Question 1

The nurse receives a hand-off report on four patients. Which patient finding should the nurse assess first?

Accepted Answer

A)  Pulse oximetry 96% 
B)  Blood pressure 102/62 mm Hg 
C)  Pulse 42 beats/min 
D)  Respiratory rate 18 breaths/min 
A)  Pulse oximetry 96% 
B)  Blood pressure 102/62 mm Hg 
C)  Pulse 42 beats/min 
D)  Respiratory rate 18 breaths/min

Question 2

A nurse observes a student taking an adult patient's tympanic temperature. What action by the student requires the nurse to intervene?

Accepted Answer

A)  Student washes hands prior to patient contact. 
B)  Student pulls the pinna of the patient's ear down and back. 
C)  Student explains the procedure to the patient. 
D)  Student pulls the pinna of the patient's ear up and back. 
A)  Student washes hands prior to patient contact. 
B)  Student pulls the pinna of the patient's ear down and back. 
C)  Student explains the procedure to the patient. 
D)  Student pulls the pinna of the patient's ear up and back.

Question 3

The nurse understands that which factors can increase blood pressure?

Accepted Answer

A)  Head injury 
B)  Decreased fluid volume 
C)  Increasing age 
D)  Recent food intake 
E)  Pain 
A)  Head injury 
B)  Decreased fluid volume 
C)  Increasing age 
D)  Recent food intake 
E)  Pain

Question 4

A nurse is going to take an oral temperature on a patient who has just consumed a cup of coffee. What action by the nurse is best?

Accepted Answer

A)  Have the patient drink room temperature water. 
B)  Return in 30 minutes to take the patient's temperature. 
C)  Take the patient's temperature rectally instead. 
D)  Document that temperature is unable to be obtained. 
A)  Have the patient drink room temperature water. 
B)  Return in 30 minutes to take the patient's temperature. 
C)  Take the patient's temperature rectally instead. 
D)  Document that temperature is unable to be obtained.

Question 5

The nursing student learns that the purpose of measuring a patient's vital signs includes which of the following rationale?

Accepted Answer

A)  Monitor body systems functioning. 
B)  Identify early signs of problems. 
C)  Evaluate effectiveness of interventions. 
D)  Determine if a cure has been obtained. 
E)  Provide a baseline to compare against. 
A)  Monitor body systems functioning. 
B)  Identify early signs of problems. 
C)  Evaluate effectiveness of interventions. 
D)  Determine if a cure has been obtained. 
E)  Provide a baseline to compare against.

Exam 19: Vital Signs

The nurse receives a hand-off report on four patients. Which patient finding should the nurse assess first?

A nurse observes a student taking an adult patient's tympanic temperature. What action by the student requires the nurse to intervene?

The nurse understands that which factors can increase blood pressure?

A nurse is going to take an oral temperature on a patient who has just consumed a cup of coffee. What action by the nurse is best?

The nursing student learns that the purpose of measuring a patient's vital signs includes which of the following rationale?

Nursing, Theory, and Professional Practice

Values, Beliefs, and Caring

Communication

Critical Thinking in Nursing

Introduction to the Nursing Process

Assessment

Nursing Diagnosis

Planning

Implementation and Evaluation

Documentation, Electronic Health Records, and Reporting

Ethical and Legal Considerations

Leadership and Management

Evidence-Based Practice and Nursing Research

Health Literacy and Patient Education

Nursing Informatics

Health and Wellness

Human Development: Conception Through Adolescence

Human Development: Young Adult Through Older Adult

Health History and Physical Assessment

Ethnicity and Cultural Assessment

Spiritual Health

Public Health, Community-Based, and Home Health Care

Human Sexuality

Safety

Asepsis and Infection Control

Hygiene and Personal Care

Activity, Immobility, and Safe Movement

Skin Integrity and Wound Care

Nutrition

Cognitive and Sensory Alterations

Stress and Coping

Sleep

Diagnostic Testing

Medication Administration

Pain Management

Perioperative Nursing Care

Oxygenation and Tissue Perfusion

Fluid, Electrolytes, and Acid-Base Balance

Bowel Elimination

Urinary Elimination

Death and Loss

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