Question 1

Match between columns
                        Premises: A flush blood pressure is a reading between the systolic and the diastolic pressure.
Core temperature is maintained when heat production equals heat loss.
The radial pulse is taken for 1 full minute.
The circulatory system is under the dual control of autoregulation and the central nervous system.
Body temperature is regulated by the pituitary gland.
Rectal temperatures measure 1°F lower than oral temperatures.
Heat production is decreased with shivering.
When the body core is cooled below 98.6°F,heat conservation is affected.
The body's temperature reflects the heat loss through conduction.
The environment plays a major role in maintaining temperature.

Accepted Answer

The Answer of False and True is...

Question 2

The blood pressure cuff is wrapped snugly and smoothly around the upper arm

Accepted Answer

A)   
Inch above the antecubital space. 
B) 1 inch above the antecubital space. 
C) 1 inch down from the axilla. 
D) 2 inches down from the axilla. 
A)   
Inch above the antecubital space. 
B) 1 inch above the antecubital space. 
C) 1 inch down from the axilla. 
D) 2 inches down from the axilla. B

Question 3

When checking the nurses' notes prior to caring for a client who has had vascular surgery,you observe that the charting of the peripheral pulses states the client has a 2+ pedal pulse.What is your interpretation of this statement?

Accepted Answer

Normal pedal pulse

Question 4

You have been obtaining the client's vital signs every hour according to the usual procedures.You have just taken the radial pulse rate,and it now appears to be irregular.What is your next nursing action?

Accepted Answer

Take apical pulse 1

Question 5

When using the stethoscope for taking a blood pressure reading,the nurse needs to remember

Accepted Answer

A) The bell detects high-pitched sounds best. 
B) The diaphragm detects low-pitched sounds best. 
C) Korotkoff sounds are best heard by the portion of the stethoscope that detects low-frequency sounds. 
D) Either bell or diaphragm can be used as frequency sounds are not detected with blood pressure readings. 
A) The bell detects high-pitched sounds best. 
B) The diaphragm detects low-pitched sounds best. 
C) Korotkoff sounds are best heard by the portion of the stethoscope that detects low-frequency sounds. 
D) Either bell or diaphragm can be used as frequency sounds are not detected with blood pressure readings.

Question 6

The most accepted method of obtaining an apical-radial pulse is

Accepted Answer

A) One nurse counts the pulse for 1 minute,first at the brachial site and then at the apical site. 
B) One nurse counts the pulse for 1 minute at the brachial and apical sites simultaneously. 
C) Two nurses count the pulse for 1 minute simultaneously,one counts at the apical site and one at the radial site,using one watch. 
D) Two nurses count the pulse for 1 minute,first one nurse counts at the apical site and then one at the radial site,each using his or her own watch. 
A) One nurse counts the pulse for 1 minute,first at the brachial site and then at the apical site. 
B) One nurse counts the pulse for 1 minute at the brachial and apical sites simultaneously. 
C) Two nurses count the pulse for 1 minute simultaneously,one counts at the apical site and one at the radial site,using one watch. 
D) Two nurses count the pulse for 1 minute,first one nurse counts at the apical site and then one at the radial site,each using his or her own watch.

Question 7

Circulatory control mechanisms include the baroreceptor reflex.Which of the following statements is correct in relation to the reflex?

Accepted Answer

A) An increased blood pressure increases the reflex action and produces vasoconstriction. 
B) Baroreceptors transmit signals that stimulate the vasomotor center to produce vasodilation when the blood pressure increases. 
C) Decreased blood pressure leads to inhibition of baroreceptor stimulation. 
D) Increased blood pressure and heart rate result from baroreceptor stimulation of the vasomotor center. 
A) An increased blood pressure increases the reflex action and produces vasoconstriction. 
B) Baroreceptors transmit signals that stimulate the vasomotor center to produce vasodilation when the blood pressure increases. 
C) Decreased blood pressure leads to inhibition of baroreceptor stimulation. 
D) Increased blood pressure and heart rate result from baroreceptor stimulation of the vasomotor center.

Question 8

The most accurate method for taking an adult client's rectal temperature is to insert the thermometer _____ inches and hold in place _____ minutes.

Accepted Answer

A)    
B) 1-2,2-3 
C)    
D)    
A)    
B) 1-2,2-3 
C)    
D)

Question 9

You receive an order to monitor pedal pulses every hour on a client with peripheral vascular disease.Your first assessment reveals a strong pedal pulse on the right and an apparent absence of a pulse on the left side.Your next intervention would be to

Accepted Answer

A) Obtain a Doppler stethoscope and auscultate for blood flow. 
B) Take the client's blood pressure to determine if client is hypotensive. 
C) Warm the client's extremity and assess in 15 minutes. 
D) Assess for the presence of a posterior tibial and popliteal pulse. 
A) Obtain a Doppler stethoscope and auscultate for blood flow. 
B) Take the client's blood pressure to determine if client is hypotensive. 
C) Warm the client's extremity and assess in 15 minutes. 
D) Assess for the presence of a posterior tibial and popliteal pulse.

Question 10

The normal range for an oral temperature is

Accepted Answer

A) 96°-105°F. 
B) 97°-99.5°F. 
C) 98.6°-99.6°F. 
D) 97.6°-98.6°F. 
A) 96°-105°F. 
B) 97°-99.5°F. 
C) 98.6°-99.6°F. 
D) 97.6°-98.6°F.

Question 11

The appropriate method for obtaining an apical pulse is,using the

Accepted Answer

A) Bell of the stethoscope,listen at the second intercostal space,right side of sternum. 
B) Bell of the stethoscope,listen at the fifth intercostal space,left sternal border. 
C) Diaphragm of the stethoscope,listen at the second intercostal space,left sternal border. 
D) Diaphragm of the stethoscope,listen at the fifth intercostal space,midclavicular line. 
A) Bell of the stethoscope,listen at the second intercostal space,right side of sternum. 
B) Bell of the stethoscope,listen at the fifth intercostal space,left sternal border. 
C) Diaphragm of the stethoscope,listen at the second intercostal space,left sternal border. 
D) Diaphragm of the stethoscope,listen at the fifth intercostal space,midclavicular line.

Question 12

The bladder of the blood pressure cuff should be what circumference percentage of the limb?

Accepted Answer

A) 40% 
B) 50% 
C) 60% 
D) 70% 
A) 40% 
B) 50% 
C) 60% 
D) 70%

Question 13

If the client's arm is positioned below the level of the heart when taking the blood pressure,the reading will be

Accepted Answer

A) Lower than normal. 
B) No different from if above the level of the heart. 
C) Higher than normal. 
D) Altered if the client has peripheral vascular disease only. 
A) Lower than normal. 
B) No different from if above the level of the heart. 
C) Higher than normal. 
D) Altered if the client has peripheral vascular disease only.

Question 14

Heart rates vary in individuals.Which statement most accurately describes the variance in heart rate?

Accepted Answer

A) Older clients have a slightly higher heart rate. 
B) Men have slightly higher pulse rates than women. 
C) Children's heart rates usually beat 120 times per minute. 
D) Normal heart rate is from 80 to 100 beats per minute. 
A) Older clients have a slightly higher heart rate. 
B) Men have slightly higher pulse rates than women. 
C) Children's heart rates usually beat 120 times per minute. 
D) Normal heart rate is from 80 to 100 beats per minute.

Question 15

There are many factors that may alter vital signs.Which one of the following factors is the most common?

Accepted Answer

A) Pain 
B) Stress 
C) Age 
D) Exercise 
A) Pain 
B) Stress 
C) Age 
D) Exercise

Question 16

The rationale for positioning the probe of the electronic thermometer in the sublingual pocket at the base of the tongue is that the

Accepted Answer

A) Client can more easily close his or her mouth and thus an accurate temperature is obtained. 
B) Teeth do not rest on the probe,which can lead to an inaccurate temperature reading. 
C) Larger blood vessel in the pocket more accurately reflects the core temperature. 
D) Blood supply is limited in that area,so it does not cause a false temperature reading. 
A) Client can more easily close his or her mouth and thus an accurate temperature is obtained. 
B) Teeth do not rest on the probe,which can lead to an inaccurate temperature reading. 
C) Larger blood vessel in the pocket more accurately reflects the core temperature. 
D) Blood supply is limited in that area,so it does not cause a false temperature reading.

Question 17

A client who requires that peripheral pulses be monitored using the Doppler can be assigned to a(n)__________ for this task.

Accepted Answer

A) CNA/UAP 
B) RN 
C) RN or LVN/LPT 
D) All of the above 
A) CNA/UAP 
B) RN 
C) RN or LVN/LPT 
D) All of the above

Question 18

While taking a radial pulse,you assess that it is irregular with a rate of 72.Your prep sheet indicates the pulse has been regular since admission.Your first nursing action is to

Accepted Answer

A) Notify the team leader immediately. 
B) Take the radial pulse again in 15 minutes. 
C) Document the findings and leave a note for the physician. 
D) Take an apical pulse for 1 full minute. 
A) Notify the team leader immediately. 
B) Take the radial pulse again in 15 minutes. 
C) Document the findings and leave a note for the physician. 
D) Take an apical pulse for 1 full minute.

Question 19

Although not considered a cardinal sign,JCAHO suggests that _____________ now be included as the 5th vital sign.

Accepted Answer

The answer of Although not considered a cardinal sign,JCAHO suggests...

Question 20

When taking an oral temperature,the client states he just had a cup of coffee.You should wait _____ minutes before taking the temperature.

Accepted Answer

A) 5-10 
B) 10-15 
C) 15-20 
D) 10-20 
A) 5-10 
B) 10-15 
C) 15-20 
D) 10-20

Exam 10: Vital Signs

The blood pressure cuff is wrapped snugly and smoothly around the upper arm

When checking the nurses' notes prior to caring for a client who has had vascular surgery,you observe that the charting of the peripheral pulses states the client has a 2+ pedal pulse.What is your interpretation of this statement?

You have been obtaining the client's vital signs every hour according to the usual procedures.You have just taken the radial pulse rate,and it now appears to be irregular.What is your next nursing action?

When using the stethoscope for taking a blood pressure reading,the nurse needs to remember

The most accepted method of obtaining an apical-radial pulse is

Circulatory control mechanisms include the baroreceptor reflex.Which of the following statements is correct in relation to the reflex?

The most accurate method for taking an adult client's rectal temperature is to insert the thermometer _____ inches and hold in place _____ minutes.

You receive an order to monitor pedal pulses every hour on a client with peripheral vascular disease.Your first assessment reveals a strong pedal pulse on the right and an apparent absence of a pulse on the left side.Your next intervention would be to

The normal range for an oral temperature is

The appropriate method for obtaining an apical pulse is,using the

The bladder of the blood pressure cuff should be what circumference percentage of the limb?

If the client's arm is positioned below the level of the heart when taking the blood pressure,the reading will be

Heart rates vary in individuals.Which statement most accurately describes the variance in heart rate?

There are many factors that may alter vital signs.Which one of the following factors is the most common?

The rationale for positioning the probe of the electronic thermometer in the sublingual pocket at the base of the tongue is that the

A client who requires that peripheral pulses be monitored using the Doppler can be assigned to a(n)__________ for this task.

While taking a radial pulse,you assess that it is irregular with a rate of 72.Your prep sheet indicates the pulse has been regular since admission.Your first nursing action is to

Although not considered a cardinal sign,JCAHO suggests that _____________ now be included as the 5th vital sign.

When taking an oral temperature,the client states he just had a cup of coffee.You should wait _____ minutes before taking the temperature.

Professional Nursing

Nursing Process and Critical Thinking

Managing Client Care: Documentation and Delegation

Communication and Nurse-Client Relationship

Admission, Transfer, and Discharge

Client Education and Discharge Planning

Safe Client Environment and Restraints

Bathing, Bedmaking, and Maintaining Skin Integrity

Personal Hygiene

Physical Assessment

Body Mechanics and Positioning

Exercise and Ambulation

Infection Control

Disaster Preparedness Bioterrorism

Pain Management

Alternative Therapies and Stress Management

Medication Administration

Nutritional Management and Ng Intubation

Specimen Collection

Diagnostic Procedures

Urinary Elimination

Bowel Elimination

Heat and Cold Therapies

Wound Care and Dressings

Perioperative Care

Orthopedic Interventions

Intravenous Therapy

Central Vascular Access

Respiratory Care

Circulatory Maintenance

Neurological Management - New

Advanced Nursing Skills

End of Life Care

Filters

The most accurate method for taking an adult client's rectal temperature is to insert the thermometer _ inches and hold in place _ minutes.