Chapter 15: Vital Signs My Nursing Test Banks

Chapter 15: Vital Signs

Potter: Essentials for Nursing Practice, 8th Edition

MULTIPLE CHOICE

1.The nursing student is obtaining the patients vital signs. The patient has gone to the clinic seeking help because she is having chest pain. Which of the following vital signs are most important to obtain?

a.

Temperature, pulse, respirations

b.

Temperature, pulse, respirations, oxygen saturation

c.

Temperature, pulse, respirations, blood pressure, oxygen saturation

d.

Temperature, pulse, respirations, blood pressure, oxygen saturation, pain

ANS: D

The cardinal vital signs are temperature, pulse, respiration, blood pressure, and oxygen saturation. A sixth vital sign, assessment of pain, is a standard of care in health care settings. Frequently pain and discomfort are the signs that lead a patient to seek health care. Therefore assessing a patients pain helps a nurse understand the patients clinical status and progress.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:270

OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Diagnosis

MSC: NCLEX: Management of Care

2.Upon a patients admission to the nursing unit, the registered nurse delegated to the nursing assistive personnel to take her vital signs. What is the registered nurses responsibility regarding delegating this task?

a.

This is inappropriate delegation; the nurse should always take the vital signs.

b.

Have the NAP repeat the measurement if vital signs appear abnormal.

c.

The nurse should review and interpret the vital sign measurements.

d.

This task has been delegated so the nurse is not responsible.

ANS: C

A nurse may delegate the measurement of selected vital signs (e.g., stable patients) to nursing assistive personnel. However, it is the nurses responsibility to review vital sign data, interpret their significance, and critically think through decisions about interventions. When vital signs appear abnormal, repeat the measurement. When caring for a patient, the nurse is responsible for vital sign monitoring.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:271

OBJ: Correctly delegate vital sign measurement to nursing assistive personnel.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

3.A 36-year-old African-American patient has been admitted to the hospital with diabetic ketoacidosis. The nurse who is admitting him notes that his blood pressure is 164/98. Which of the following should the nurse do next?

a.

Call the health care provider because the patients values differ from the standard range.

b.

Immediately call the health care provider and request antihypertensive medication.

c.

Ask the patient what his blood pressure normally measures for comparison.

d.

Do nothing; this is within a normal range for a patient with diabetic ketoacidosis.

ANS: C

Know the patients usual range of vital signs. A patients usual values sometimes differ from the standard range for that age or physical state. Use the patients usual values as a baseline for comparison with findings taken later. A single measurement does not adequately reflect a patients blood pressure. Blood pressure trends, not individual measurements, guide your nursing interventions. Hypertension is defined as systolic blood pressure (SBP) greater than 140 mm Hg, diastolic blood pressure (DBP) greater than 90 mm Hg

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:271 | 282

OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Diagnosis

MSC: NCLEX: Management of Care

4.A nurse is working on a medical unit in an acute care hospital. One of the patients she is caring for has a fever of 100.6 F. Which of the following is the best reason why the patient should not receive an antipyretic at this time?

a.

A temperature of 100.3 F is within the normal range.

b.

Shivering is a more effective way to dissipate heat energy.

c.

Corticosteroids are safer to use than antipyretics.

d.

Mild fevers are an important defense mechanism of the body.

ANS: D

Fever, or pyrexia, is an important defense mechanism. Therefore most health care providers will not treat an adults fever until it is higher than 39 C (102.2 F). For healthy young adults the average oral temperature is 37 C (98.6 F). In the elderly population, the average core temperature ranges from 35 to 36.1 C (95 to 97 F) because of decreased immunity. Shivering is counterproductive because of the heat produced by muscle activity. Although not used to treat fever, corticosteroids reduce heat production by interfering with the hypothalamic response. It is important to note that these drugs mask signs of infection by suppressing the immune system.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: 173 | 174 OBJ: Explain the principles and mechanisms of thermoregulation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

5.A nursing assistant asks the nurse why she needs to bathe a febrile patient. The best response is that this intervention increases heat loss through which of the following?

a.

Convection

b.

Radiation

c.

Conduction

d.

Evaporation

ANS: C

Heat loss occurs through conduction, which is the transfer of heat from one object to another with direct contact. When the warm skin touches a cooler object, heat transfers from the skin to the object until temperatures equalize. Convection is the transfer of heat away from the body by air movement. Fans promote heat loss through convection. Radiation is the transfer of heat between two objects without physical contact. Evaporation is the transfer of heat energy when a liquid is changed to a gas.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:273

OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

6.A 6-year-old was taken to the hospital after having a seizure at home. The patients mother tells the nurse that she has been ill for the past week and has had a fever with nausea and vomiting. The patients mother believes that the seizure was caused by a fever of 99.5 F, which the patient had during the course of her illness. What is the nurses best response?

a.

With a temperature that high, we can only hope that there is no permanent damage.

b.

Fevers in this range are part of the bodys natural defense system

c.

Febrile seizures are common in children Nancys age.

d.

The child will need antibiotics. Does she have any allergies?

ANS: B

Fever serves as an important defense mechanism. Therefore most health care providers will not treat an adults fever until it is greater than 39 C (102.2 F). A fever is usually not harmful if it stays below 39 C (102.2 F) in adults or 40 C (104 F) in children. Dehydration and febrile seizures occur during rising temperatures of children between 6 months and 3 years of age. Febrile seizures are unusual in children older than 5 years of age.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: 274 | 275 OBJ: Discuss physiological changes associated with fever.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

7.A 5-year-old child was admitted for a diagnosis of meningitis with a fever of 104.5 F and nuchal rigidity. She responded to antipyretics that were ordered. In addition, the patients mother was asked to help reduce the fever by limiting the number of blankets covering the patient. After interventions, the childs temperature is 100.5 F. The nurse recognized that the mother has an understanding of the patients condition when she states which of the following?

a.

The high temperature is useful in fighting bacteria and viruses as long as its not too high.

b.

You need to get her temperature down quickly. Shes so uncomfortable.

c.

Her fever is dropping because she is shivering. She must be cold.

d.

She probably picked up a bacteria. Thats what kids do. Thats why they get infected.

ANS: A

A fever is usually not harmful if it stays below 39 C (102.2 F) in adults or 40 C (104 F) in children. Increased temperature reduces the concentration of iron in the blood plasma, causing bacterial growth to slow. Fever also fights viral infections by stimulating interferon, the bodys natural virus-fighting substance. The goal is a safe rather than a low temperature. A true fever results from an alteration in the hypothalamic set point. To reach the new set point, the body produces and conserves heat. The patient experiences chills, shivers, and feels cold, even though the body temperature is rising. Most fevers in children are of viral origin, lasting only briefly, and have limited effects

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: 273 | 274 OBJ: Discuss physiological changes associated with fever.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

8.The young mother of an 8-month-old patient brought her daughter to the clinic after taking the little girls temperature rectally and obtaining a reading of 100.4 F. The mother was concerned that her daughter might be ill. Which of the following is the best response?

a.

Children usually run lower rather than higher temperatures when ill.

b.

Because of her age, it is probably a bacterial infection.

c.

Rectal temperatures are higher than temperatures obtained orally.

d.

When taking multiple temperatures, the sites should be rotated.

ANS: C

Depending on the site, temperatures will normally vary between 36 C (96.8 F) and 38 C (100.4 F). It is generally accepted that rectal temperatures are usually 0.5 C (0.9 F) higher than oral temperatures. Children have immature temperature control mechanisms, so temperatures sometimes rise rapidly. Most fevers in children are of viral origin, lasting only briefly, and have limited effects. Use the same site when repeated measurements are needed.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:273 | 274 | 275

OBJiscuss physiological changes associated with fever.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

9.A 6-year-old child was taken to the after-hours pediatric clinic with a fever and a rash. She had been seen by her pediatrician earlier in the day and had been given a prescription for an antibiotic. Later that evening she developed a fever and a rash on her abdomen. The nurse who assesses the child in the clinic suspected the symptoms are associated with which of the following?

a.

Dehydration

b.

An allergic response to the prescribed medication

c.

Febrile seizures

d.

Fever of unknown origin (FUO)

ANS: B

Sometimes a fever results from a hypersensitivity response to a medication, especially when the medication is taken for the first time. These fevers are often accompanied by other allergy symptoms such as rash, hives, or itching. Treatment involves stopping the medication responsible for the reaction. Dehydration and febrile seizures occur during rising temperatures in children between 6 months and 3 years of age. Febrile seizures are unusual in children greater than 5 years of age. The term fever of unknown origin (FUO) refers to a fever whose cause cannot be determined.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 273 | 274 OBJ: Discuss physiological changes associated with fever.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

10.A 56-year-old grandmother has been admitted to the hospital with a fever of 103.2 F after caring for her 5-year-old granddaughter who also developed a fever. The health care provider has ordered blood cultures, antibiotics, antipyretics, a clear liquid diet, and a chest radiograph. Which of the orders should the nurse do first?

a.

Administer antibiotic.

b.

Administer antipyretic.

c.

Draw blood cultures.

d.

Apply water cooled blankets.

ANS: C

Before antibiotic therapy, obtain blood cultures when ordered. Obtain blood specimens at the same time as a temperature spike, when the causative organism is most prevalent. Antipyretics are medications that reduce fever. It is important to note that these drugs mask signs of infection by suppressing the immune system. Physical cooling, including the use of water-cooled blankets, is appropriate when the patients own thermoregulation fails or in patients with neurological damage (e.g., spinal cord injury).

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:274

OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

11.A 26-year-old man was helping a friend replace a roof on his backyard shed after work on a hot July afternoon. His friend brought him to the hospital after the patient complained of severe muscle cramps and became confused. Which of the following should the admitting nurse do first when assessing the patient?

a.

Place the patient in a tub of iced water.

b.

Take the patients temperature.

c.

Remove fans to prevent premature chilling.

d.

Apply a hyperthermia blanket to lower temperature slowly.

ANS: B

Assessment includes taking the patients temperature. The nurse then uses that measurement to guide care of that patient. Placing the patient in a tub of iced water, removing fans to prevent premature chilling, and applying a hyperthermia blanket to lower temperature slowly are not assessments but interventions. Prolonged exposure to the sun or high environmental temperatures overwhelms the bodys heat loss mechanisms. These conditions cause heat stroke, a dangerous heat emergency, defined as a body temperature of 40 C (104 F) or higher. Signs and symptoms of heat stroke include giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and even incontinence. The most important sign of heat stroke is hot, dry skin. A heat stroke can be fatal. Cool the person quickly. Ways to cool include placing wet towels over the skin, placing the person in a tub of tepid (not iced) water or into a tepid shower, spraying the person with cool water from a garden hose, and placing oscillating fans in the room. Emergency medical treatment includes applying hypothermia blankets, giving intravenous (IV) fluids, and irrigating the stomach and lower bowel with cool solutions.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:275

OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

12.A 15-year-old girl was taken to a small rural hospital by her mother. The family had been camping, and it had become very cold during the night. The mother had difficulty waking her daughter in the morning, and she was shivering uncontrollably. The patient is still unconscious. Which of the following interventions should the admitting nurse do first?

a.

Have the patient drink hot liquids.

b.

Wrap the girl in warm blankets.

c.

Uncover the head to allow the head to warm.

d.

Place heating pads on the bottom of the feet.

ANS: B

The priority treatment for hypothermia is to prevent a further decrease in body temperature. Removing wet clothes, replacing them with dry ones, and wrapping the patient in blankets are strategic nursing interventions. In emergencies, when a patient is not in a health care setting, place the patient under blankets next to a warm person. A conscious patient benefits from drinking hot liquids such as soup, while avoiding alcohol and caffeinated fluids. An unconscious patient should not be given any fluids. Keeping the head covered, increasing room temperature, or placing heating pads next to areas of the body (head and neck) that lose heat the quickest helps. The severity of the hypothermia dictates the treatments performed.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:275

OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

13.A senior nursing student is doing her community clinical rotation. When visiting a young family to whom she has been assigned, the mother of a 3-year-old child states that her daughter does not feel well. The nursing student feels her skin, which is warm. She asks the mother if she has taken her temperature to which the mother replies, Yes, I used the same thermometer that was my great-grandmothers; it has been used by my family for years. Her oral temperature was 102.3 F. The most important action for the nursing student to perform is to do which of the following?

a.

Teach that temporal artery thermometers are more accurate than others.

b.

Tell the mother that hospitals still use mercury thermometers.

c.

Ask to see the thermometer.

d.

Recommend a chemical thermometer for greater accuracy.

ANS: C

Inspect the thermometer to make sure that it is mercury. The mercury-in-glass thermometers are obsolete in the health care setting because of the environmental hazards of mercury. However, some patients still use mercury-in-glass thermometers at home. If you find a mercury-in-glass thermometer in the home, teach the patient about safer temperature devices and encourage him or her to take the thermometer to a neighborhood hazardous disposal location. There is a growing bed of research supporting the discontinuation of temporal artery thermometers in the clinical setting because of reported inaccurate readings. Chemical thermometers are useful for screening temperatures, especially in infants and young children. You need to confirm readings with electronic thermometers when treatment decisions need to be made.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:277 | 278

OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Diagnosis

MSC: NCLEX: Management of Care

14.A 38-year-old postoperative patient is suddenly unresponsive but is still breathing. The nurse will use which site to assess the patients pulse?

a.

Apical artery

b.

Radial artery

c.

Carotid artery

d.

Brachial artery

ANS: C

When a patients condition suddenly deteriorates, use the carotid site to quickly locate a pulse. Assess any accessible artery for pulse rate; however, use the radial or carotid arteries most often because they are easy to locate and palpate. The radial and apical locations are the most common sites for pulse rate assessment. Use the radial or carotid pulse when teaching patients how to monitor their own heart rates. The brachial artery is not usually a primary site for checking pulse.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:279

OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Implementation

MSC: NCLEX: Management of Care

15.A man has been admitted to the hospital with lethargy. He was placed on the telemetry unit and is being continuously monitored. He is due to receive his dose of digoxin. The nurse knows that the medication is to be held if the pulse rate is less than 60 beats per minute. The nurse will use which site to assess the patients pulse?

a.

Apical

b.

Radial

c.

Brachial

d.

Carotid

ANS: A

When a patient takes a medication that affects the heart rate, the apical pulse provides a more accurate assessment of heart rate. The radial pulse is the most common site used to assess character of pulse peripherally and assesses the status of circulation to the hand. The brachial site is used to assess upper extremity blood pressure; used during infant CPR.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:279 | 280

OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Implementation

MSC: NCLEX: Management of Care

16.The nurse is having difficulty hearing his patients apical pulse with his stethoscope. Which of the following would best maximize the sound quality of what is heard through the stethoscope?

a.

Positioning the diaphragm very lightly on the area to which he is listening

b.

Placing the stethoscope chest piece directly on the patients skin

c.

Make sure that the earpieces fit loosely in the ear canals

d.

Use a stethoscope with the longest tubing available

ANS: B

Always place the stethoscope directly on the skin because clothing obscures the sound. Position the diaphragm to make a tight seal against the patients skin. Exert enough pressure on the diaphragm to leave a temporary red ring on the patients skin when the diaphragm is removed. Make sure the plastic or rubber earpieces fit snugly in the ear canal and that the binaurals are angled and strong enough so the earpieces stay firmly in place without causing discomfort. The polyvinyl tubing is flexible and 30 to 45 cm (12 to 18 inches) in length. Longer tubing decreases sound wave transmission.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:279

OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Implementation

MSC: NCLEX: Management of Care

17.A nurse notices that a patient has an irregular pulse. The nurse should do which of the following?

a.

Count the number of lub-dubs occurring in 30 seconds.

b.

Assess how often the dysrhythmia is occurring.

c.

Assess the radial pulse for a pulse deficit.

d.

Chart the abnormally low heart rate as tachycardia.

ANS: B

A regular interval interrupted by an early beat, late beat, or a missed beat indicates an abnormal rhythm or dysrhythmia. A dysrhythmia alters cardiac function, particularly if it occurs repetitively. If your patient has a dysrhythmia you need to assess how often it is occurring. After properly positioning the bell or the diaphragm of the stethoscope on the chest, try to identify the first and second heart sounds (S1 and S2). At normal slow rates, S1 is low pitched and dull, sounding like a lub. S2 is a higher pitched and shorter sound and creates the sound dub. Count the number of lub-dubs occurring in 1 minute. An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. To assess a pulse deficit, ask another nurse to assess the radial pulse rate while you assess the apical rate. Tachycardia is an abnormally elevated heart rate, more than 100 beats per minute in adults. Bradycardia is a slow rate, less than 60 beats per minute in adults.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 279 | 281 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

18.The nurse is taking the pulse of an adult patient and finds that the patients heart rate is 48. He knows that this is considered:

a.

tachycardia.

b.

bradycardia.

c.

a normal heart rate for an infant.

d.

a normal heart rate for an adult.

ANS: B

Tachycardia is an abnormally elevated heart rate, greater than 100 beats per minute in adults. Bradycardia is a slow rate, less than 60 beats per minute in adults; 120 to 160 beats per minute is a normal heart rate for an infant. The normal heart rate for an adult is 60 to 100 beats per minute.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 281 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

19.A 45-year-old mother of three children is at the doctors office and her blood pressure 152/92. This is the first time that she has ever shown an elevated reading. She is concerned that she has hypertension. The nurses best response would be:

a.

A single reading may not mean anything. We will take it again at your next visit.

b.

It looks like you have high blood pressure now. Well check it again in 3 months.

c.

Fortunately, hypertension isnt related to other diseases and is easily treated.

d.

You may have hypertension, but there is little else that can be done except medicines.

ANS: A

The diagnosis of hypertension in adults is made on the average of two or more readings taken at each of two or more visits after an initial screening. One blood pressure recording revealing a high SBP or DBP does not qualify as a diagnosis of hypertension. However, if you assess a high reading (for example, 150/90 mm Hg), encourage the patient to return for another checkup within 2 months. Hypertension is a known risk factor for cardiovascular morbidity and mortality. Obesity, cigarette smoking, excessive alcohol intake, elevated blood cholesterol, and continued exposure to stress are also linked to hypertension. Controlling these factors may reduce blood pressure.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

20.The patient has just returned to the postsurgical unit after undergoing surgery to remove a lung tumor. During one of the postoperative vital sign checks, the nurse notes that the patients systolic blood pressure had dropped by 30 points. In addition to the drop in systolic blood pressure, the patients skin is pale and clammy. The nurse should do which of the following?

a.

Report the findings to the health care provider immediately.

b.

Understand that the patients arteries are constricting, causing pallor.

c.

Wait to see if the blood pressure increases in 30 minutes.

d.

Nothing; this is a normal occurrence following a thoracic surgery.

ANS: A

Signs and symptoms associated with hypotension include pallor, skin mottling, clamminess, confusion, dizziness, chest pain, increased heart rate, and decreased urine output. Hypotension is usually life threatening and needs to be reported immediately to the patients health care provider. Doing nothing can lead to the patients death. Hypotension occurs when arteries dilate; the peripheral vascular resistance decreases, the circulating blood volume decreases, or the heart fails to provide adequate cardiac output.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

21.A patient is obese. At the bedside is a standard-size blood pressure cuff. The nurse realizes that the use of this cuff will provide which of the following?

a.

Accurate readings as long as it is 20% of the circumference of the midpoint of the limb.

b.

Indistinct readings if the bladder encircles 80% of the adults arm.

c.

A falsely low reading if the cuff is wrapped too loosely around the arm.

d.

Inaccurate readings and needs to be replaced with a larger cuff.

ANS: D

When the incorrect size cuff is used, it is possible to obtain a false reading. The size selected is proportional to the circumference of the limb being assessed. Ideally select a cuff that is 40% of the circumference (or 20% wider than the diameter) of the midpoint of the limb being used to be obtain measurements. The bladder, enclosed by the cuff, encircles at least 80% of the arm of an adult and the entire arm of a child. A cuff that is wrapped too loosely or unevenly will yield false-high readings.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: 285 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

22.A woman has been hospitalized with pneumonia. She has had oxygen on via nasal cannula at a rate of 2 L per minute. A nursing student is taking her vital signs. She notes that her respirations are labored and the rate is 32 respirations per minute. The nursing student recognizes this as which of the following?

a.

Normal.

b.

Tachypnea.

c.

Bradypnea.

d.

Apnea.

ANS: B

Tachypnea is a respiratory rate greater than 20, and a rate less than 12 per minute or lower than acceptable limits is bradypnea. Apnea is the lack of respiratory movements. A normal respiratory rate for an adult is 12 to 20 breaths per minute.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: 289 | 290 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

23.The patients temperature has reached 103.4 F. The nurse prepares to draw a blood culture before giving the patient an antipyretic medication. What is the best reason to draw a blood culture before giving an antipyretic medication?

a.

The causative organism is most prevalent during a spike in temperature.

b.

Elevated temperatures slow metabolic rate and improve blood oxygenation.

c.

Increased blood flow leads to moist mucous membranes making blood draws easier.

d.

Venous distention is greater because of fluid retention secondary to hyperthermia.

ANS: A

Obtain blood specimens at the same time as a temperature spike, when the causative organism is most prevalent. Satisfy requirements for increased metabolic rate. Provide supplemental oxygen therapy as ordered to improve oxygen delivery to body cells. Encourage oral hygiene because oral mucous membranes dry easily from dehydration and have increased potential for bacterial invasion. Replace fluids lost through insensible water loss and sweating.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:274

OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Diagnosis

MSC: NCLEX: Management of Care

24.A nurse is ready to take the temperature of an adult patient rectally. The nurses realizes that rectal temperatures are which of the following?

a.

Preferable to oral temperatures

b.

Safer than oral temperatures if the patient has neutropenia

c.

The best way to obtain temperatures in newborns

d.

That readings can be influenced by impacted stool

ANS: D

Rectal temperature readings are sometimes influenced by impacted stool. A rectal temperature is argued to be more reliable than alternative sites when oral temperature is difficult or impossible to obtain, but are not used for patients with diarrhea or those who have had rectal surgery, rectal disorders, bleeding tendencies, or neutropenia, and are not used for routine vital signs in newborns.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: 276 | 277 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

25.A nurse delegates the task of obtaining vital signs to a nursing assistant. The nurse reminds the nursing assistant that blood pressure:

a.

will be lower if the cuff is too wide.

b.

is not affected by cuff length.

c.

should be taken slowly for more accuracy.

d.

should be taken with the arm above heart level.

ANS: A

A bladder or cuff that is too wide will yield false-low readings. A cuff that is wrapped too loosely or unevenly will yield false-high readings. Deflating a cuff too slowly will produce false-high diastolic readings. The arm should be at the level of the heart. Having the arm above heart level will produce a false-low reading.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 285 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

26.To determine the patients actual temperature, the nurse is aware that:

a.

the patients core temperature is not affected by environmental temperature

b.

surface temperatures are the most stable

c.

circadian rhythms keep the body temperature stable throughout the day.

d.

gender and age have no effect on body temperature.

ANS: A

Despite environmental temperature extremes and physical activity, temperature-control mechanisms of human beings keep the bodys core temperature, or temperature of deep tissues, relatively constant during sleep, exposure to cold, and strenuous exercise. However, surface temperature fluctuates, depending on blood flow to the skin and the amount of heat lost to the external environment. Time of day also affects body temperature with the lowest temperature at 6 AM and the highest body temperature at 4 PM in healthy people. The circadian rhythm alters body temperature about 0.5 C (0.9 F) throughout each day. An acceptable temperature range for adults depends on age, gender, range of physical activity, and state of health.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 272 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

27.One of the ways the body increases heat production is through:

a.

convection.

b.

radiation.

c.

shivering.

d.

evaporation.

ANS: C

Shivering is an involuntary body response to temperature differences in the body. Shivering can increase heat production 4 to 5 times greater than normal. Radiation is the transfer of heat between two objects without physical contact. Heat radiates from the skin to any surrounding cooler object. Up to 85% of the human bodys surface area radiates heat to the environment. A small amount of heat loss occurs through conduction, which is the transfer of heat from one object to another with direct contact. When the warm skin touches a cooler object, heat transfers from the skin to the object until the temperatures equalize. Convection is the transfer of heat away from the body by air movement. Fans promote heat loss through convection. The rate of heat loss increases when moist skin comes into contact with slightly moving air. Through evaporation, heat energy transfers from a liquid to a gas state. The body continuously loses heat by evaporation; approximately 600 to 900 mL of water evaporates daily from the skin and lungs.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 272 | 273 OBJ: Explain the principles and mechanisms of thermoregulation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

28.When the fever breaks, the temperature returns to an acceptable range and the patient becomes:

a.

febrile.

b.

afebrile.

c.

fever of unknown origin (FUO).

d.

pyrexic.

ANS: B

When the fever breaks, the temperature returns to an acceptable range and the patient becomes afebrile (a- means not or without, so afebrile means without fever). A true fever results from an alteration in the hypothalamic set point. Substances that trigger the immune system, such as bacteria or viruses, stimulate the release of hormones in an effort to promote the bodys defense against infection. These hormones also trigger the hypothalamus to raise the set point, inducing a febrile episode. Febrile means the patient does have a fever. The term fever of unknown origin (FUO) refers to a fever whose cause cannot be determined. The condition of 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.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 273 | 274 OBJ: Explain the principles and mechanisms of thermoregulation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

29.What term refers to a fever whose cause cannot be determined?

a.

Febrile

b.

Afebrile

c.

Fever of unknown origin (FUO)

d.

Pyrexic

ANS: C

The term fever of unknown origin (FUO) refers to a fever whose cause cannot be determined. When the fever breaks, the temperature returns to an acceptable range and the patient becomes afebrile (a- means not or without, so afebrile means without fever). A true fever results from an alteration in the hypothalamic set point. Substances that trigger the immune system, such as bacteria or viruses, stimulate the release of hormones in an effort to promote the bodys defense against infection. These hormones also trigger the hypothalamus to raise the set point, inducing a febrile episode. The condition of 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. Febrile means the patient does have a fever.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 273 | 274 OBJ: Explain the principles and mechanisms of thermoregulation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

30.Medications that reduce fever by interfering with the hypothalamic response include:

a.

salicylates.

b.

acetaminophen.

c.

ibuprofen.

d.

corticosteroids.

ANS: D

Antipyretics are medications that reduce fever. Nonsteroidal drugs such as acetaminophen, salicylates, indomethacin, ibuprofen, and ketorolac reduce fever by increasing heat loss. Although not used to treat fever, corticosteroids reduce heat production by interfering with the hypothalamic response.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:274 | 275

OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

31.An elevated body temperature related to the bodys inability to promote heat loss or reduce heat production is known as:

a.

hyperthermia.

b.

heat stroke.

c.

hypothermia.

d.

fever of unknown origin.

ANS: A

An elevated body temperature related to the bodys inability to promote heat loss or reduce heat production is hyperthermia (hyper- means excessive; therm means heat). Prolonged exposure to the sun or high environmental temperatures overwhelms the bodys heat loss mechanisms. Heat also depresses hypothalamic function. These conditions cause heat stroke, a dangerous heat emergency, defined as a body temperature of 40.2 C (104.4 F) or more. Heat loss during prolonged exposure to cold overwhelms the bodys ability to produce heat, causing hypothermia. The term fever of unknown origin (FUO) refers to a fever whose cause cannot be determined.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 274 | 275 OBJ: Discuss physiological changes associated with fever.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

32.A regular interval interrupted by an early beat, late beat, or missed beat indicates an abnormal rhythm or:

a.

dysrhythmia.

b.

tachycardia.

c.

bradycardia.

d.

a pulse deficit.

ANS: A

A regular interval interrupted by an early beat, late beat, or a missed beat indicates an abnormal rhythm (not rate) or dysrhythmia. Pulse rate assessment often reveals variations in heart rate. Two common abnormalities in heart rate are tachycardia and bradycardia. Tachycardia is an abnormally elevated heart rate, more than 100 beats per minute in adults. Bradycardia is a slow rate, less than 60 beats per minute in adults. An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 280 | 281 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

33.An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates:

a.

dysrhythmia.

b.

tachycardia.

c.

bradycardia.

d.

a pulse deficit.

ANS: D

An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. A regular interval interrupted by an early beat, late beat, or a missed beat indicates an abnormal rhythm (not rate) or dysrhythmia. Pulse rate assessment often reveals variations in heart rate. Two common abnormalities in heart rate are tachycardia and bradycardia. Tachycardia is an abnormally elevated heart rate, more than 100 beats per minute in adults. Bradycardia is a slow rate, less than 60 beats per minute in adults.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 280 | 281 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

34.Under high pressure, the left ventricle ejects blood into the aorta; the peak pressure is known as:

a.

diastolic pressure.

b.

pulse pressure.

c.

hypertension.

d.

systolic pressure.

ANS: D

Under high pressure, the left ventricle ejects blood into the aorta; the peak pressure is known as systolic pressure. When the ventricles relax, the blood remaining in the arteries exerts a minimum or diastolic pressure. The difference between systolic and diastolic pressure is the pulse pressure. The most common alteration in blood pressure is hypertension, an often asymptomatic disorder characterized by persistently elevated blood pressure (BP). Hypertension is defined as systolic blood pressure (SBP) greater than 140 mm Hg, diastolic blood pressure (DBP) greater than 90 mm Hg.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

35.When the ventricles relax, the blood remaining in the arteries exerts a minimum or:

a.

diastolic pressure.

b.

pulse pressure.

c.

hypertension.

d.

systolic pressure.

ANS: A

When the ventricles relax, the blood remaining in the arteries exerts a minimum or diastolic pressure. Under high pressure, the left ventricle ejects blood into the aorta; the peak pressure is known as systolic pressure. The difference between systolic and diastolic pressure is the pulse pressure. The most common alteration in blood pressure is hypertension, an often asymptomatic disorder characterized by persistently elevated blood pressure (BP). Hypertension is defined as systolic blood pressure (SBP) greater than 140 mm Hg, diastolic blood pressure (DBP) greater than 90 mm Hg.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

36.What is the difference between systolic and diastolic pressure?

a.

Diastolic pressure

b.

Pulse pressure

c.

Hypertension

d.

Systolic pressure

ANS: B

The difference between systolic and diastolic pressure is the pulse pressure. For a blood pressure (BP) of 120/80 mm Hg, the pulse pressure is 40. When the ventricles relax, the blood remaining in the arteries exerts a minimum or diastolic pressure. Under high pressure, the left ventricle ejects blood into the aorta; the peak pressure is known as systolic pressure. The most common alteration in blood pressure is hypertension, an often asymptomatic disorder characterized by persistently elevated BP. Hypertension is defined as systolic blood pressure (SBP) greater than 140 mm Hg, diastolic blood pressure (DBP) greater than 90 mm Hg.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

37.A systolic blood pressure (BP) less than 90 mm Hg or a diastolic BP less than 60 mm Hg is known as:

a.

hypertension.

b.

hypotension.

c.

orthostatic hypotension.

d.

postural hypotension.

ANS: B

Hypotension is a systolic blood pressure (SBP) less than 90 mm Hg or a diastolic blood pressure (DBP) less than 60 mm Hg. The most common alteration in blood pressure is hypertension, an often asymptomatic disorder characterized by persistently elevated blood pressure. Hypertension is defined as SBP greater than 140 mm Hg, DBP greater than 90 mm Hg. Orthostatic hypotension, also referred to as postural hypotension, is a reduction of SBP of at least 20 mm Hg or reduction of DBP of at least 10 mm Hg within 3 minutes of quiet standing. It occurs when patients with normal blood pressure experience a drop in blood pressure upon rising to an upright position and is associated with symptoms of lightheadedness or dizziness.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

38.When patients with normal blood pressure experience a drop in blood pressure upon rising to an upright position and have symptoms of light-headedness or dizziness, the condition is known as:

a.

hypertension.

b.

hypotension.

c.

orthostatic hypotension.

d.

the pulse pressure.

ANS: C

Orthostatic hypotension, also referred to as postural hypotension, is a reduction of systolic blood pressure (SBP) of at least 20 mm Hg or reduction of diastolic blood pressure (DBP) of at least 10 mm Hg within 3 minutes of quiet standing. It occurs when patients with normal blood pressure experience a drop in blood pressure upon rising to an upright position and it is associated with symptoms of lightheadedness or dizziness. Hypotension is a SBP less than 90 mm Hg or a DBP less than 60 mm Hg. The most common alteration in blood pressure is hypertension, an often asymptomatic disorder characterized by persistently elevated BP. Hypertension is defined as SBP greater than 140 mm Hg, DBP greater than 90 mm Hg. The difference between systolic and diastolic pressure is the pulse pressure. For a blood pressure of 120/80 mm Hg, the pulse pressure is 40.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

39.The mechanical movement of gases into and out of the lungs is known as:

a.

respiration.

b.

ventilation.

c.

perfusion.

d.

eupnea.

ANS: B

Respiration is the mechanism the body uses to exchange gases between the atmosphere, blood, and cells. Respiration involves three processes: ventilation (the mechanical movement of gases into and out of the lungs), diffusion (the movement of oxygen [O2] and carbon dioxide [CO2] between the alveoli and the red blood cells), and perfusion (the distribution of red blood cells to and from the pulmonary capillaries). The normal rate and depth of ventilation is known as eupnea.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 288 | 289 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

40.The movement of oxygen and carbon dioxide between the alveoli and the red blood cells is known as:

a.

diffusion.

b.

perfusion.

c.

respiration.

d.

eupnea.

ANS: A

Respiration is the mechanism the body uses to exchange gases between the atmosphere, blood, and cells. Respiration involves three processes: ventilation (the mechanical movement of gases into and out of the lungs), diffusion (the movement of oxygen [O2] and carbon dioxide [CO2] between the alveoli and the red blood cells), and perfusion (the distribution of red blood cells to and from the pulmonary capillaries). The normal rate and depth of ventilation is known as eupnea.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 288 | 289 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

41.What term refers to the distribution of red blood cells to and from the pulmonary capillaries?

a.

Diffusion

b.

Perfusion

c.

Respiration

d.

Eupnea

ANS: B

Respiration is the mechanism the body uses to exchange gases between the atmosphere, blood, and cells. Respiration involves three processes: ventilation (the mechanical movement of gases into and out of the lungs), diffusion (the movement of oxygen [O2] and carbon dioxide [CO2] between the alveoli and the red blood cells), and perfusion (the distribution of red blood cells to and from the pulmonary capillaries).  The normal rate and depth of ventilation is known as eupnea.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 288 | 289 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

MULTIPLE RESPONSE

1.The bodys tissues and cells function efficiently within a relatively narrow temperature range, from 36 to 38 C (96.8 to 100.4 F). Factors that cause fluctuations in body temperature include which of the following? (Select all that apply.)

a.

The bodys core temperature

b.

Age

c.

Time of day

d.

Circadian rhythm

e.

physical activity

ANS: B, C, D, E

The bodys tissues and cells function efficiently within a relatively narrow temperature range, from 36 to 38 C (96.8 to 100.4 F), but no single temperature is normal for all people. For healthy young adults the average oral temperature is 37 C (98.6 F). In the elderly population, the average core temperature ranges from 35 to 36.1 C (95.0 to 97.0 F) because of decreased immunity. Time of day also affects body temperature with the lowest temperature at 6 AM and the highest body temperature at 4 PM in healthy people. The circadian rhythm alters body temperature about 0.5 C (0.9 F) throughout each day. An acceptable temperature range for adults depends on age, gender, range of physical activity, and state of health. Despite environmental temperature extremes and physical activity, temperature-control mechanisms of human beings keep the bodys core temperature, or temperature of deep tissues, relatively constant during sleep, during exposure to cold, and during strenuous exercise.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: 272 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

2.A registered nurse is caring for a patient who was admitted to the hospital after being involved in a motor vehicle accident. The patient has undergone two surgeries and now has a health careacquired infection. Multiple medications were ordered. Which of the following would be appropriate for the nurse to administer to reduce the fever without masking signs of infection? (Select all that apply.)

a.

Acetaminophen

b.

Corticosteroid

c.

Ibuprofen

d.

Indomethacin

e.

Salicylates

ANS: A, C, D, E

Nonsteroidal drugs such as acetaminophen, salicylates, indomethacin, ibuprofen, and ketorolac reduce fever by increasing heat loss. Health care providers order antipyretics if a fever is greater than 39 C (102.2 F). Although not used to treat fever, corticosteroids reduce heat production by interfering with the hypothalamic response. It is important to note that these drugs mask signs of infection by suppressing the immune system.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:274 | 275

OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

3.Any injury to the hypothalamus impairs heat loss mechanisms. Educate patients at risk for hyperthermia to do which of the following? (Select all that apply.)

a.

Avoid strenuous exercise in hot, humid weather.

b.

Avoid exercising in areas with poor ventilation.

c.

Drink clear fluids before and after exercising, not during.

d.

Wear light, loose-fitting clothing.

e.

Do not visit hot climates.

ANS: A, B, D

Any injury to the hypothalamus impairs heat loss mechanisms. Educate patients at risk for hyperthermia to do the following: avoid strenuous exercise in hot, humid weather; avoid exercising in areas with poor ventilation; drink fluids such as water and clear fruit juices before, during, and after exercise; wear light, loose-fitting, light-colored clothing; wear a protective covering over the head when outdoors; and expose themselves to hot climates gradually.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:275

OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

4.Core temperatures are obtained via which of the following? (Select all that apply.)

a.

Axillae

b.

Rectal

c.

Oral

d.

Pulmonary artery

e.

Urinary bladder

ANS: D, E

The core temperatures of the pulmonary artery, esophagus, and urinary bladder are often used in critical care settings and require continuous invasive monitoring devices placed in arteries or internal orifices. The most common sites for intermittent temperature measurements are surface sites, such as the tympanic membrane, temporal artery, mouth, rectum, and axilla.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:275

OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Assessment

MSC: NCLEX: Management of Care

5.Blood pressure depends on the interrelationships of which of the following? (Select all that apply.)

a.

Cardiac output

b.

Peripheral vascular resistance

c.

Blood volume

d.

Blood viscosity

e.

Pulse pressure

ANS: A, B, C, D

Blood pressure depends on the interrelationships of cardiac output, peripheral vascular resistance, blood volume, blood viscosity, and artery elasticity. The difference between systolic and diastolic pressure is the pulse pressure. For a BP of 120/80 mm Hg, the pulse pressure is 40.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

6.The nurse has assessed the need to check the patient for orthostatic hypotension. Conditions that would cause the nurse to be concerned about this would be which of the following? (Select all that apply.)

a.

Dehydration

b.

Obesity

c.

Recent blood loss

d.

Cigarette smoking

e.

Prolonged bed rest

ANS: A, C, E

Fluid volume deficit from decreased blood volume, dehydration, or recent blood loss, as well as prolonged bed rest, anemia, or antihypertensive medications, place patients at risk for orthostatic hypotension. Obesity, cigarette smoking, excessive alcohol intake, elevated blood cholesterol, and continued exposure to stress are also linked to hypertension.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

7.While being tested for orthostatic hypotension, the patient stands up and begins to feel light-headed and feels faint. The nurse should do which of the following? (Select all that apply.)

a.

Have the patient lie down.

b.

Report findings to the health care provider.

c.

Have the nursing assistive personnel (NAP) check orthostatic blood pressure.

d.

Instruct the patient not to get out of bed without assistance.

e.

Take the BP in each arm and use the arm with the lowest systolic reading.

ANS: A, B, D

Orthostatic hypotension occurs when patients with normal blood pressure experience a drop in blood pressure upon rising to an upright position and is associated with symptoms of lightheadedness or dizziness. If orthostatic signs or symptoms such as dizziness, weakness, lightheadedness, feeling faint, or sudden pallor occur, stop BP measurement and return patient to a supine position. Report the findings of orthostatic hypotension or orthostatic signs or symptoms to the nurse in charge or the health care provider. Instruct the patient to ask for assistance when getting out of bed if orthostatic hypotension is present or orthostatic signs or symptoms occur. The skill of measuring orthostatic blood pressure (BP) cannot be delegated to nursing assistive personnel (NAP) in an unstable patient. With the patient supine, take a BP reading in each arm. Select the arm with the highest systolic reading for subsequent measurements.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:284

OBJ: Correctly delegate vital sign measurement to nursing assistive personnel.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

8.The nurse is obtaining an oxygen saturation reading from a female patient who was brought in after collapsing at a party. Factors that may lead to inaccurate SpO2 readings include which of the following? (Select all that apply.)

a.

Using a pulsatile area to attach the probe

b.

The patient wearing fingernail polish

c.

Measuring the level intermittently

d.

The patient being anemic

e.

Measuring the level continuously

ANS: B, D

A vascular, pulsatile area (e.g., fingertip or earlobe) is needed to detect the degree of change in the transmitted light. Factors that affect light transmission (e.g., sensor movement, fingernail polish) or peripheral arterial pulsations (e.g., hypotension, anemia) also affect the measurement of SpO2. An awareness of these factors allows for accurate interpretation of abnormal SpO2 measurements. Measuring SpO2 can be conducted intermittently or continuously to assess ongoing therapies.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 290 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

9.Two common abnormalities in heart rate are:

a.

dysrhythmia.

b.

apical pulse.

c.

tachycardia.

d.

bradycardia.

e.

pulse deficit.

ANS: C, D

Pulse rate assessment often reveals variations in heart rate. Two common abnormalities in heart rate are tachycardia and bradycardia. Tachycardia is an abnormally elevated heart rate, more than 100 beats per minute in adults. Bradycardia is a slow rate, less than 60 beats per minute in adults. A regular interval interrupted by an early beat, late beat, or a missed beat indicates an abnormal rhythm (not rate) or dysrhythmia. The apical pulse is located on the anterior chest wall at approximately the fourth to fifth intercostal space just medial to the left midclavicular line. An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 280 | 281 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

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