Exam 15: Vital Signs

The nurse is caring for a patient with a temperature of 100.3° F.Why will the nurse refrain from administering an antipyretic at this time?

The nurse is assessing a patient with shortness of breath.Which is the optimal technique to auscultate the patient's lung sounds?

The nurse delegates vital signs for a patient to the nurse assistant.What is the nurse's responsibility regarding delegation of this task?

The nurse is caring for a patient who was just pulled from a freezing lake.The patient's pulse oximetry reads 68% although the patient is not in respiratory distress.What is the correct interpretation of these assessment findings?

The patient's blood pressure is 152/92 but the primary health care provider does not diagnose the patient with hypertension.What is the rationale for this decision?

The nurse is having difficulty hearing his patient's apical pulse with his stethoscope.Which action will help the nurse hear the heartbeat more clearly?

The nurse is caring for a patient who lost consciousness and collapsed.Which site will be used to determine if the patient has a pulse?

The nurse is caring for a patient who collapsed after working outside on a hot day.The patient is disoriented with hot,dry skin and heart rate of 140 beats/minute.What is the priority action of the nurse?

The nurse is shown the mercury thermometer which was used to take the patient's temperature before coming to the hospital.What is the appropriate statement of the nurse?

The nurse is caring for a patient with the following vital signs: Temperature: 98.9° F Pulse: 94 Respirations: 20 Blood pressure: 144/94 Pulse oximetry: 94% What is the priority action of the nurse?

Which medications may be administered to reduce the patient's fever without masking signs of infection?

Which patient should have the temperature taken orally rather than using a tympanic thermometer?

A patient's blood pressure suddenly drops from 132/82 to 104/52.The nurse notes that the patient's skin is pale and the patient appears ready to faint.What is the priority action of the nurse?

The nurse is caring for a patient with a bacterial infection.After antibiotic treatment is started,the patient develops a generalized itchy rash.What is the most likely reason for the rash?

The nurse applies a cooling blanket to a patient with a dangerously high fever.Which is the most accurate method to monitor the patient's temperature?

The nurse notes that the patient is utilizing accessory and intercostal muscles to breathe.What is the priority action of the nurse?

The patient calls the health care provider's office after obtaining a reading of 170/88 with a home wrist blood pressure monitor.What is the appropriate recommendation of the nurse?

The nurse is caring for an adult patient with a temperature of 101.2° F.Which statement will the nurse make to the patient's family member who verbalizes concern over the patient's fever?

The nurse is unable to hear the blood pressure for a patient who is in septic shock.What is the best option of the nurse?

Which site will the nurse use to measure the patient's pulse rate before administering the cardiac medication digoxin?