Nursing Chapter 20 Vital Signs Quiz

Questions and Answers

Based on the temperature change of a client whose heart rate would be how many beats/min?

112

What action would be most important for the nurse after a surgical procedure on the left leg?

Compare the left pedal pulse with the right pedal pulse.

What nursing intervention would be appropriate after hearing rhonchi when auscultating a client's lungs?

Ask the client to take a deep breath and cough.

Which set of vital signs are all within normal limits for patients at rest?

Adolescent: T 98.2°F (37°C) (oral); HR 80; RR 18; BP 108/68 mm Hg Signup and view all the answers

Which client situation should be reported to the primary care provider?

Decreased blood pressure (BP) after standing up Signup and view all the answers

What is the nurse's next best action for a 1-day postoperative client with a temperature of 36.8°C?

Document the temperature, and continue with nursing care. Signup and view all the answers

Which site should the nurse use to obtain a pulse rate prior to administering digitalis?

Apical Signup and view all the answers

Based on the expected relationship between temperature and respiratory rate, which respiratory rate would the nurse expect?

18 Signup and view all the answers

Which client would probably have a higher than normal respiratory rate?

A client who has had surgery and lost a unit of blood intraoperatively. Signup and view all the answers

For which adult client should the nurse make follow-up observations and monitor the vital signs closely?

A client whose resting morning BP is 128/78 mm Hg, whereas the afternoon BP is 122/76 mm Hg. Signup and view all the answers

What is the best response by the nurse to a client who thinks their stable vital signs mean they are cured?

"Your vital signs are stable, but there are other things to monitor." Signup and view all the answers

Which parameter would the nurse document as a 7/10 after assessing the client's fifth vital sign?

Pain Signup and view all the answers

What should the nurse do to obtain a good estimate of the core temperature for a client with an axillary temperature of 100.8°F?

Obtain a rectal temperature reading. Signup and view all the answers

What is the nurse's best initial action for a 42-year-old client with a rectal temperature of 39.2°C?

Ask the UAP to obtain another set of vital signs in 4 hours. Signup and view all the answers

Which action is most important for the nurse when teaching a client to use a portable blood pressure device?

Ask the client to demonstrate the use of the blood pressure device. Signup and view all the answers

What should be the nurse's first intervention after reassessing a client with vital signs that include an oral temperature of 103.2°F?

Ask the client whether he has had a warm drink in the last 30 minutes. Signup and view all the answers

Which temperature would be expected during the night for a healthy, young adult client?

97.2°F (36.2°C) Signup and view all the answers

Which instruction is most important when dressing an infant in cold weather?

Place a cap on the infant's head. Signup and view all the answers

What is the most important action for the nurse when evaluating a client's BP for hypertension?

Monitor BP for a pattern. Signup and view all the answers

What is the best initial action for the nurse upon hearing a high-pitched sound while taking vital signs?

Assess the client's airway patency. Signup and view all the answers

What statement indicates a client understands education regarding hypertension prevention and management?

"I can lose some weight to help lower my BP." Signup and view all the answers

For which patient is it most important to obtain an apical-radial pulse and calculate the pulse deficit?

A patient who has a heart or lung disease. Signup and view all the answers

Which procedure technique affects the accuracy of an irregular apical pulse count?

Counting the rate for 1 full minute. Signup and view all the answers

Which assessment data best supports a report of severe pain in an adult client?

Respiratory rate: 26 breaths/min and shallow. Signup and view all the answers

What is the appropriate action for a nurse when a client experiences dizziness upon standing?

Measure vital signs with the client supine, sitting, and standing. Signup and view all the answers

What is the first action by the nurse after obtaining a BP reading of 160/90 mm Hg from a cardiac patient?

Check the patient's BP pattern over the past 3 days. Signup and view all the answers

What is the first action by the nurse after obtaining vital signs: T 100.6°F, BP 100/60 mm Hg, HR 110 beats/min, RR 36 breaths/min?

Obtain a pulse oximetry reading. Signup and view all the answers

What is the likely schedule for measuring vital signs in a skilled nursing center?

Once a week. Signup and view all the answers

What is the most appropriate response when a CNA states, 'I just took the BP' after the nurse requests another reading?

"I need to check the patient's response to the BP medications." Signup and view all the answers

Which vital sign is most critical to monitor for a critically ill patient with a severe midbrain injury?

Temperature Signup and view all the answers

What assessment finding will alert the nurse that a runner is experiencing heat exhaustion?

Diaphoresis Signup and view all the answers

What is the most appropriate nursing action after documenting a patient's radial pulse rate as irregular?

Place the patient on a cardiac monitor. Signup and view all the answers

What is the appropriate method to count an irregular radial pulse in an 80-year-old patient?

Count for 1 full minute. Signup and view all the answers

What is the highest priority nursing diagnosis for a patient with a history of postural hypotension?

Risk for falls Signup and view all the answers

What must be followed to prevent a decrease in heart rate when palpating a patient's carotid pulse?

Careful technique must be followed. Signup and view all the answers

What is the appropriate action by the nurse after noting respirations at 56 breaths/min in a newborn infant?

Document the finding while continuing the assessment. Signup and view all the answers

What clinical data should the nurse document after administering acetaminophen for a postoperative patient with a temperature of 102°F?

Oral temperature 102°F (38.9°C), Called the surgeon to obtain the order, Administered acetaminophen 650 mg orally. Signup and view all the answers

Which blood pressure readings has a pulse pressure within normal limits? (Select all that apply)

120/80 mm Hg Signup and view all the answers

Which interventions would be appropriate for a client who has a fever? (Select all that apply)

Put an ice pack on the client's neck and axillae. Signup and view all the answers

Comparing the changes in vital signs as a person ages, which statements are correct? (Select all that apply)

Men have higher blood pressure than women until after menopause. Signup and view all the answers

Which of these steps in taking a blood pressure are correct? (Select all that apply)

Have the client sit with feet flat on the floor. Signup and view all the answers

When assessing the quality of a client's pedal pulses, what is the nurse assessing? (Select all that apply)

Bilateral equality of pulses Signup and view all the answers

Which nursing interventions are appropriate for a patient admitted with dehydration and a temperature of 101.5°F? (Select all that apply)

Take vital signs every 2 hours. Signup and view all the answers

Which signs and symptoms associated with heat stroke should the nurse be most alert to for a 70-year-old homeless man admitted with heat stroke? (Select all that apply)

Throbbing headache Signup and view all the answers

Study Notes

Vital Signs Assessment

Normal vital sign ranges: Oral temperature 97°F to 100°F, heart rate 60-100 beats/min, respiratory rate 12-20 breaths/min, blood pressure 90/60 to 120/80 mm Hg.
Elevated temperature can indicate fever; for instance, a temperature rise from 99.3°F to 102.3°F typically leads to an increased heart rate, forecasting 112 beats/min.
Changes in vital signs post-surgery, like comparing pedal pulses on either leg, are critical to check for circulatory issues.

Nursing Interventions

In the presence of lung rhonchi, encouraging deep breathing and coughing may improve lung function before reassessment.
Monitoring is essential postoperatively; report significant changes like decreased blood pressure after standing.
Accurate pain assessment is critical; a score of 7/10 indicates the presence of significant pain needing intervention.

Temperature Measurement

Axillary temperature readings should be validated with rectal measurements for precision in fever assessments.
A typical core body temperature for a healthy young adult at night can be as low as 97.2°F.
In pediatric care, particularly in infants, proper dressing includes a cap to conserve body heat.

Blood Pressure Monitoring

For hypertension assessment, consistency is vital; observe patterns instead of isolated readings.
In patients with potential heart issues, apical-radial pulse checks help identify discrepancies in pulse rates.

Emergency Situations

Immediate airway assessment is crucial when abnormal sounds are noted during breathing, indicating potential obstruction.
Signs of heat exhaustion include excessive sweating (diaphoresis) and require rapid cooling measures.

Patient Education and Follow-Up

Clients should understand that stable vital signs do not equate to overall health recovery; continued monitoring is critical.
For home care, clients should demonstrate appropriate techniques when learning to measure blood pressure.

Documentation and Communication

Accurate documentation includes recording symptoms like fever and actions taken, such as medication administration.
Collaboration with healthcare teams involves notifying providers of significant vital sign changes or patient symptoms.

Pediatric Considerations

Newborns' vital signs require careful documentation; notable respiratory rates like 56 breaths/min can be normal.
Understanding hydration importance, especially in older adults or those with a fever, guides nursing interventions such as fluid replacement.

Aging and Vital Signs

As people age, blood pressure tends to rise while respiratory rates decrease, highlighting the need for tailored assessments in older populations.

Interventions for Fever Management

Appropriate fever management includes providing fluids and external cooling methods, like ice packs.
Regular monitoring of vital signs in patients with fever or dehydration is critical for detecting worsening conditions.

Assessment Techniques

Correct blood pressure measurement involves properly fitting cuffs and ensuring the client's posture is correct (e.g. sitting with feet flat).
Assessing pedal pulses includes evaluating strength and symmetry, indicators of peripheral circulation health.

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Description

Test your knowledge on vital signs assessment in nursing with this Chapter 20 quiz. Each question will challenge your understanding of how to interpret changes in vital signs, crucial for effective patient care. Get ready to apply your nursing skills and knowledge in practical scenarios.