this is 8. 312) 9. 26 minus 8 = 18 breaths per minute. (V1. 323) 11.
(B) Change in pain sensation is not a symptom of a fever. A Response: With a fever. p. 323) 17. (V1. 309. Men's blood pressure is higher than women's until after menopause. 323. 305) 14. are axillary. axillary. when women's blood pressure increases (D) (V1. oral. temperature information on p. and tympanic. For oral. because of peripheral vasodilation. but self-monitoring of blood pressure is of little value unless it is done correctly. 313) 16. 38) . (V1.9oF degree difference between each site and the next higher one.8oF to have an equivalent rectal temperature. rectal. the heart rate and respiratory rate are usually elevated. and rectal temperatures. A Response: All are important things to include in client teaching. (V1. p. so option A would be appropriate because having a hot drink would cause a false reading. 307. pp. they are within normal limits. should know norms for all vital signs to answer question) Nursing process: Assessment Client need: Physiological Integrity 19. C. p. from lowest to highest. 305) 15. increasing a person's respiratory rate.9oF to an axillary to have an equivalent oral temperature and 1. C (V1.be monitored. p. 332) 18. D Response: Heart rate and respiratory rate decrease as people age. (V1. In this case.” (V1. D Response: Body temperatures. D Response: The metabolic rate increases with a fever. p. A Response: Pain is considered to be the “fifth vital sign. whereas the blood pressure increases because of increased vascular resistance (C). there is a 0. (C) The blood pressure is more likely to decrease with a fever. (A) Urine output would more likely go down because of increased insensible loss and possible loss of intake because of loss of appetite. 317. Add 0.
310) 21. 2007 Page 13 . high sodium diet. D Response: (D) Blood pressure fluctuates a great deal during the day. it is most important to cover the head. D Response: Crossed legs or dangling legs can increase BP. 217) 23.Chapter 17: Measuring Vital Signs 20. (V1. (B and D) Crackles and orthopnea are abnormal respiratory findings. (V1. the arm should be supported. (A) The bladder should encircle 80% of the arm. Monday. age. p. C Response: All are correct. October 29. 330-331. (C) Inflating the cuff to only 30 mm Hg above the palpated BP prevents unnecessary discomfort to the client but does not affect the BP reading. p. A. 334) 25. pp. (C) Holding the arm out can increase BP. p. but because infants lose 30% of their body heat through the head (because of the many blood vessels close to the skin surface). pp. although the mercury manometer is more accurate. smoking. (V1. B. dizziness. B Response: The quality of a pulse refers to the pulse volume (strength) and bilateral equality of the pulses. Any determination of hypertension must be done after two or more BP readings taken on separate occasions. A Response: The lowest temperature occurs during the night when we have a low metabolic rate. p. and an increased heart rate are all manifestations of hypoxia. 328. but they do not necessarily indicate poor oxygenation. C Response: Apprehension. (B) Just the first and last Korotkoff sounds are necessary to determine a BP reading. confusion. pp. V2. race. (V1. (V1. 334) Nursing process: Diagnosis 26. Kidney disease is a cause of secondary hypertension. (V1. 311. Temperature normally increases until it peaks in the early evening. 320-321) 24. and high cholesterol levels put a client at risk for primary hypertension. 309) 22. (A) The type of manometer does not greatly influence BP readings. B Response: Heavy alcohol consumption. family history of hypertension.
or sixth intercostal spaces in the midclavicular line. p. mild/moderate pain. adequate amounts of water are necessary to carry on body functions. Smoking. (V1.(V1. 31D. eating. E. (Distractors A & B: V1. pp. p. p. C Response: A single lifestyle change can lower BP. 28C. 5. 328-329 and V2. (D) A diet high in calcium is recommended to prevent and manage hypertension. distractors. distractor C: V2. Auscultate at 3 inches to the left of client's sternum at the fourth. and exercise all stimulate and increase BP. 317) 31A. Response: Apical pulse is heard at the apex of the heart. & G: V1. F.25 L per minute Response: Cardiac output is calculated by multiplying the heart rate times the stroke volume. 319) . 330. 31C. C D E A Response: Descriptions of the various breath sounds are as stated (V1. (V1. fifth. (V1. p. E250 mL per minute. 28B. p. 319 30. distractor D: V1. 31B. 217. 334) 28A. Regardless of BP. p. Severe pain can lower BP. 31F. (A) Any elevated BP reading should be followed up. The position of the apex of the heart is different for a child than an adult. 31E. but water consumption is not. p. 325) 29. p. 28D. (B) Drinking too much liquor is associated with hypertension. 316) 27. erroneously high erroneously low temporarily high temporarily high temporarily high temporarily low temporarily high Response: Improper cuff size affects BP readings. 31G.
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