Chapter 2- Vital Signs - test practice PDF

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1. A nurse is attempting to obtain vital signs from a restless toddler who is clinging to his mother's legs and asking to go home. Which of the following would be the best nursing intervention to accomplish this task? A) Perform the blood pressure assessment first because it is the most frightening procedure for a child. B) Perform as many of the assessments as possible with the child seated on the parent's lap. C) Do not allow the child to see the instruments until they are ready to be used. D) Remove any distractions (e.g., toys/dolls from the room to improve concentration).

2. A nurse assesses the rectal temperature of a patient who is postoperative following oral surgery. What patient assessment needs to be made before taking this temperature? A) Pain assessment B) Pulse rate C) Platelet count D) Fecal occult blood test

3. A patient informs the nurse that she still uses a mercury thermometer to take the temperature of her children when they are sick. Which of the following is a recommended teaching guideline for patients using these types of thermometers? A) Teach patient safety related to accidental breakage of the thermometer. B) Tell patients using mercury thermometers to throw them in the trash and buy a new type of instrument. C) Encourage patients to use alternative devices to assess temperature in their home. D) Tell patients that mercury thermometers should be used only in a hospital setting with appropriate safeguards.

4. A nurse is obtaining vital signs from patients using the tympanic method for measuring temperature. Which of the following guidelines should be followed when taking a tympanic temperature? A) Do not take a tympanic temperature if the patient has an earache. B) Do not take a tympanic temperature if there is noticeable earwax present. C) Do not take a tympanic temperature if the patient has an ear infection. D) If the patient has been sleeping with head to one side, take the temperature in the ear facing down.

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5. Which of the following statements accurately describe the types of equipment that are used to assess temperature? Select all that apply. A) Nonmercury glass thermometers used for oral readings commonly have blunt bulbs to prevent injury. B) Axillary temperatures are generally about one degree less than oral temperatures. C) Rectal temperatures are generally about one degree higher than other temperatures. D) The nurse should wait 5 minutes before taking an oral temperature on a patient who was drinking iced tea. E) Nasal oxygen is not thought to affect oral temperature readings, but oxygen by mask does. F) A dirty probe lens and cone on the temporal artery thermometer can cause a falsely high reading.

6. A nurse teaching a student nurse how to take temperatures with a nonmercury glass thermometer would be correct in stating the following: A) If the thermometer is stored in a chemical solution, wipe the thermometer dry with a soft tissue, using a firm, twisting motion from the fingers to the bulb. B) Grasp the thermometer firmly with the thumb and the forefinger and, using strong wrist movements, shake it until the chemical line reaches at least 92ºF. C) Read the thermometer by holding it horizontally at eye level, and rotate it between your fingers until you can see the chemical line. D) Leave the thermometer in place for 3 minutes for oral, rectal, and axillary routes or according to agency protocol.

7. Which of the following patients would be an appropriate candidate for the use of a radiant heater? A) An older adult suffering from hypothermia B) A premature infant C) An infant with jaundice D) A child recovering from a near-drowning incident

8. A nurse responds to an order to place an infant in an overhead radiant heater. Which of the following are recommended guidelines the nurse should follow? A) Attach the probe to the infant's skin over a bony area. B) Allow the blankets to warm before placing the infant under the warmer. C) Make sure nothing is covering the probe to allow it to register an accurate temperature. D) Keep the setting of the warmer on manual and adjust it at 15-minute intervals according to the temperature registered.

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9. A nurse is using a cooling blanket on an adult patient with an uncontrolled fever. Which of the following statements accurately describes a recommended guideline for using this type of equipment? A) Position the blanket under the patient so that the top edge of the pad is aligned with the patient's neck. B) For patients who are comatose or anesthetized, use a rectal probe to monitor core body temperature. C) Cover the hypothermia blanket with a thick blanket or mattress pad. D) Do not apply lanolin to the patient's skin where it will be in contact with the blanket.

10. A nurse records a pulse rate of 170 beats/minute on a patient's flow chart. For which of the following age groups would this be considered a normal reading? A) Newborn B) Ten-year-old C) Adolescent D) Adult

11. A nurse palpates the pulse of a patient and documents the following: 6/6/12 pulse 85 and regular, 3+, and equal in radial, popliteal, and dorsalis pedis. What does the number 3+ represent? A) Pulse rate B) Pulse quality (amplitude) C) Pulse rhythm D) Pulse deficit

12. On assessment, a nurse notes that a patient's pulse is weak and applying light pressure causes it to disappear. What pulse amplitude would the nurse document on the flow chart? A) 1+ B) 2+ C) 3+ D) 4+

13. A patient is taking medications to treat a heart arrhythmia. Which site should be used to assess pulse in this patient? A) Brachial B) Radial C) Dorsalis pedis D) Apical

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14. Which peripheral pulse site is generally used in emergency situations? A) Carotid B) Apical C) Radial D) Temporal

15. What is the pulse pressure of a patient whose blood pressure is 132/82 mm Hg? A) 100 B) 1.6 C) 214 D) 50

16. A nurse attempts to count the respiratory rate for a patient via inspection and finds that the patient is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this patient? A) Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2. B) Palpate the posterior thorax excursion, count respirations for 30 seconds, and multiply by 2. C) Use a pulse oximeter to count the respirations for 1 minute. D) Monitor arterial blood gas results for 1 minute.

17. Which of the following accurately reflects a recommended guideline when assessing blood pressure? A) If this is the initial nursing assessment of a patient, take the blood pressure on both arms and use the arm with the lower reading for subsequent pressures. B) Use electronic monitoring devices on patients with irregular heartbeats, tremors, or the inability to hold the arm still. C) Raise the patient's arm over the head to help relieve congestion of blood in the limb and make the sounds louder and more distinct. D) In newborns, take the blood pressure in one arm and one leg and document the difference to check for heart defects.

18. A nurse is assigned to take vital signs in a pediatric unit. Which of the following sites would be most appropriate for taking the blood pressure of children? A) Popiteal B) Temporal C) Brachial D) Radial

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19. Which of the following is an accurate guideline to follow when assessing blood pressure using a Doppler ultrasound? A) Take the measurement with the patient in a standing position with the appropriate limb exposed. B) Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery. C) If using a mercury manometer, check to see that the manometer is in the horizontal position and that the mercury is within the zero level. D) Using your nondominant hand, place the Doppler tip in the gel and adjust the volume as needed; move the Doppler tip around until you hear the pulse.

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Answer Key 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

B C C A B, C, E C B B A A B B D A D A C A B

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