29 - Vital Signs

Chapter 17: Measuring Vital Signs

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 98.6F (rectal), HR 140, RR 18, BP 100/54. B) Teenager: T 98.6F (oral), HR 100, RR 18, BP 108/68. C) Adult: T 98.9F (oral), HR 54, RR 22, BP 130/84. D) Older adult: T 98.6F (oral), HR 110, RR 22, BP 170/95.

Monday, October 29, 2007

Page 1

6. The nurse assesses the following changes in a client's vital signs. Which client situation should be reported to the primary care provider? A) A decrease in blood pressure (BP) after standing up. B) A decrease in temperature after a period of diaphoresis. C) An increase in heart rate after walking down the hall. D) An increase in respiratory rate when the heart rate increases. 7. Which of the following interventions would be appropriate for a client who has a fever? Choose all that apply. A) Put a cold ice pack on the client's neck and axillae. B) Offer the client a blanket when he is shivering. C) Offer the client fluids to drink every 1-2 hours. D) Take the client's temperature hourly with a tympanic thermometer. 8. The client's temperature is 101.1oF. Which is the correct conversion to centigrade? A) 38.0C. B) 38.4C. C) 38.8C. D) 39.2C. 9. The client has had a fever, ranging from 99.8oF orally to 103oF orally, over the last 24 hours. The client's fever would be classified as: A) Constant. B) Intermittent. C) Relapsing. D) Remittent. 10. A client's vital signs 4 hours ago were: temperature (oral) 101.4oF (38.6oC); heart rate 110; respiratory rate 26; and blood pressure 124/78. The temperature is now 99.4oF (37.4oC). Based on the temperature change, the nurse might best anticipate the client's respiratory rate to be: A) 16. B) 18. C) 20. D) 22.


11. 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. B) Had surgery and lost a unit of blood. C) Lived at a high altitude and has moved to sea level. D) Been exposed to the cold and is hypothermic. 12. 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. B) Oral temperature is 97.9oF in the morning and 99.8oF in the evening. C) Heart rate was 76 before eating and 88 after eating. D) Respiratory rate is 16 when standing and 18 when lying down. 13. A client who has been hospitalized for an infection states, The nursing assistant told me my vital signs are all within normal limits; that means I'm cured. The nurse's best response would be: A) Your vital signs do confirm your infection is gone; how do you feel? B) I'll let your health care provider know so you can be discharged. C) Your vitals signs are stable, but there are other things to assess. D) We still need to keep monitoring your temperature for a while. 14. The nursing instructor asks his students how they would assess the fifth vital sign. Which student would be correct? I would: A) Have the client rate her pain on a scale of 0-10. B) Ask the client when she had her last bowel movement. C) Take the client's pulse oximetry reading. D) Ask the client about her smoking history. 15. A client's axillary temperature is 98.4oF. This is equivalent to: A) 98.4oF orally. B) 99.9oF orally. C) 98.4oF rectally. D) 100.2oF rectally.


Page 3

16. In caring for a client who has a fever, it would be important for the nurse to monitor for increased: A) Urine output. B) Sensitivity to pain. C) Blood pressure. D) Respiratory rate. 17. The nurse is teaching a client how to use a portable blood pressure device to monitor his blood pressure at home. It would be most important for the nurse to: A) Have the client demonstrate the use of the blood pressure device. B) Explain the importance of frequent calibration of the device. C) Give the client a chart to record his blood pressure readings. D) Give the client written instructions of what was taught. 18. The client's vital signs are temperature (oral) 101.2oF (38.5oC), heart rate 80, respiratory rate 16, and blood pressure 128/80. 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. B) Notify the primary care provider of the client's temperature. C) Ask the client if he is feeling chilled. D) Take the temperature by a different route. 19. Comparing the changes in vital signs as a person ages, which statement(s) is/are correct? Select all that apply. A) Blood pressure decreases less than heart rate and respiratory rate. B) Respiratory rate remains fairly stable throughout a person's life. C) Blood pressure increases; heart rate and respiratory rate decline. D) Men have higher blood pressure than women until after menopause. 20. 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) 97.2oF. B) 98oF. C) 98.6oF. D) 99.2oF.


21. The nurse is instructing a client how to appropriately dress an infant in cold weather. Which of the following instructions would be most important for the nurse to include? A) Be sure to put mittens on. B) Layer the infant's clothing. C) Put a cap on the head. D) Put warm booties on. 22. Which of these steps in taking a blood pressure is correct? Choose all that apply. A) Use a bladder that encircles 40% of the arm. B) Wrap the cuff snugly around the client's arm. C) Ask the client to hold the arm at heart level. D) Have the client sit with feet flat on the floor. 23. When assessing the quality of a client's pedal pulses, the nurse is assessing: A) Rhythm of the pulses. B) Strength of the pulses. C) How loud the pulses are on auscultation. D) Rate compared with the apical pulse rate. 24. In evaluating a client's blood pressure for hypertension, it would be most important to: A) Use the same type of manometer each time. B) Auscultate all five Korotkoff sounds. C) Inflate the cuff rapidly 30 mm Hg above the palpated BP. D) Monitor the blood pressure for a pattern. 25. Which of the following information given by a client would indicate a risk for primary hypertension? A) Eats a high-protein diet. B) Drinks three to four beers every day. C) Has a family history of kidney disease. D) Does not participate in any physical activity.


Page 5

26. Which of the following may indicate inadequate oxygenation (choose all that apply)? A client: A) Complains of feeling anxious. B) Has crackles in the lung bases. C) Has an increased heart rate. D) Breathes easier sitting up. 27. A client has been given instructions about hypertension prevention and management. 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. B) I guess I will have to make sure I don't drink too much water. C) I can lose some weight to help lower my blood pressure. D) I will need to reduce the amount milk and milk products I use.


28. Match the breath sound with the appropriate description. _____ Crackles A. High-pitched sound heard on inspiration in infants _____ Rhonchi B. High-pitched, continuous musical sound _____ Stridor C. High-pitched popping or low-pitched bubbling sounds _____ Wheezes D. Low-pitched continuous sounds that clear with coughing

E. Labored, snoring sound


Page 7

29. Describe where to auscultate the apical pulse on an adult client.

30. Using the average stroke volume, calculate the cardiac output for a client with a heart rate of 75.


31. How will each of the errors affect a client's blood pressure reading? _____ A. Blood pressure cuff too narrow _____ B. Blood pressure cuff too wide _____ C. Assessing immediately after smoking _____ D. 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. Assessing immediately after exercise


Page 9

Answer Key1. C Response: Heart rate increases 10 bpm for each degree of temperature to meet increased metabolic needs and compensate for peripheral dilation. (V1, p. 318) 2. C, D Response: The pulse pressure is the systolic blood pressure minus the diastolic BP. The pulse pressure is usually approximately 1/3 of the systolic pressure. (120 80 = 40; 40 = 1/3 of 120) (130 86 = 44; 1/3 of 130 = 43.3) (V1, p. 327) 3. A Response: All answers are correct, but option A is the most important because after surgery on an extremity, it is important to assess whether the circulation has been compromised because of the surgery. This can only be done by comparing one side with the other. (V1, entire chapter; specific information about pulses in V1, p. 321 and V2, pp. 202, 204) 4. B Response: Rhonchi are caused by secretions in the large airways and may clear with coughing. This is how you differentiate between rhonchi and other adventitious sounds. The other interventions will not help to clear rhonchi. (V1, p. 325) 5. B Response: All of the teenager's VS are within normal parameters for the age. (A) The temperature is below normal, the HR is high, the RR is low, and the BP is high for the age. (C) The temperature is high, the HR is low, the RR is high, and the BP is high for the age. (D) The temperature is high, the HR is high, the RR is high, and the BP is high for the age. (V1, p. 306) 6. A Response: A drop in the client's BP when standing indicates orthostatic hypotension, and the cause should be investigated. The changes in the other answers are normal changes for the situations. (V1, BP on p. 333, but should read content about all of the vital signs) 7. A, C Response: (A) If ice packs are used, they are applied to the groin, neck or axillae. (C) A fever increases metabolic needs, so fluids are necessary to prevent dehydration. (B) This would


increase the client's temperature. (D) A tympanic thermometer is not appropriate when an accurate temperature is needed. (V1, pp. 315-316) 8. B Response: To convert Fahrenheit to centigrade, subtract 32 from the temperature, and multiply by 5/9. (V1, p. 312) 9. D Response: Remittent fevers fluctuate widely over a 24-hour period. (B) Intermittent fevers alternate between normal or subnormal temperatures with periods of fever. (A) Constant fevers stay above normal with only slight fluctuations. (C) Relapsing fevers alternate between periods of fever and periods of normal temperature; each phase lasting 1-2 days. (V1, p. 314) 10. B Response: For every degree Fahrenheit (0.6oC) the temperature falls, the respiratory rate may decrease up to 4 breaths per minute. The client's temperature has fallen 2 degrees; multiplied by 4, this is 8. It was 26/min. 26 minus 8 = 18 breaths per minute. (V1, p. 323) 11. B Response: A reduction in hemoglobin from blood loss would increase the respiratory rate. (A) Narcotics and hypothermia slow the respiratory rate. (C) Going from lower altitudes to higher altitudes inhibits oxygen binding, so going to a lower altitude would decrease the respiratory rate or have no effect. (D) Hypothermia decreases the metabolic rate, so the respiratory rate would decrease. (V1, p. 325) 12. A Response: Both the blood pressures would be classified as prehypertension according to the JNC 7 Express guidelines. (B) Body temperature normally increases during the course of a day. (C) Heart rate increases for several hours after eating. (D) Respiratory depth decreases when lying down, so the rate would increase. (V1, p. 327) 13. C Response: Vital signs are one indicator of a client's physiological status, but they are not an absolute indicator of well-being; therefore C is the correct answer. Stating that the vital signs indicate the infection is gone (A) may not be accurate. The decision to be discharged is not based on vital signs alone (B). Although D is true, more than just the temperature will


Page 11

be monitored. (V1, p. 305) 14. A Response: Pain is considered to be the fifth vital sign. (V1, p. 305) 15. D Response: Body temperatures, from lowest to highest, are axillary, oral, rectal, and tympanic. For oral, axillary, and rectal temperatures, there is a 0.9oF degree difference between each site and the next higher one. Add 0.9oF to an axillary to have an equivalent oral temperature and 1.8oF to have an equivalent rectal temperature. C (V1, p. 313) 16. D Response: The metabolic rate increases with a fever, increasing a person's respiratory rate. (A) Urine output would more likely go down because of increased insensible loss and possible loss of intake because of loss of appetite. (B) Change in pain sensation is not a symptom of a fever. (C) The blood pressure is more likely to decrease with a fever, because of peripheral vasodilation. (V1, p. 323) 17. A Response: All are important things to include in client teaching, but self-monitoring of blood pressure is of little value unless it is done correctly. (V1, p. 332) 18. A Response: With a fever, the heart rate and respiratory rate are usually elevated. In this case, they are within normal limits, so option A would be appropriate because having a hot drink would cause a false reading. (V1, temperature information on p. 307; should know norms for all vital signs to answer question) Nursing process: Assessment Client need: Physiological Integrity 19. C, D Response: Heart rate and respiratory rate decrease as people age, whereas the blood pressure increases because of increased vascular resistance (C). Men's blood pressure is higher than women's until after menopause, when women's blood pressure increases (D) (V1, pp. 309, 317, 323, 38)


20. A Response: The lowest temperature occurs during the night when we have a low metabolic rate. Temperature normally increases until it peaks in the early evening. (V1, p. 310) 21. C Response: All are correct, but because infants lose 30% of their body heat through the head (because of the many blood vessels close to the skin surface), it is most important to cover the head. (V1, p. 309) 22. B, D Response: Crossed legs or dangling legs can increase BP. (A) The bladder should encircle 80% of the arm. (C) Holding the arm out can increase BP; the arm should be supported. (V1, pp. 311, 330-331; V2, p. 217) 23. B Response: The quality of a pulse refers to the pulse volume (strength) and bilateral equality of the pulses. (V1, pp. 320-321) 24. D Response: (D) Blood pressure fluctuates a great deal during the day. Any determination of hypertension must be done after two or more BP readings taken on separate occasions. (A) The type of manometer does not greatly influence BP readings, although the mercury manometer is more accurate. (B) Just the first and last Korotkoff sounds are necessary to determine a BP reading. (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. (V1, pp. 328, 334) 25. B Response: Heavy alcohol consumption, age, race, high sodium diet, smoking, family history of hypertension, and high cholesterol levels put a client at risk for primary hypertension. Kidney disease is a cause of secondary hypertension. (V1, p. 334) Nursing process: Diagnosis 26. A, C Response: Apprehension, confusion, dizziness, and an increased heart rate are all manifestations of hypoxia. (B and D) Crackles and orthopnea are abnormal respiratory findings, but they do not necessarily indicate poor oxygenation.


Page 13

(V1, p. 316) 27. C Response: A single lifestyle change can lower BP. (A) Any elevated BP reading should be followed up. (B) Drinking too much liquor is associated with hypertension, but water consumption is not. Regardless of BP, adequate amounts of water are necessary to carry on body functions. (D) A diet high in calcium is recommended to prevent and manage hypertension. (V1, p. 334) 28A. 28B. 28C. 28D. C D E A Response: Descriptions of the various breath sounds are as stated (V1, p. 325)

29. Auscultate at 3 inches to the left of client's sternum at the fourth, fifth, or sixth intercostal spaces in the midclavicular line. Response: Apical pulse is heard at the apex of the heart. The position of the apex of the heart is different for a child than an adult. (V1, p. 319 30. E250 mL per minute; 5.25 L per minute Response: Cardiac output is calculated by multiplying the heart rate times the stroke volume. (V1, p. 317) 31A. 31B. 31C. 31D. 31E. 31F. 31G. erroneously high erroneously low temporarily high temporarily high temporarily high temporarily low temporarily high Response: Improper cuff size affects BP readings. Smoking, eating, mild/moderate pain, and exercise all stimulate and increase BP. Severe pain can lower BP. (Distractors A & B: V1, p. 330; distractor C: V2; distractor D: V1, pp. 328-329 and V2, p. 217; distractors, E, F, & G: V1, p. 319)

Date post:	06-Sep-2014
Category:	Documents
Upload:	loneranger25
View:	242 times
Download:	18 times

29 - Vital Signs

Documents