Wk3--Ch29--OverviewOfVitalSign--Sherpath
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Questions and Answers

Which measurements are included as cardinal vital signs? Select all that apply.

  • Pain
  • Pulse/ Blood pressure (correct)
  • Respirations (correct)
  • Oxygen saturation
  • What is the expected pulse range for an adult patient?

  • 50-90
  • 60-100 (correct)
  • 50-100
  • 65-105
  • How frequently would the nurse take vital sign measurements for a stable hospitalized patient?

  • Every 5 minutes
  • Every 15 to 60 minutes
  • Every hour
  • Every 4 to 8 hours (correct)
  • Which finding takes precedence when interpreting a patient's vital sign values?

    <p>Patient's baseline result</p> Signup and view all the answers

    Which situations require vital sign assessment? Select all that apply.

    <p>In ongoing care</p> Signup and view all the answers

    Which tasks would the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

    <p>Report vital signs for a stable patient.</p> Signup and view all the answers

    Which action would the nurse take before notifying the health care provider about a patient's vital signs?

    <p>Compare the findings to the patient's baseline.</p> Signup and view all the answers

    Which response indicates a nurse has a correct understanding about the components of a vital sign assessment?

    <p>&quot;Pulse is the detectable rhythmic expansion of an artery from the pumping action of the heart.&quot;</p> Signup and view all the answers

    Which actions are strictly a nurse's responsibility? Select all that apply.

    <p>Assess patients to determine if medically stable.</p> Signup and view all the answers

    Which actions are required for proper documentation of vital signs? Select all that apply.

    <p>Documenting in a standardized format.</p> Signup and view all the answers

    How frequently would the nurse assess vital signs for a patient with a head injury who suddenly reports a severe headache and whose blood pressure rises from 118/62 to 170/94?

    <p>Every 5 minutes</p> Signup and view all the answers

    Which action would the nurse take for a stable patient who is scheduled for a transfer to the rehabilitation unit later in the afternoon?

    <p>Take vital signs before the transfer.</p> Signup and view all the answers

    Which action would the nurse take when the unlicensed assistive personnel (UAP) reports the patient’s pulse increased from 74 beats/min to 100 beats/min and the temperature increased from 99° to 101.8°F (37.2° to 38.8°C)?

    <p>Reassess the patient.</p> Signup and view all the answers

    Which entries would the nurse include when documenting vital signs? Select all that apply.

    <p>Date of assessment</p> Signup and view all the answers

    Which vital sign finding indicates the adult patient is improving?

    <p>Respiratory rate decreases from 36 to 20.</p> Signup and view all the answers

    Which actions are responsibilities of the nurse when assigning vital signs to the unlicensed assistive personnel (UAP)? Select all that apply.

    <p>Ensure that the UAP uses the proper technique for measuring vital signs.</p> Signup and view all the answers

    Which factors influence the interpretation of a patient’s vital signs? Select all that apply.

    <p>Patient status</p> Signup and view all the answers

    Which finding is unexpected for a 15-year-old patient?

    <p>Respirations 30</p> Signup and view all the answers

    Which information about a patient’s pain is accurate?

    <p>It is a subjective experience.</p> Signup and view all the answers

    Which vital sign measurements are unexpected? Select all that apply.

    <p>60 pulse rate for a 1-year-old</p> Signup and view all the answers

    Which vital sign measurements of adult patients would require the nurse to immediately notify the health care provider? Select all that apply.

    <p>158 pulse rate</p> Signup and view all the answers

    Which patient trend does the vital sign graphic indicate?

    <p>The systolic blood pressure is rising slightly while the diastolic pressure is steady.</p> Signup and view all the answers

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