Question 1

A nurse performs orthostatic blood pressure readings on a patient with the following results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best?

Accepted Answer

A)  Instruct the patient not to get up without help. 
B)  Document the findings and continue to monitor. 
C)  Reassure the patient that these findings are normal. 
D)  Reassess the blood pressures in 1 hour. 
A)  Instruct the patient not to get up without help. 
B)  Document the findings and continue to monitor. 
C)  Reassure the patient that these findings are normal. 
D)  Reassess the blood pressures in 1 hour.

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

A nurse is going to take a patient's oral temperature. The patient has been drinking 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 4

A nurse assesses a patient's radial pulse rate to be 110 beats/min and regular. What action by the nurse is best?

Accepted Answer

A)  Assess the patient for causes of tachycardia. 
B)  Take an apical heart rate and compare the two. 
C)  Document the findings in the patient's chart. 
D)  Notify the patient's health care provider. 
A)  Assess the patient for causes of tachycardia. 
B)  Take an apical heart rate and compare the two. 
C)  Document the findings in the patient's chart. 
D)  Notify the patient's health care provider.

Question 5

A patient returned from a procedure and has vital sign measurements ordered every hour. The patient's blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg. What action by the nurse is most appropriate?

Accepted Answer

A)  Take the vital signs again in another hour. 
B)  Document the findings in the patient's chart. 
C)  Have another nurse recheck the vital signs. 
D)  Plan to take the vital signs more often. 
A)  Take the vital signs again in another hour. 
B)  Document the findings in the patient's chart. 
C)  Have another nurse recheck the vital signs. 
D)  Plan to take the vital signs more often.

Exam 19: Vital Signs

A nurse performs orthostatic blood pressure readings on a patient with the following results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best?

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

A nurse is going to take a patient's oral temperature. The patient has been drinking coffee. What action by the nurse is best?

A nurse assesses a patient's radial pulse rate to be 110 beats/min and regular. What action by the nurse is best?

A patient returned from a procedure and has vital sign measurements ordered every hour. The patient's blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg. What action by the nurse is most appropriate?

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