Vital signs - Pottery and Perry Test Bank PDF

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Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 32: Vital Signs MULTIPLE CHOICE 1. A client has developed pneumonia, and his temperature has increased to 37.7° C. The client is shivering and “feels uncomfortable.” The nurse should: 1. Apply hot packs to the axilla and groin 2. Wrap the client’s four extremities 3. Restrict oral fluid consumption 4. Apply a hypothermia mattress ANS: 3 Wrapping the client’s extremities has been recommended to reduce the incidence and intensity of shivering. Hot packs should not be applied to the client’s axilla and groin. Fluids should not be restricted, but increased to replace fluids lost as a result of the fever. Hypothermia blankets may be used to reduce fever, but if the client is already shivering, a hypothermia blanket is not used, as further stimulation of shivering should be avoided. DIF: A REF: 506 OBJ: Comprehension TOP: Nursing Process: Application MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 2. The client comes to the emergency department after having been in the sun for an extended period of time. The nurse also determines that the client is taking a diuretic. Heatstroke is suspected and the nurse observes for: 1. Diaphoresis 2. Confusion 3. Temperature of 36° C 4. Decreased heart rate ANS: 2 Confusion is a symptom of heatstroke, along with delirium, nausea, muscle cramps, visual disturbances, and even incontinence. The most important sign of heatstroke is hot, dry skin, not diaphoresis. Victims of heatstroke do not sweat because of severe electrolyte loss and hypothalamic malfunction. A normal temperature is 36° to 38° C. With heatstroke the client’s body temperature may reach as high as 45°C. The heart rate is increased with heatstroke, not decreased. DIF: A REF: 507 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 3. A construction worker is seen in the emergency department with low blood pressure, normal pulse rate, diaphoresis, and weakness. These are clinical signs of: Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

Test Bank 1. 2. 3. 4.

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Heatstroke Heat cramp Hypothermia Heat exhaustion

ANS: 4 The client is exhibiting signs of heat exhaustion (e.g., symptoms of fluid volume deficit). If the client were experiencing heatstroke, the client would have an increased pulse rate and would not be sweating. Muscle cramps are related to heatstroke. The client is not exhibiting signs consistent with heatstroke. The client is not exhibiting signs of hypothermia such as shivering, loss of memory, or cyanosis. DIF: A REF: 508 OBJ: Comprehension TOP: Nursing Process: Diagnosis MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 4. A 6-year-old boy has just eaten a grape popsicle and the nurse is ready to take vital signs. An appropriate action would be to: 1. Take the rectal temperature 2. Take the oral temperature as planned 3. Have the child rinse out the mouth with warm water 4. Wait 20 minutes before assessing the oral temperature ANS: 4 The nurse should wait 20 to 30 minutes before measuring the oral temperature. The nurse should wait, rather than measuring the child’s temperature rectally, as this is not an emergency situation. Taking the oral temperature at this time would result in an inaccurate reading. Rinsing the mouth with warm water may also provide an inaccurate reading of the child’s actual body temperature. The nurse should wait 20 minutes and measure the child’s oral temperature. DIF: A REF: 510 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 5. The client is seen in the emergency center for heat exhaustion as a result of exposure. The nurse anticipates that treatment will include: 1. Replacement of fluid and electrolytes 2. Initiation of oral antibiotic therapy 3. Application of hypothermia wraps 4. Alcohol sponge baths ANS: 1 The treatment of heat exhaustion includes transporting the client to a cooler environment and restoring fluid and electrolyte balance. Antibiotic therapy is not warranted. Hypothermia wraps are not used to treat heat exhaustion. Alcohol baths are not recommended.

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DIF: A REF: 508 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 6. The appropriate site for taking the pulse of a 2-year-old is: 1. Radial 2. Apical 3. Femoral 4. Pedal ANS: 2 The brachial or apical pulse is the best site for assessing an infant’s or young child’s pulse because other peripheral pulses are deep and difficult to palpate accurately. The radial pulse is not the best site for assessing a 2-year-old’s pulse. The femoral pulse is not the best site for assessing a 2-year-old’s pulse. The pedal pulse is not the best site for assessing a 2-year-old’s pulse. DIF: A REF: 521 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 7. The client appears to be breathing faster than before. The nurse should: 1. Ask the client if he has felt stressful 2. Have the client lay down on the bed 3. Count the client’s rate of respirations 4. Palpate the client’s own radial pulse ANS: 3 The first action the nurse should take is to assess the client’s respiratory rate. The nurse can then determine if it is within normal limits and will be able to compare it to the previous measurement to determine if the client is breathing faster than before. Stress may increase an individual’s respiratory rate. The nurse should first make the objective measurement of the client’s rate. Having the client lay down may decrease a client’s respiratory rate, but the nurse should first assess the client before implementing any nursing measures. The nurse should count the respiratory rate. Based on these findings the nurse may or may not need to take the client’s pulse. Assessing the pulse will not verify if the client is breathing faster. DIF: A REF: 529 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 8. A nurse administers pain medication for a client complaining of pain. The nurse first assesses vital signs and finds them to be as follows: blood pressure, 134/92 mm Hg; pulse, 90 beats per minute; respirations, 26 breaths per minute. The nurse’s most appropriate action is to: 1. Give the medication

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2. Ask if the client is anxious 3. Check the client’s dressing for bleeding 4. Recheck the client’s vital signs in 30 minutes ANS: 1 The client’s vital signs are consistent with the client being in pain. It would be safe and appropriate for the nurse to give the pain medication. Asking if the client is anxious is not the most appropriate action. The client is not demonstrating signs of shock (e.g., decreased blood pressure, increased pulse). The most appropriate action is for the nurse to administer pain medication. Rechecking would not be the most appropriate action. The nurse should medicate the client for pain. DIF: C REF: 529 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 9. The client has bilateral casts on the upper extremities, so the nurse will be measuring the blood pressure in the leg. The nurse expects the diastolic pressure to be: 1. 10 to 40 mm Hg higher than in the brachial artery 2. 20 to 30 mm Hg lower than in the brachial artery 3. 40 to 50 mm Hg higher than in the brachial artery 4. Essentially the same as that in the brachial artery ANS: 4 When measuring the blood pressure in the legs, systolic pressure is usually higher by 10 to 40 mm Hg than that in the brachial artery, but the diastolic pressure is the same. The systolic pressure, not the diastolic pressure, is 10 to 40 mm Hg higher than that in the brachial artery. Measurements of 20 to 30 mm Hg lower and 40 to 50 mm Hg higher are not true statements. DIF: A REF: 546 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 10. An 84-year-old client with diabetes is admitted for insulin regulation. Which of the following blood pressure, pulse, and respiration measurements, respectively, is considered to be within the expected limits for a client of this age? 1. BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/min 2. BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min 3. BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min 4. BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min ANS: 1

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These measurements are within the expected limits for an older client. An adult’s average blood pressure is 120/80 mm Hg. The systolic pressure may increase with age, but the blood pressure should not exceed 140/90 mm Hg. The range for an adult’s pulse is 60100 beats/min. The expected respiratory rate is 16-25 breaths/min. BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min; BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min; and BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min are not within the expected limits for a client of this age. DIF: A REF: 527 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 11. The student nurse is assessing the vital signs of a 10-year-old client. The expected values for a client of this age are: 1. P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg 2. P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm Hg 3. P = 80 beats/min, R = 22 breaths/min, BP = 110/70 mm Hg 4. P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hg ANS: 3 These are expected findings of a 10-year-old client. The normal pulse range for a 10year-old is 75-100 beats/min; the normal respiratory rate is 20-30 breaths/min. The expected blood pressure range for a 7-year-old is 87-117/48-64 mm Hg; children who are larger (e.g., heavier and/or taller) have higher blood pressures. The average blood pressure for a 10-year-old is 110/65 mm Hg mm Hg. P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg; P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm Hg; and P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hg are not expected values of a 10-year-old client. DIF: A REF: 537 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 12. The nurse has just taken vital signs for a 30-year-old client. Based on the results, the nurse will report the following finding that is out of the expected range for a client of this age: 1. T = 37.4° C 2. P = 110 beats/min 3. R = 20 breaths/min 4. BP = 120/76 mm Hg ANS: 2 The expected pulse range for an adult is 60-100 beats/min. This client’s pulse is elevated at 110 beats/min. This client’s temperature is within the normal range of 36° to 38° C for an adult. This client’s respiratory rate is within the normal range of 12-20 breaths/min for an adult. This client’s blood pressure reading is within the normal range of 120/80 mm Hg for an adult.

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DIF: A REF: 527 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 13. When using a glass thermometer at home to accurately assess axillary temperature, the nurse should tell the parent of a 1 1/2-year-old child to: 1. Hold the thermometer at the bulb end 2. Cleanse the thermometer in hot water 3. Assess the thermometer for 5 minutes 4. Allow the child to hold the thermometer ANS: 3 When assessing a client’s axillary temperature with a glass thermometer, the thermometer should be left in place for 3 to 5 minutes. The thermometer should be held at the opposite end of the bulb. The thermometer should be covered with a plastic sheath when in use and after used the plastic sheath is discarded. If the thermometer requires cleaning, the nurse should not use hot water, as it could cause the thermometer to break. The parent should hold the thermometer, not the child. A 1 1/2-year-old client may drop the thermometer, creating a mercury spill. DIF: A REF: 630 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 14. The postoperative vital signs of an average size adult client are: BP = 110/68 mm Hg, P = 54 beats/min, R = 8 breaths/min. The client appears pale, is disoriented, and has minimal urinary output. The nurse should: 1. Retake the vital signs in 30 minutes 2. Continue with care as planned 3. Administer a stimulant 4. Notify the physician ANS: 4 The nurse should notify the physician, as these are abnormal findings. The client’s respirations are becoming dangerously low at 8 breaths/min (normal 12-20 breaths/min). The client’s pulse rate is low at 54 beats/min (expected 60-100 beats/min), and the blood pressure should be =120/80 mm Hg, which it is at 110/68 mm Hg. The additional assessment findings are also not normal, and should be reported to the physician. The nurse should not wait another 30 minutes to retake vital signs. The present readings warrant notifying the physician. These are abnormal findings. The nurse should not continue with care as planned. The nurse should first notify the physician. Administering a stimulant would require a physician’s order and may not be what the client requires. For example, the client may need a narcotic antagonist rather than a stimulant. DIF: B REF: 504 TOP: Nursing Process: Evaluation

OBJ: Application

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MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 15. A client has just gotten out of bed to go to the bathroom. As the nurse enters the room, the client says, “I feel dizzy.” The nurse should: 1. Go for help 2. Take the client’s blood pressure 3. Assist the client into a sitting position 4. Tell the client to take several deep breaths ANS: 3 The nurse’s primary concern should be the patient’s safety and preventing an accidental fall. If the client just got up from bed and is complaining of dizziness, the client may be experiencing orthostatic hypotension. The nurse should first assist the client to sit down before performing any other assessment. The nurse should not leave the client and go for help. The nurse should assist the client to a sitting position. If help is required, the nurse can then put on the client’s call light. The nurse may take the client’s blood pressure after assisting the client to a sitting position to prevent the client from falling. The nurse should first assist the client to sit down to prevent the client from falling accidentally. The nurse may then assess the client. If the nurse finds during the assessment that the client’s pulse oximetry is low, the nurse may instruct the client to take deep breaths. DIF: B REF: 538 OBJ: Application TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 16. A false high blood pressure reading may be assessed, as the nurse explains to the nurse assistant, if the assistant: 1. Wraps the cuff too loosely around the arm 2. Deflates the blood pressure cuff too quickly 3. Repeats the blood pressure assessment too soon 4. Presses the stethoscope too firmly in the antecubital fossa ANS: 1 If the cuff is wrapped too loosely or unevenly around the arm, the effect on the blood pressure measurement may be a false high reading. A false low systolic and false high diastolic blood pressure reading may occur if the cuff is deflated too quickly. A false high systolic reading may be obtained if the blood pressure assessment is repeated too soon. A false low diastolic reading may be obtained if the stethoscope is applied too firmly against the antecubital fossa. DIF: A REF: 541 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 17. The client is febrile, and the temperature needs to be reduced. The nurse anticipates that treatment will include:

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An alcohol and water bath Ice packs to the axillae and groin Tepid, plain water sponge down Application of a cooling blanket

ANS: 4 Blankets cooled by circulating water delivered by motorized units increase conductive heat loss. Cooling blankets are used to reduce a fever. Bathing with an alcohol/water solution is not recommended because it may lead to shivering. Shivering is counterproductive and can increase energy expenditure up to 400%. Application of ice packs to the axillae and groin is no longer recommended because they may induce shivering (which is counterproductive and increases the client’s energy expenditure), and because they have no advantage over antipyretic medications. Tepid sponge baths are no longer recommended because it may lead to shivering and is no more advantageous than administering antipyretics. DIF: A REF: 520 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 18. The nurse is alert to which of the following factors that lowers the blood pressure? 1. Stress-producing anxiety 2. Heavy alcohol consumption 3. Cigarette, cigar, or pipe smoking 4. Prescribed diuretic administration ANS: 4 Diuretics lower blood pressure by reducing reabsorption of sodium and water by the kidneys, thus lowering circulating fluid volume. The effects of sympathetic nerve stimulation, such as with anxiety, increase blood pressure. Heavy alcohol consumption has been linked to hypertension. Cigarette smoking has been linked to hypertension. DIF: A REF: 537 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 19. While the nurse is taking the client’s blood pressure, the client asks if the reading is high. In accordance with the newest guidelines, the nurse informs the client that a blood pressure measurement that is consistent with hypertension is: 1. 120/70 mm Hg 2. 130/84 mm Hg 3. 120/78 mm Hg 4. 118/80 mm Hg ANS: 2

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The diagnosis of prehypertension in adults is made when an average of two or more diastolic readings on at least two subsequent visits is between 80 and 89 mm Hg or when the average of multiple systolic blood pressures on two or more subsequent visits is between 120 and 139 mm Hg. Hypertension is noted with diastolic readings greater than 90 mm Hg and systolic readings greater than 140 mm Hg. According to the newest guidelines, this client’s blood pressure reading (130/84 mm Hg) would fall into the prehypertension category. Normal is 120/80 mm Hg; this is a normal blood pressure reading. Normal is 120/80 mm Hg; this is a normal blood pressure reading. Normal is 120/80 mm Hg; this is a normal blood pressure reading. DIF: A REF: 537 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Reduction of Risk Potential/Vital Signs 20. After measuring the client’s vital signs, the nurse obtains the following results: blood pressure = 180/100 mm Hg, pulse = 82 beats/min, R = 16 breaths/min, and rectal temp = 37.5° C. The nurse should: 1. Retake the blood pressure 2. Retake the client’s temperature 3. Report all of the findings immediately 4. Record the findings as within normal lim...