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ISB: Vital Signs
Nightingale BSN 205, Week 3 ISB, Vital Signs
| Question | Answer |
|---|---|
| 1. Which of the following patients would require follow-up? | An adults with a respiratory rate of 10 breaths per minutes. |
| Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? | Temp 90.7F (36.1C), Pulse 60, Respirations 16, Blood Pressure 116/78, O2 95% |
| The nurse had delegated the task of temperature assessment to the NAP. Which information should be provided to the NAP? (SELECT ALL THAT APPLY) | The frequency for taking or monitoring the temperature, What changes to report immediately to the nurse. The type of temperature required. |
| Which of the following situations may affect a patients vital signs? (SELECT ALL THAT APPLY) | Paton rated as a 7 on a 0-10 pain scale. Moving from lying to standing position. Time of day. |
| The nurse will take the patient's vital signs preoperatively and record them as part of the patient's preparation for surgery. Why is it necessary to take vital signs preoperatively? (Select all that apply.) | To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention. To provide a set f vital signs to use for comparison during and after surgery. |
| The NAP reports to the nurse a 65-year-old patient s blood pressure is 160/98. What is the appropriate initial response of the nurse? | Assess the patient’s blood pressure. |
| Which patient would it be appropriate for the nurse to delegate vital signs? | Elderly nursing home resident. |
| 2. Which person would be expected to have the lowest body temperature? | An 80-year old who walked half a mile. |
| The NAP is preparing to measure a patient's vital signs. The patient reports having eaten a bowl of warm soup. The NAP asks the RN what he should do. What is the best response? | ‘ Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature." |
| For which patient would a tympanic thermometer be the preferred thermometer to use? | A tachypneic patient who is receiving oxygen by nasal cannula. |
| Which of the following patients would require frequent assessment of their temperature? (Select all that apply.) | An adult female in the recovery room following a hysterectomy. A young adult with a white blood count of 15,000/mm3. A patient receiving a blood transfusion for chronic anemia. |
| The NAP reports that the patient's temperature is 39° C (102.2 °F). | Remove the patient’s blankets. Administer an antipyretic to the patient as ordered. |
| Which of the following actions, if made by the NAP, would require intervention and further instruction by the nurse? (Select all that apply.) | The NAP inserts the red-tipped electronic thermometer probe into the patient’s mouth after applying a probe cover. The NAP wipes the single-use chemical stuff thermometer and places it back int he patient’s drawer for future use. |
| Identify the factors that may have an effect on an elderly patient's temperature: (Select all that apply.) | Participation in physical therapy exercises. Drinking a glass of cold water. Room temperature. Infection. |
| If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? | 96.8-100.4 °F (36-38 °C) |
| A newborn patient's temperature has been rising rapidly and the baby has been crying. Which of the following thermometers would be the best to use in measuring this patient's temperature? | Temporal artery. |
| 3. The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select all that apply.) | A radial pulse on a patient with a 1200mL fluid restriction. The temporal pulse of a child. |
| The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select all that apply.) | A patient with peripheral vascular disease. The patient who was just informed of a diagnosis of cancer. A patient who is receiving bonus IV fluids. |
| Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, the nurse should initially do which of the following? | Auscultate the apical pulse for quality and rate. |
| What is the normal pulse range for an adult? | 60 to 100 beats per minute. |
| The nurse should routinely auscultate the apical pulse with the bell side of the stethoscope, and use the diaphragm side to identify heart murmurs. | False. |
| In which of the following patients would the nurse expect to find a decrease in pulse rate? (Select all that apply.) | A patient returning from the operating room. A patient who received morphine for pain. |
| The new NAP is unable to palpate a patient’s radial pulse. What could be a possible explanation for this difficulty? (Select all that apply.) | The NAP is assessing for a pulse on the ulnar side of the wrist. The NAP is pressing down too hard on the patient’s radial site. |
| 4. What is an appropriate nursing intervention for an adult patient with a respiratory rate of 30 breaths per minute? (Select all that apply.) | Count the respiratory rate again for a full 60 seconds (1 minute). Assess physiologi factors that may be causing the patient to breathe so fast. |
| Which of the following may increase both rate and depth of respiration? (Select all that apply.) | Having an addiction problem with amphetamines/cocaine. Feeling anxious when taking a test. Walking 1 mile briskly. |
| When assessing the respiratory rate, the nurse has difficulty seeing the patient's chest rise and fall with inspiration and expiration. What is the nurse’s best action? | Move the patient's arm over their chest and feel the rise and fall of the chest. |
| How can the nurse best obtain an accurate measurement of a patient’s respiratory rate? | Continue to act as though taking the patient’s pulse while discretely observing the rise and fall of the patient’s chest. |
| The nurse is validating the NAP’s skill with respiratory rate assessment. Which of the following actions, if made by the NAP, indicates that further instruction is needed? | When a patient inhales a breath, the NAP counts that as one, and when the patient exhales the breath, the NAP counts that as two. |
| 5. The nurse assesses the BP in both arms of a newly admitted patient. Why would the nurse do this? | To determine if there is a difference in the readings between the two arms. |
| Which of the following patients would be considered hypertensive after having two or more consistent readings of these values? | A football player with a diastolic BP of 94. |
| For which patient should you avoid using a leg pressure cuff (thigh cuff) to assess BP? | A patient with a deep vein thrombosis (blood clot, usually in the lower extremities) |
| The student nurse is unsure of the BP measurement. What should the student nurse do first? | Assess the BP in the other arm. |
| Using the image below, please choose the correct BP combination: <IMG src=" (you may need to right click this link for it to open). | Image A = 120/80, Image B = 128/76, Image C = 140/90, Image D = 138/84 |
| It is 7 a.m. and the nurse takes the vital signs of a postoperative patient and finds his blood pressure is elevated. Which of the following could explain the cause for this alteration in BP? | The patient complains of pain at a 9 on a 0-10 pain scale. |
| The patient has a history of a left mastectomy. Where should the nurse take the patient’s blood pressure? | In the right arm. |
| The nurse is unable to obtain a BP reading using an electronic BP machine on a post-operative patient. The machine reads "Error." What priority action should the nurse take? | Take the patient's BP manually using a sphygmomanometer. |
| 6. The NAP reports to the nurse the patient's respirations are 32 and the patient is complaining of shortness of breath. What is the best action by the nurse at this time? | Assess the patient, including the pulse oximetry reading. |
| Which patient is at high risk for for the pulse oximetry alarm to sound? | A patient with a continuous pulse oximetry reading of 84%. |
| A patient complains of feeling excessively tired. Which statement, if made by the NAP, indicates further instruction is necessary? | I will turn the continuous pulse oximetry alarms off at night so you can sleep." |
| The NAP tells the nurse the patient's pulse oximetry is 85% on room air. What nursing action(s) should the nurse take? (Select all that apply.) | Reassess the patient’s pulse oximetry. Place the patient in the high-Fowler’s position. Assess the patient’s respiratory and cardiac status. |
| The nurse reads the following entry in a patient's health record. The patient has an order for SpO2 every 4 hours. Based on this information, what would be the nurse's best action? | Have the NAP use a different site, such as the ear lobe, to obtain the SpO2 reading. |
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alishalynne93
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