Chapter 25 Vital Signs nclex questions

Chapter 25 Vital Signs nclex questions ScienceMedicineNursing crystal_janicek Save Vital Signs Practice for NCLEX Ques...15 terms lizzyohmesPreview Vital signs NCLEX Questions 10 terms Tchatlin34Preview

Chapter 30: Vital Signs NCLEX Style ...

15 terms O-RahPreview Medica 60 terms Spi A nurse assesses an oral temperature for an adult patient and records that the patient is "afebrile." What would be the nurse's best response to this finding?a.Check the patient record for prescribed antipyretic medication.b.Report the finding to the primary care provider.c.Take the patient temperature using a different method.d.No action is necessary; this is a normal reading.d.Afebrile means without fever. Therefore the temperature assessed is within the normal range for an adult. The nurse does not need to perform any other actions based on this finding.

A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variations in normal vital signs, which patients would the nurse document as having a vital sign within normal limits? Select all that apply.

• A 4-month-old infant whose temperature is 38.1°C (100.5°F)
• A 3-year-old whose blood pressure is 118/80
• A 9-year-old whose temperature is 39°C (102.2°F)

d.An adolescent whose pulse rate is 70 beats/min

• An adult whose respiratory rate is 20 breaths/min

f.A 72-year-old whose pulse rate is 42 beats/min a, d, e, f.The normal temperature range for infants is 37.1° to 38.1°C (98.7° to 100.5°F). The normal pulse rate for an adolescent is 55 to 105. The normal respiratory rate for an adult is 12 to 20 breaths/min and the normal pulse for an older adult is 40 to 100 beats/min. The normal blood pressure for a toddler is 89/46 and the normal temperature for a child is 36.8° to 37.8°C (98.2° to 100°F; refer to Table 25-1).Upon assessment of a patient, the nurse determines that a patient is at risk of losing body heat through the process of convection. What would be the nurse's best response?

• Turn off the overhead fan in the patient's room.
• Remove the patient's ice pack.
• Reduce the temperature in the room.
• Increase the temperature in the room.

a.With convection, the heat is disseminated by motion between areas of unequal density, for example, the action of a fan blowing cool air over the body. Turning off the fan would reduce heat loss via convection. Removing the patient's ice pack is an intervention to prevent heat loss via conduction. Reducing the temperature in the room may decrease heat loss via perspiration (evaporation); increasing the temperature in the room might increase heat loss via evaporation.The rectal temperature, a core temperature, is considered to be one of the most accurate routes. In which cases would taking a rectal temperature be contraindicated? Select all that apply.

• A newborn who has hypothermia
• A child who has pneumonia
• An older adult who is post MI (heart attack)
• A teenager who has leukemia
• A patient receiving erythropoietin to replace red blood cells
• An adult patient who is newly diagnosed with pancreatitis

a, c, d, e.The rectal site should not be used in newborns, children with diarrhea, and in patients who have undergone rectal surgery. The insertion of the thermometer can slow the heart rate by stimulating the vagus nerve, thus patients post-MI should not have a rectal temperature taken. Assessing a rectal temperature is also contraindicated in patients who are neutropenic (have low white blood cell counts, such as in leukemia), in patients who have certain neurologic disorders, and in patients with low platelet counts.

While taking an adult patient's pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next?

• Check the pulse again in 2 hours.
• Check the blood pressure.
• Record the information.
• Report the rate to the primary care provider.

d.A rate of 140 beats/min in an adult is an abnormal pulse and should be reported to the primary care provider or the nurse in charge of the patient.A patient reports severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments? Select all that apply.

• An increase in the pulse rate
• A decrease in body temperature
• A decrease in blood pressure
• An increase in respiratory depth
• An increase in respiratory rate
• An increase in body temperature

a, e.The pulse often increases when a person is experiencing pain. Pain does not affect body temperature and may increase (not decrease) blood pressure. Acute pain may increase respiratory rate but decrease respiratory depth.Two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 beats/min. How will the nurse document this difference?

• Pulse deficit
• Pulse amplitude
• Ventricular rhythm
• Heart arrhythmia

a.The difference between the apical and radial pulse rate is called the pulse deficit.The nurse instructor is teaching student nurses about the factors that may affect a patient's blood pressure. Which statements accurately describe these factors? Select all that apply.

• Blood pressure decreases with age.

b.Blood pressure is usually lowest on arising in the morning.c.Women usually have lower blood pressure than men until menopause.d.Blood pressure decreases after eating food.e.Blood pressure tends to be lower in the prone or supine position.

• Increased blood pressure is more prevalent in African Americans.

b, c, e, f.Blood pressure increases with age due to a decreased elasticity of the arteries, increasing peripheral resistance. Blood pressure is usually lowest on arising in the morning. Women usually have lower blood pressure than men until menopause occurs. Blood pressure increases after eating food. Blood pressure tends to be lower in the prone or supine position. Increased blood pressure is more prevalent and severe in African American men and women.

A patient is experiencing dyspnea. What is the nurse's priority action?

• Remove pillows from under the head.
• Elevate the head of the bed.
• Elevate the foot of the bed.
• Take the blood pressure.

b.Elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm greater room for expansion and facilitating lung expansion.A nurse assesses orthostatic hypotension in an older adult. What would be an appropriate intervention for this patient?

• Encourage the patient to rise from a sitting position quickly to improve blood flow.
• Allow the patient to "dangle" for a few minutes prior to rising to a standing position.
• If the patient feels faint or dizzy, return the patient to bed and place in Fowler's position.
• Administer a beta-adrenergic blocker to increase blood pressure.

b.Allowing the patient to "dangle" on the edge of the bed prior to rising might prevent orthostatic hypotension. Arising and moving about slowly, especially after a period of bed rest, might also prevent orthostatic hypotension. If a patient becomes dizzy or feels faint, the nurse should return the patient to bed and place in a supine position, which restores blood flow to the brain. A beta blocker is given to decrease blood pressure for a patient with hypertension. There are several medications that raise blood pressure and are used to treat orthostatic hypotension.Prioritization: Place the following descriptions of the phases of Korotkoff sounds in order from phase I to phase V.

• Characterized by muffled or swishing sounds that may temporarily disappear; also known as the auscultatory gap
• Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery
• The last sound heard before a period of continuous silence, known as the second diastolic pressure
• Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; known as the systolic pressure
• Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; considered to be the first diastolic pressure

d, a, b, e, c.Phase I is characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; the first tapping sound is the systolic pressure. Phase II is characterized by muffled or swishing sounds, which may temporarily disappear, especially in hypertensive people; the disappearance of the sound during the latter part of phase I and during phase II is called the auscultatory gap. Phase III is characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery. Phase IV is characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; in adults, the onset of this phase is considered to be the first diastolic pressure.Phase V is the last sound heard before a period of continuous silence; the pressure at which the last sound is heard is the second diastolic pressure.A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient?

• Follow-up measurements of blood pressure
• Immediate treatment by a health care provider
• No action, because the nurse considers this reading is due to anxiety
• A change in dietary intake

a.A single blood pressure reading that is mildly elevated is not significant, but the measurement should be taken again over time to determine if hypertension is a problem. The nurse would recommend a return visit to the clinic for a recheck.