Vital signs NCLEX Questions

Vital signs NCLEX Questions ScienceMedicineNursing Tchatlin34 Save Vital Signs Practice for NCLEX Ques...15 terms lizzyohmesPreview Vital signs NCLEX questions 12 terms ajleeAnnPreview Vital Signs NCLEX Questions 28 terms arianna_leigh8 Preview Vital Si Teacher Dea The nurse assesses the following vital signs in a 78-year-old man: T 36.6°C, temporal; P 72 bpm, regular, 2 ; R 18 breaths/minute, regular, no use of accessory muscles; BP 142/92 mm Hg. Which of the findings is abnormal?

• Pulse
• BP
• Respirations
• Temperature
• BP. Rationale: In older adults, both the SBP and DBP increase due to increased stiffness of arterial walls. This finding is outside of the normal

range. Temperature in the older adult tends to be at the lower range of normal.What are the four characteristics of respirations?Rate, rhythm, depth, and quality The patient's radial pulse is weak and thready. The next action of the nurse is to A. transfer the patient to a critical care unit. B. notify the primary care provider.

• compare findings to previous findings and opposite extremity.
• assess vital signs every 15 minutes.
• compare findings to previous findings and opposite extremity . Rationale: The popliteal pulse is often difficult to palpate. Comparing to

previous findings and to the opposite extremity can assist to determine if any acute changes have occurred. Always assess before calling physician. Gain as much information as possible.

Which of the following patients should not have a temperature measured orally?

• An 84-year-old woman with diarrhea
• A 30-year-old patient with an earache
• A 45-year-old man with chest pain
• A 62-year-old woman who has had oral surgery
• A 62-year-old woman who has had oral surgery. Rationale: Oral temperature measurement is contraindicated in patients who have altered

mental status, those who are mouth breathers, those who have had recent oral intake or who have recently smoked, and those who have recently undergone oral surgery, or intubation. Any oral issues don't do an oral temp.The nurse notes an irregular radial pulse in a patient. Further evaluation includes assessing

• for a pulse deficit.
• the carotid pulse.
• for diminished peripheral circulation.
• the brachial pulse.
• for a pulse deficit. Rationale: Assessing for a pulse deficit provides an indirect evaluation of the heart's ability to eject enough blood to

produce a peripheral pulse. When a pulse deficit is present, the radial pulse is less than the apical pulse. Peripheral pulse-apical pulse=pulse deficit Which actions will result in an inaccurate BP reading? Select all that apply.

• Obtaining a BP immediately after the patient has entered the room
• Using a BP cuff 80% of the arm circumference
• Asking the patient to hold out his or her arm above heart level
• Pumping the cuff 10 mm Hg above the palpated systolic BP"
• Obtaining a BP immediately after the patient has entered the room; B. Using a BP cuff 80% of the arm circumference; D. Pumping the cuff 10

mm Hg above the palpated systolic BP. Rationale: Common errors in blood pressure measurements can occur because of physical activity, incorrect cuff size, and placing the heart above or below heart level and failure to auscultate an auscultatory gap. It is recommended to pump the cuff 20 to 30 mm Hg above the last sound." Adult patients may have variations in pulse rates with

• respirations.
• food intake.
• heat.
• exercise
• exercise. Rationale: Exercise will increase heart rate due to increased metabolic demands. Sinus arrhythmia, a variation in pulse with

respiration, is common among children. The pulse rate varies with respiration, speeding up during inspiration and slowing down during expiration.An unconscious 22-year-old man arrives at the hospital after experimenting with hallucinogenic substances. His vital signs are T 37.2°C, po; P 142 bpm; R 20 breaths/ min; BP 100/64 mm Hg. The patient is experiencing...

• tachycardia
• eupnea
• auscultatory gap
• asystole
• tachycardia. Rationale: Tachycardia is a heart rate greater than 100 beats/min in an adult. Eupnea is normal RR, auscultatory gap is the absence

of korotkoff sounds when doing a manual BP, a systole is no hr. Use the process of elimination. C & D we're not relevant.

An auscultatory gap is defined as

• a drop in the SBP of 15 mm Hg or more with position change.
• a period of silence heard between Korotkoff sounds.
• the difference between the apical and radial pulse.
• SBP minus the DBP
• a period of silence heard between Korotkoff sounds. Rationale: The auscultatory gap is the period of no Korotkoff sounds during auscultation

of a blood pressure. It is caused by stiffening of the arterioles and is common in the elderly and in those with chronic disease. C is pulse deficit D is pulse pressure Which of the following findings during the general survey may indicate a change in mental status? Select all that apply.

• Disheveled appearance
• Rapid speech
• Lethargy
• Asymmetrical movements
• Disheveled appearance; B. Rapid speech; C. Lethargy. Rationale: The general survey provides valuable clues to the patient's overall status.

Changes in appearance, speech, and alertness may indicate a change in mental status and require further evaluation. Asymmetrical movements may indicate a stroke and a specific change in neurological status. Terms (10) Hide definitions