Nurse 202: Vital Signs Reading NCLEX Questions

Nurse 202: Vital Signs Reading NCLEX Questions

ScienceMedicineNursing Brett_Byrne Save Vital Signs Practice for NCLEX Ques...15 terms lizzyohmesPreview

Nurse 202: Health Assessment Read...

15 terms Brett_ByrnePreview

VITAL SIGNS

Teacher 61 terms Denise_Wheatley Preview

RLE - V

Teacher Lee A nurse assess an oral temperature for an adult patient. The patient's temperature is 37.5C (99.5F). What term would the nurse use to report this temperature 1) Febrile 2) Hypothermia 3) Hypertension 4) Afebrile --> Afebrile A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variation sin normal vital signs, which patients would the nurse document as having a normal vital sign? Select all the apply 1) A 4 month old infant whose temperature is 38.1C (100.5F) 2) A 3yrs old who blood pressure is 118/80 3) A 9yr old whose temperature is 39C (102.2F) 4) An adolescent whose pulse rate is 70bpm 5) An adult whose respiratory rate is 20bpm 6) A 72yr old whose pulse rate is 42bpm --> 1,4,5, and 6 A patient who is febrile may lose body heat through perspiration. The nurse recognizes that this is an example of what mechanism of heat loss?1) Evaporation 2) Convection 3) Radiation 4) Conduction --> Evaporation

The rectal temperature, a cover temperature, is considered to be one of of the most accurate routes. In which cases would taking a rectal temperature be contraindicated? Select all that apply 1) A newborn who has hypothermia 2) A child who has pneumonia 3) An older patient who is post myocardial infarction (heart attack) 4) A teenager who has leukemia 5) A patient receiving erythropoietin to replace red blood cells 6) An adult patient who is newly diagnosed with pancreatitis --> 1, 3, 4, 5 While taking an adult patient's pulse, a nurse finds the rate to be 140bpm. What should the nurse do next?1) Check the pulse again in 2 hours 2) Check the blood pressure 3) Record the information 4) Report the rate to the primary care provider --> 4 A patient complains of severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find the assessments? Select all that applies 1) An increase in the pulse rate 2) A decrease in body temperature 3) A decrease in blood pressure 4) An increase in respiratory depth 5) An increase in respiratory rate 6) An increase in body temperature --> 1, 5 The Nurses are taking apical-radial pulse and not a difference in pulse rate of 8bpm. The nurse would document this difference as which of the following?1) Pulse deficit 2) Pulse Amplitude 3) Ventricular rhythm 4) Heart Arrhythmia --> 1 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 1) Blood pressure decrease with age 2) Blood pressure is usually lowest on arising in the morning 3) Women usually have lower blood pressure than men until menopause 4) Blood pressure decrease after eating food 5) Blood pressure tends to be lower in the prone or supine position 6) Increased blood pressure is more prevalent in African American --> 2, 3, 5, and 6

A patient is having dyspnea. What would the nurse do first?1) Remove pillows from under the head 2) Elevate the head of the bed 3) Elevate the foot of the bed 4) Take the blood pressure --> 2 A student nurse is learning to assess blood pressure. what does the blood pressure measure?1) Flow of blood through the circulation 2) Force of blood against the arterial walls 3) Force of blood against venous walls 4) Flow of blood through the heart --> 2 Prioritization. Place the follow descriptions of the phases of Korotkoff sounds in order from Phase I to Phase V 1) Characterized by muffled or swishing sounds that may temporarily disappear; also known as the auscultatory gap 2) Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery.3) The last sound heart before a period of continuous silence, known as the second diastolic pressure 4) Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; known as the systolic pressure 5) Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; considered to be the first diastolic pressure --> 4, 1, 2, 5, 3 A patient has a blood pressure reading of 130/90mmHg when visiting a clinic. What would the nurse recommend to the patient?1) Follow-up measurements of blood pressure 2) Immediate treatment by a physician 3) No action, because the nurse considers this reading is due to anxiety 4) A change in dietary intake --> 1 A nurse is documenting a blood pressure of 120/80mmHg. The nurse interprets the 120 to represent 1) The rhythmic distention of the arterial walls as a result of increased pressure due to surges of blood with ventricular contraction 2) The lowest pressure present on arterial walls while the ventricles relax 3) The highest pressure present on arterial walls while the ventricles contract 4) The difference between the pressure on arterial walls with ventricular contraction and relaxation --> 3 It is important to have the appropriate cuff size when taking the blood pressure. What error may result from a cuff that is too large or too small?1) An incorrect reading 2) Injury to the patient 3) Prolonged pressure on the arm 4) Loss of Korotkoff sounds --> 1

A patient has intravenous fluids infusing in the right arm. When taking a blood pressure on this patient., what would the nurse do in this situation?1) Take the blood pressure in right arm 2) Take the blood pressure in the left arm 3) Use the smallest possible cuff 4) Report inability to take the blood pressure --> 2 Terms (15) Hide definitions