TB Ch: 30 - Vital Signs

Question 1

A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely?

a. Pulse
b. Respirations
c. Temperature
d. Blood pressure

Answer 1

ANS: C

Disease or trauma to the hypothalamus or the spinal cord, which carries hypothalamic messages, causes serious alterations in temperature control. The hypothalamus does not control pulse, respirations, or blood pressure.

Question 2

A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss?

a. Radiation
b. Conduction
c. Convection
d. Evaporation

Answer 2

ANS: C

Convection is the transfer of heat away from the body by air movement. Conduction is the transfer of heat from one object to another with direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas.

Question 3

The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient’s temperature?

a. Radiation
b. Conduction
c. Convection
d. Evaporation

Answer 3

ANS: B

Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss because of the direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement.

Question 4

A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take?

a. Apply just a diaper.
b. Double the clothing.
c. Place a cap on their heads.
d. Increase room temperature to 90 degrees.

Answer 4

ANS: C

A newborn loses up to 30% of body heat through the head and therefore needs to wear a cap to prevent heat loss. Temperature control mechanisms in newborns are immature and respond drastically to changes in the environment; do not increase the room temperature to 90 degrees. Take extra care to protect newborns from environmental temperatures. Provide adequate clothing; do not double the clothing or apply just a diaper.

Question 5

The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The nurse notices that the patient’s temperature is 96.8° F (36° C), whereas at 4:00 PM the preceding day, it was 98.6° F (37° C). What should the nurse do?

a. Call the health care provider immediately to report a possible infection.
b. Administer medication to lower the temperature further.
c. Provide another blanket to conserve body temperature.
d. Realize that this is a normal temperature variation.

Answer 5

ANS: D

Body temperature normally changes 0.5° to 1° C (0.9° to 1.8° F) during a 24-hour period and is usually lowest between 1:00 and 4:00 AM, with a maximum temperature at 4:00 PM, making this variation normal for the time of day. Unless the patient reports being cold, there is no physiological need for providing an extra blanket or medication to lower the body temperature further. There is also no need to call a health care provider to report a normal temperature variation.

Question 6

The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). The patient’s last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). Which action will the nurse take?

a. Wait 30 minutes and recheck the patient’s temperature.
b. Assume that the patient has an infection and order blood cultures.
c. Encourage the patient to move around to increase muscular activity.
d. Be aware that temperatures this high are harmful and affect patient safety.

Answer 6

ANS: A

Waiting 30 minutes and rechecking the patient’s temperature would be the most appropriate action in this case. A fever is usually not harmful if it stays below 102.2° F (39° C), and a single temperature reading does not always indicate a fever. In addition to physical signs and symptoms of infection, a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time. Nurses should base actions on knowledge, not on assumptions. Encouraging the patient to increase muscular activity will cause heat production to increase up to 50 times normal. The temperature has decreased and a symptom of infection would be an increase in temperature.

Question 7

A patient is pyrexic. Which piece of equipment will the nurse obtain to monitor this condition?

a. Stethoscope
b. Thermometer
c. Blood pressure cuff
d. Sphygmomanometer

Answer 7

ANS: B

Pyrexia, or fever, occurs because heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature; therefore, a thermometer is needed. A stethoscope is not used to take a temperature but can be used for apical pulse and blood pressure. A pulse oximeter is used to determine oxygen content in the blood. A sphygmomanometer and blood pressure cuff is used to determine blood pressure and will be used for blood pressure problems.

Question 8

The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient?

a. Hyperthermia and fever are the same thing.
b. Hyperthermia is an upward shift in the set point.
c. Hyperthermia occurs when the body cannot reduce heat production.
d. Hyperthermia results from a reduction in thermoregulatory mechanisms.

Answer 8

ANS: C

An elevated body temperature related to the inability of the body to promote heat loss or reduce heat production is hyperthermia. Whereas fever is an upward shift in the set point, hyperthermia results from an overload of the thermoregulatory mechanisms of the body.

Question 9

The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take?

a. Place the patient on oxygen.
b. Encourage the patient to cough.
c. Restrict the patient’s fluid intake.
d. Increase the patient’s metabolic rate.

Answer 9

ANS: A

Interventions during a fever include oxygen therapy. During a fever, cellular metabolism increases and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for fluid volume deficit. Fluids should not be restricted, even though the patient has heart failure; the patient needs fluids at this time due to the fever. Increasing the metabolic rate further would not be advisable. Coughing will increase muscular activity, which will increase fever.

Question 10

The patient requires temperatures to be taken every 2 hours. Which task will the nurse assign to an RN?

a. Using appropriate route and device
b. Assessing changes in body temperature
c. Being aware of the usual values for the patient
d. Obtaining temperature measurement at ordered frequency

Answer 10

ANS: B

The nurse is responsible for assessing changes in body temperature. The nursing assistive personnel can use the appropriate route and device to measure temperature, obtain temperature measurement at ordered frequency, and be aware of the usual values for the patient.

Question 11

The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient’s temperature?

a. Oral
b. Rectal
c. Axillary
d. Tympanic

Answer 11

ANS: D

The tympanic route is easily accessible, requires minimal patient repositioning, and often can be used without disturbing the patient. It also has a very rapid measurement time. Oral temperatures require patient cooperation and are not recommended for patients with a history of seizures. Rectal temperatures require positioning and may increase patient agitation. Axillary temperatures need long measurement times and continuous positioning. The patient’s agitation state may not allow for long periods of attention.

Question 12

The patient is being admitted to the emergency department following a motor vehicle accident. The patient’s jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature reading?

a. Oral
b. Axillary
c. Tympanic
d. Temporal

Answer 12

ANS: C

The tympanic route is the best choice in this situation. Oral temperatures are not used for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills. Axillary temperature is affected by exposure to the environment, including time to place the thermometer. It also requires a long measurement time. Temporal artery temperature is affected by skin moisture such as diaphoresis or sweating.

Question 13

The nurse is caring for an infant and is obtaining the patient’s vital signs. Which artery will the nurse use to best obtain the infant’s pulse?

a. Radial
b. Brachial
c. Femoral
d. Popliteal

Answer 13

ANS: B

The brachial or apical pulse is the best site for assessing an infant’s or a young child’s pulse because other peripheral pulses such as the radial, femoral, and popliteal arteries are deep and difficult to palpate accurately.

Question 14

The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use?

a. Radial
b. Apical
c. Carotid
d. Brachial

Answer 14

ANS: C

The heart continues to deliver blood through the carotid artery to the brain as long as possible. The carotid pulse is easily accessible during physiological shock or cardiac arrest. The radial pulse is used to assess peripheral circulation or to assess the status of circulation to the hand. The brachial site is used to assess the status of circulation to the lower arm. The apical pulse is used to auscultate the apical area.

Question 15

The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement?

a. Place the tips of the first two fingers over the groove along the thumb side of the patient’s wrist.
b. Place the tips of the first two fingers over the groove along the little finger side of the patient’s wrist.
c. Place the thumb over the groove along the little finger side of the patient’s wrist.
d. Place the thumb over the groove along the thumb side of the patient’s wrist.

Answer 15

ANS: A

Place the tips of the first two or middle three fingers of the hand over the groove along the radial or thumb side of the patient’s inner wrist. Fingertips are the most sensitive parts of the hand to palpate arterial pulsation. The thumb has a pulsation that interferes with accuracy. The groove along the little finger is the ulnar pulse.

Question 16

The nurse is assessing the patient’s respirations. Which action by the nurse is most appropriate?

a. Inform the patient that she is counting respirations.
b. Do not touch the patient until completed.
c. Obtain without the patient knowing.
d. Estimate respirations.

Answer 16

ANS: C

Do not let a patient know that you are assessing respirations. A patient aware of the assessment can alter the rate and depth of breathing. Assess respirations immediately after measuring pulse rate, with your hand still on the patient’s wrist as it rests over the chest or abdomen. Respirations are the easiest of all vital signs to assess, but they are often the most haphazardly measured. Do not estimate respirations.

Question 17

The patient’s blood pressure is 140/60. Which value will the nurse record for the pulse pressure?

a. 60
b. 80
c. 140
d. 200

Answer 17

ANS: B

The difference between the systolic pressure and the diastolic pressure is the pulse pressure. For a blood pressure of 140/60, the pulse pressure is 80 (140 − 60 = 80). 140 is the systolic pressure. 60 is the diastolic pressure. 200 is the systolic (140) added to the diastolic (60), but this has no clinical significance.

Question 18

The nurse reviews the laboratory results for a patient and determines the viscosity of the blood is thick. Which laboratory result did the nurse check?

a. Arterial blood gas
b. Blood culture
c. Hematocrit
d. Potassium

Answer 18

ANS: C

The hematocrit, or the percentage of red blood cells in the blood, determines blood viscosity. Blood cultures determine the causative agent of an infection. Abnormal potassium levels can cause dysrhythmias. Arterial blood gases determine acid-base balance or the pH levels of the blood.

Question 19

The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do?

a. Allow the patient to breathe into a paper bag.
b. Use oxygen cautiously in this patient.
c. Administer high levels of oxygen.
d. Give CO2 via mask.

Answer 19

ANS: B

Oxygen must be used cautiously in these types of patients. Hypoxemia helps to control ventilation in patients with chronic lung disease. Because low levels of arterial O2 provide the stimulus that allows a patient to breathe, administration of high oxygen levels may be fatal for patients with chronic lung disease. Patients with chronic lung disease have ongoing hypercarbia (elevated CO2 levels) and do not need to have CO2 administered or “rebreathed” with a paper bag.

Question 20

A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up?

a. 35 mm Hg
b. 40 mm Hg
c. 45 mm Hg
d. 50 mm Hg

Answer 20

ANS: D

50 mm Hg is abnormal so the nurse will follow up. Normal capnography results are 35 to 45 mm Hg.

Question 21

The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient’s low heart rate?

a. The patient has a fever.
b. The patient has possible hemorrhage or bleeding.
c. The patient has chronic obstructive pulmonary disease (COPD).
d. The patient has calcium channel blockers or digitalis medication prescriptions.

Answer 21

ANS: D

Negative chronotropic drugs such as digitalis, beta-adrenergic agents, and calcium channel blockers can slow down pulse rate. Fever, bleeding, hemorrhage, and COPD all increase the body’s need for oxygen, leading to an increased heart rate.

Question 22

The patient was found unresponsive in an apartment and is being brought to the emergency department. The patient has arm, hand, and leg edema, temperature is 95.6° F, and hands are cold secondary to a history of peripheral vascular disease. It is reported that the patient has a latex allergy. What should the nurse do to quickly measure the patient’s oxygen saturation?

a. Attach a finger probe to the patient’s index finger.
b. Place a nonadhesive sensor on the patient’s earlobe.
c. Attach a disposable adhesive sensor to the bridge of the patient’s nose.
d. Place the sensor on the same arm that the electronic blood pressure cuff is on.

Answer 22

A non-adhesive sensor is best for latex allergy, and the earlobe site is the best choice for this patient with peripheral vascular disease and edema. Select forehead, ear or bridge of nose if an adult patient has a history of peripheral vascular disease. Do not attach probe to finger, ear, forehead, or bridge of nose if area is edematous or skin integrity is compromised. Do not use disposable adhesive probes if the patient has latex allergy. Do not attach probe to fingers that are hypothermic. Do not place the sensor on the same extremity as the electronic blood pressure cuff because blood flow to the finger will be temporarily interrupted when the cuff inflates.

Question 23

The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient’s symptoms?

a. Red blood cell count of 5.0 million/mm3
b. Hemoglobin level of 8.0 g/100 mL
c. Hematocrit level of 45%
d. Pulse oximetry of 95%

Answer 23

ANS: B

The concentration of hemoglobin reflects the patient’s capacity to carry oxygen, which if low can lead to shortness of breath and chest discomfort. Normal hemoglobin levels range from 14 to 18 g/100 mL in males and from 12 to 16 g/100 mL in females. Hemoglobin of 8.0 is low and indicates a decreased ability to deliver oxygen to meet bodily needs. All other values in the selection are considered normal.

Question 24

A nurse reviews blood pressures of several patients. Which finding will the nurse report as prehypertension?

a. 98/50 in a 7-year-old child
b. 115/70 in an infant
c. 120/80 in a middle-aged adult
d. 146/90 in an older adult

Answer 24

ANS: C

An adult’s blood pressure tends to rise with advancing age. The optimal blood pressure for a healthy, middle-aged adult is less than 120/80. Values of 120 to 139/80 to 89 mm Hg are considered prehypertension. Blood pressure greater than 140/90 is defined as hypertension. Blood pressure of 98/50 is normal for a child, whereas 115/70 can be normal for an infant.

Question 25

The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address?

a. Non-Hispanic Caucasians
b. European Americans
c. African-Americans
d. Asian Americans

Answer 25

ANS: C

The incidence of hypertension is greater in diabetic patients, older adults, and African-Americans. The incidence of hypertension (high BP) is higher in African-Americans than in European Americans.

Question 26

A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient’s blood pressure (BP)?

a. Smoking increases BP for up to 3 hours.
b. Caffeine increases BP for up to 15 minutes.
c. Smoking result in vasoconstriction, falsely elevating BP.
d. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement.

Answer 26

ANS: C

Smoking results in vasoconstriction, a narrowing of blood vessels. BP rises when a person smokes and returns to baseline about 15-20 minutes after stopping smoking. Caffeine increases BP for up to 3 hours. Be sure that patient has not ingested caffeine or smoked 20 to 30 minutes before BP measurement.

Question 27

When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding?

a. This is normal for an infant.
b. This is too fast for an infant.
c. This is too slow for an infant.
d. This is not a rate for an infant but for a toddler.

Answer 27

ANS: A

The normal rate for an infant is 120 to 160 beats/min. The rate obtained (145 beats/min) is within the normal range for an infant. The normal rate for a toddler is between 90 and 140 beats/min; 145 is too high for a toddler.

Question 28

The nurse is caring for an older-adult patient and notes that the temperature is 96.8° F (36° C). How will the nurse interpret this finding?

a. The patient has hyperthermia.
b. The patient has a normal temperature.
c. The patient is suffering from hypothermia.
d. The patient is demonstrating increased metabolism.

Answer 28

ANS: B

The average body temperature of older adults is approximately 35° to 36.1° C (95° to 97° F). This is not hypothermia or hyperthermia. Older adults have poor vasomotor control, reduced amounts of subcutaneous tissue, reduced sweat gland activity, and reduced metabolism. The end result is lowered body temperature.

Question 29

When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse’s action?

a. It is not affected by skin moisture.
b. It has no risk of injury to patient or nurse.
c. It reflects rapid changes in radiant temperature.
d. It is accurate even when the forehead is covered with hair.

Answer 29

ANS: B

The temporal artery thermometer is especially beneficial when used in premature infants, newborns, and children because there is no risk of injury to the patient or nurse. Temporal artery temperature is a reliable noninvasive measure of core temperature. However, it is inaccurate with head covering or hair on the forehead and is affected by skin moisture such as diaphoresis, or sweating. It provides very rapid measurement and reflects rapid changes in core temperature, not radiant temperature.

Question 30

The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to praise the NAP?

a. Ulnar site
b. Radial site
c. Brachial site
d. Femoral site

Answer 30

ANS: C

The nurse will praise the NAP when obtaining the pulse from the brachial site. The brachial or apical pulse is the best site for assessing an infant’s or a young child’s pulse because other peripheral pulses are deep and difficult to palpate accurately.

Question 31

The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn?

a. 30 to 60
b. 22 to 28
c. 16 to 20
d. 10 to 15

Answer 31

ANS: A

The acceptable respiratory rate range for a newborn is 30 to 60 breaths/min. An infant (6 months) is expected to have a rate between 30 and 50 breaths/min. A toddler’s respiratory range is 25 to 32 breaths/min. A child should breathe 20 to 30 times a minute. An adolescent should breathe 16 to 20 times a minute. An adult should breathe 12 to 20 times a minute.

Question 32

The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take?

a. Secure the sensor to the toddler’s earlobe.
b. Determine whether the toddler has a latex allergy.
c. Place the sensor on the bridge of the toddler’s nose.
d. Overlook variations between an oximeter pulse rate and the toddler’s pulse rate.

Answer 32

ANS: B

The nurse should determine whether the patient has latex allergy because disposable adhesive probes should not be used on patients with latex allergies. Earlobe and bridge of the nose sensors should not be used on infants and toddlers because of skin fragility. Oximeter pulse rate and the patient’s apical pulse rate should be the same. Any difference requires re-evaluation of oximeter sensor probe placement and reassessment of pulse rates.

Question 33

The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed?

a. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds.
b. Obtain the reading before the child has a chance to “settle down.”
c. Choose the cuff that says “Child” instead of “Infant.”
d. Explain the procedure to the child.

Answer 33

ANS: D

The child’s cooperation is increased when you or the parent have prepared the child for the unusual sensation of the BP cuff. Most children understand the analogy of a “tight hug on your arm.” Different arm sizes require careful and appropriate cuff size selection. Do not choose a cuff based on the name of the cuff. An “Infant” cuff is too small for some infants. Readings are difficult to obtain in restless or anxious infants and children. Allow at least 15 minutes for children to recover from recent activities and become less apprehensive. Korotkoff sounds are difficult to hear in children because of low frequency and amplitude. A pediatric stethoscope bell is often helpful.

Question 34

A nurse is caring for a group of patients. Which patient will the nurse see first?

a. A crying infant with P-165 and R-54
b. A sleeping toddler with P-88 and R-23
c. A calm adolescent with P-95 and R-26
d. An exercising adult with P-108 and R-24

Answer 34

ANS: C

A calm adolescent should have the following findings: P—60-90 and R—16-20. Since both findings are elevated, the nurse should see this patient first. An infant should have the following findings: P—120-160 and R—30-50; however, since the infant is crying these values will be elevated and this is normal. A toddler should have the following findings: P—90-140 and R—25-32; however, since the toddler is sleeping these values can be slightly decreased and this is normal. An adult should have the following findings: P—60-100 and R—12-20; however, since the adult is exercising these values will be elevated and this is normal.

Question 35

The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take blood pressure 3 times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient?

a. You can apply the cuff in any manner.
b. You will need to recalibrate the machine.
c. You can move your arm during the reading.
d. You will need to use a stethoscope properly.

Answer 35

ANS: B

Electronic devices are easier to manipulate but require frequent recalibration—more than once a year. Because of their sensitivity, improper cuff placement or movement of the arm causes electronic devices to give incorrect readings. The portable home devices include the aneroid sphygmomanometer and electronic digital readout devices that do not require the use of a stethoscope. The cuff will need to be applied correctly, and the patient’s arm needs to be still during the reading.

Question 36

The nurse is caring for a patient who reports feeling light-headed and “woozy.” The nurse checks the patient’s pulse and finds that it is irregular. The patient’s blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do?

a. Apply more pressure to the radial artery to feel pulse.
b. Perform an apical/radial pulse assessment.
c. Call the health care provider immediately.
d. Obtain arterial blood gases.

Answer 36

ANS: B

If the pulse is irregular, do an apical/radial pulse assessment to detect a pulse deficit. If pulse count differs by more than 2, a pulse deficit exists, which sometimes indicates alterations in cardiac output. The nurse needs to gather as much information as possible before calling the health care provider. The radial pulse is more accurately assessed with moderate pressure. Too much pressure occludes the pulse and impairs blood flow. Arterial blood gases is a laboratory test that measures blood pH and oxygenation status. Arterial blood gases would be appropriate if respirations were abnormal or if pulse oximetry results were severely low.

Question 37

A nurse is caring for a group of patients. Which patient will the nurse see first?

a. A 17-year-old male who has just returned from outside “for a smoke” who needs a temperature taken
b. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60
c. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74
d. An 87-year-old male suspected of hypothermia whose temperature is below normal

Answer 37

ANS: B

When a blood pressure drops in a postoperative patient, bleeding may be occurring and lead to shock. The nurse should assess this patient first. Pain will cause the blood pressure to elevate so this is an expected finding, and while it does need to be assessed, it is not the first one to assess. A teenager who has returned from smoking will have to wait at least 20 minutes before a temperature can be taken, so this is not the first one to see. A patient with hypothermia is expected to have a temperature below normal, so this is not the first one to see.

Question 38

The health care provider prescription reads “Metoprolol (Lopressor) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic.” The patient’s blood pressure is 92/66. The nurse does not give the medication. Which action should the nurse take?

a. Documents that the medication was not given because of low blood pressure
b. Does not inform the health care provider that the medication was held
c. Does not tell the patient what the blood pressure is
d. Documents only what the blood pressure was.

Answer 38

ANS: A

The nurse must document any interventions initiated as a result of vital sign measurement such as holding an antihypertensive drug. The nurse should inform the patient of the blood pressure value and the need for periodic reassessment of the blood pressure. Documenting the blood pressure only is not sufficient. Any intervention must be documented as well. Abnormal findings must be reported to the nurse in charge or to the health care provider.

Question 39

After taking the patient’s temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse’s action?

a. Temperatures vary depending on the route used.
b. Temperatures are readings of core measurements.
c. Rectal temperatures are cooler than when taken orally.
d. Axillary temperatures are higher than oral temperatures.

Answer 39

ANS: A

Temperatures obtained vary depending on the site used. Rectal temperatures are usually 0.5° C (0.9° F) higher than oral temperatures, and axillary temperatures are usually 0.5° C (0.9° F) lower than oral temperatures. There are core temperature readings and body surface readings.

Question 40

When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding?

a. 68
b. 76
c. 138/62
d. 138/70

Answer 40

ANS: C

138/62 is the correct reading. The fifth sound marks the disappearance of sound. In adolescents and adults the fifth sound corresponds with the diastolic pressure. The fourth sound becomes muffled and low pitched as the cuff is further deflated. At this point the cuff pressure has fallen below the pressure within the vessel walls; this sound is the diastolic pressure in infants and children. 68 is the pulse pressure of 138/70; 76 is the pulse pressure for 138/62.

Question 41

The nursing assistive personnel (NAP) is taking vital signs and reports that a patient’s blood pressure is abnormally low. What should the nurse do next?

a. Ask the NAP retake the blood pressure.
b. Instruct the NAP to assess the patient’s other vital signs.
c. Disregard the report and have it rechecked at the next scheduled time.
d. Retake the blood pressure personally and assess the patient’s condition.

Answer 41

ANS: D

The nursing assistive personnel should report abnormalities to the nurse, who should further assess the patient. The nursing assistive personnel should not retake the blood pressure or other vital signs because the nurse needs to assess the patient. The report cannot be disregarded. Assessment must be done by the nurse.

Question 42

A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature?

• (Select all that apply.)*
  a. Rectal
  b. Tympanic
  c. Esophagus
  d. Temporal artery
  e. Pulmonary artery

Answer 42

ANS: B, C, E

Intensive care units use the core temperatures of the pulmonary artery, esophagus, and urinary bladder. Because the tympanic membrane shares the same arterial blood supply as the hypothalamus, the tympanic temperature is a core temperature. Temporal artery measurements detect the temperature of cutaneous blood flow. Oral, rectal, axillary, and skin temperature sites rely on effective blood circulation at the measurement site.

Question 43

The patient has new-onset restlessness and confusion. Pulse rate is elevated, as is respiratory rate. Oxygen saturation is 94%. The nurse ignores the pulse oximeter reading and calls the health care provider for orders because the pulse oximetry reading is inaccurate. Which factors can cause inaccurate pulse oximetry readings?

• (Select all that apply.)*
• a. O2 saturations (SaO2) > 70%*
• b. Carbon monoxide inhalation*
• c. Hypothermic fingers*
• d. Intravascular dyes*
• e. Nail polish*
• f. Jaundice*

Answer 43

ANS: B, C, D, E, F

Inaccurate pulse oximetry readings can be caused by outside light sources, carbon monoxide (caused by smoke inhalation or poisoning), patient motion, jaundice, intravascular dyes (methylene blue), nail polish, artificial nails, metal studs, or dark skin. SpO2 is a reliable estimate of SaO2 when the SaO2 is over 70%.

Question 44

The nurse is assessing the patient and family for probable familial causes of the patient’s hypertension. The nurse begins by analyzing the patient’s personal history, as well as family history and current lifestyle situation. Which findings will the nurse consider to be risk factors?

• (Select all that apply.)*
  a. Obesity
  b. Cigarette smoking
  c. Recent weight loss
  d. Heavy alcohol intake
  e. Regular exercise sessions

Answer 44

ANS: A, B, D

Obesity, cigarette smoking, and heavy alcohol consumption are risk factors linked to hypertension. Weight loss and regular exercise can decrease the risk for hypertension.

Question 45

The patient is being encouraged to purchase a portable automatic blood pressure device to monitor blood pressure at home. Which information will the nurse present as benefits for this type of treatment? (Select all that apply.)

a. Patients can actively participate in their treatment.
b. Self-monitoring helps with compliance and treatment.
c. The risk of obtaining an inaccurate reading is decreased.
d. Blood pressures can be obtained if pulse rates become irregular.
e. Patients can provide information about patterns to health care providers.

Answer 45

ANS: A, B, E

Self-measurement of blood pressure has several benefits. Sometimes elevated blood pressure is detected in persons previously unaware of a problem. Persons with prehypertension provide information about the pattern of blood pressure values to their health care provider. Patients with hypertension benefit from participating actively in their treatment through self-monitoring, which promotes compliance with treatment. Disadvantages of self-measurement include the risk of inaccurate readings. Electronic devices are not recommended if the patient has an irregular heart rate.

Question 46

A nurse is teaching the staff about alterations in breathing patterns. Which information will the nurse include in the teaching session? (Select all that apply.)

a. Apnea—no respirations
b. Tachypnea—regular, rapid respirations
c. Kussmaul’s—abnormally deep, regular, fast respirations
d. Hyperventilation—labored, increased in depth and rate respirations
e. Cheyne-Stokes—abnormally slow and depressed ventilation respirations
f. Biot’s—irregular with alternating periods of apnea and hyperventilation respirations

Answer 46

ANS: A, B, C

Apnea—Respirations cease for several seconds. Persistent cessation results in respiratory arrest. Tachypnea—Rate of breathing is regular but abnormally rapid (greater than 20 breaths/min). Kussmaul’s—Respirations are abnormally deep, regular, and increased in rate. Hyperventilation—Rate and depth of respirations increase; breaths are not labored. Hypocarbia sometimes occurs. Cheyne-Stokes—Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Biot’s—Respirations are abnormally shallow for 2 to 3 breaths followed by irregular period of apnea.

Question 47

A nurse is assessing results of vital signs for a group of patients. Match the condition to the assessment findings the nurse is reviewing.

a. Patient’s temperature is 113° F (45° C) with hot, dry skin.
b. Patient’s blood pressure sitting is 130/60 and 110/40 standing.
c. Patient’s pulse is 110 beats/min.
d. Patient’s temperature is 93.2° F (34° C).
e. Patient’s blood pressure went from 126/76 to 90/50.
1. Hypothermia
2. Shock/Hypotension
3. Heatstroke
4. Orthostatic hypotension
5. Tachycardia

Answer 47

A = 3

B = 4

C = 5

D = 1

E =2