Question 1

The nurse caring for a postsurgical patient obtains an oral temperature reading of 103°F.She contacts the surgeon,obtains an order,and administers acetaminophen 650 mg orally.Which clinical information should the nurse document? Select all that apply.

Accepted Answer

A)  Oral temperature reading of 102°F 
B)  The call to the surgeon to obtain the order 
C)  Administering acetaminophen 650 mg orally 
D)  All of the above

Question 2

Which of the following sets of vital signs are all within normal limits for patients at rest?

Accepted Answer

A)  Infant: T 98.8°F (rectal), HR 160, RR 16, BP 120/54 
B)  Adolescent: T 98.2°F (oral), HR 80, RR 18, BP 108/68 
C)  Adult: T 99.6°F (oral), HR 48, RR 22, BP 130/84 
D)  Older adult: T 98.6°F (oral), HR 110, RR 28, BP 170/95

Question 3

The nurse is assessing vital signs for a client after a surgical procedure on the left leg.IV fluids are infusing.It would be most important for the nurse to:

Accepted Answer

A)  Compare the left pedal pulse with the right pedal pulse 
B)  Count the client's respiratory rate for 1 full minute 
C)  Take the blood pressure in the arm without an IV 
D)  Take an oral temperature with an electronic thermometer

Question 4

A client's vital signs 4 hours ago were temperature (oral)101.4°F (38.6°C),heart rate 110 beats/min,respiratory rate 26 breaths/min,and blood pressure 124/78 mm Hg.The temperature is now 99.4°F (37.4°C).Based only on the expected relationship between temperature and respiratory rate,the nurse might best anticipate the client's respiratory rate to be:

Accepted Answer

A)  16 
B)  18 
C)  20 
D)  22

Question 5

A 1-day postoperative client has a temperature of 36.8°C.What is the nurse's next best action?

Accepted Answer

A)  Contact the primary care provider for guidance. 
B)  Document the temperature and continue with his care. 
C)  Administer the prescribed antipyretic medication. 
D)  Instruct the client to drink more fluids.

Question 6

The client has an order for the drug digitalis,which has the effect of decreasing the heart rate.Which site should the nurse use to obtain a pulse rate prior to administering the medication?

Accepted Answer

A)  Radial 
B)  Temporal 
C)  Apical 
D)  Brachial

Question 7

A client's average normal temperature is 98°F.Which of the following temperatures would be expected during the night in this healthy,young adult client who does not have a fever,inflammatory process,or underlying health problems?

Accepted Answer

A)  97.2°F 
B)  98.0°F 
C)  98.6°F 
D)  99.2°F

Question 8

Which of the following interventions would be appropriate for a client who has a fever? Select all that apply.

Accepted Answer

A)  Put an ice pack on the client's neck and axillae. 
B)  Provide the client a blanket when he is shivering. 
C)  Offer the client fluids to drink every 1 to 2 hours. 
D)  Take the temperature using a tympanic thermometer.

Question 9

Which assessment data best support a report of severe pain in an adult client whose baseline vital signs are within an average normal range?

Accepted Answer

A)  Oral temperature 100°F (37.8°
C)  
B)  Respiratory rate 26 breaths/min and shallow 
C)  Apical heart rate 56 beats/min 
D)  Blood pressure 124/82 mm Hg

Question 10

The nurse hears rhonchi when auscultating a client's lungs.Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds?

Accepted Answer

A)  Have the client take several deep breaths. 
B)  Request the client take a deep breath and cough. 
C)  Take the client's blood pressure and apical pulse readings. 
D)  Count the client's respiratory rate for 1 minute.

Question 11

For which of the following adult clients should the nurse make follow-up observations and monitor the vital signs closely? A client whose:

Accepted Answer

A)  Resting morning blood pressure is 136/86, whereas the afternoon BP is 128/84 mm Hg 
B)  Oral temperature is 97.9°F in the morning and 99.8°F in the evening 
C)  Heart rate was 76 beats/min before eating and 88 beats/min after eating 
D)  Respiratory rate is 16 breaths/min when standing and 18 when lying down

Question 12

A 70-year-old homeless man is admitted to the emergency department with heat stroke following 3 days of overexposure to outside temperatures.The nurse is most alerted to which signs and symptoms associated with heat stroke? Select all that apply.

Accepted Answer

A)  Temperature of 103.8°F 
B)  Throbbing headache 
C)  Diaphoresis 
D)  Confusion

Question 13

During a clinic interview,a client states he has been experiencing dizziness upon standing.Which nursing action is appropriate for the nurse to implement?

Accepted Answer

A)  Ask the client when in the day dizziness occurs. 
B)  Help the client to assume a recumbent position. 
C)  Measure both heart rate and blood pressure with the client standing. 
D)  Measure vital signs with the client supine, sitting, and standing.

Question 14

The nurse provides client education regarding hypertension prevention and management.Which of these statements indicates that the client understands the instructions?

Accepted Answer

A)  "I don't have to worry if my blood pressure is high once in a while." 
B)  "I guess I will have to make sure I don't drink too much water." 
C)  "I can lose some weight to help lower my blood pressure." 
D)  "I will need to reduce the amount milk and other dairy products I use."

Question 15

The nurse is obtaining vital signs on a newborn infant and notes respirations at 56 breaths/min.What is the most appropriate action by the nurse?

Accepted Answer

A)  Apply oxygen immediately. 
B)  Document the finding and continue the assessment. 
C)  Contact the obstetrician for orders. 
D)  Compare the finding with other infants in the nursery.

Question 16

Which of these steps in taking a blood pressure is/are correct? Select all that apply.

Accepted Answer

A)  Use a bladder that encircles 40% of the arm. 
B)  Wrap the cuff snugly around the client's arm. 
C)  Ask the client to hold the arm at heart level. 
D)  Have the client sit with feet flat on the floor.

Question 17

The nurse on a medical-surgical unit palpates a patient's carotid pulse for 30 seconds and obtains a rate of 80 beats/min.The nurse knows in obtaining a patient's carotid pulse she must be careful that her technique does not cause a/an:

Accepted Answer

A)  Increase in heart rate 
B)  Decrease in heart rate 
C)  Increase in blood pressure 
D)  Irregular heart rhythm

Question 18

A client who has been hospitalized for an infection states,"The nursing assistant told me my vital signs are all within normal limits; that means I'm cured." The nurse's best response would be which of the following?

Accepted Answer

A)  "Your vital signs confirm that your infection is resolved; how do you feel?" 
B)  "I'll let your healthcare provider know so you can be discharged." 
C)  "Your vital signs are stable, but there are other things to assess." 
D)  "We still need to keep monitoring your temperature for a while."

Question 19

A 42-year-old client has a rectal temperature reading of 39.2°C (102.6°F).Her blood pressure has decreased from 124/76 to 118/70 since taken 4 hours earlier.Her pulse rate has increased from 68 to 78.The nurse's initial best action is to:

Accepted Answer

A)  Document the vital signs and continue with her assessment 
B)  Contact the provider immediately due to the alarming changes in the vital signs 
C)  Obtain a pulmonary artery temperature reading before initiating any type of treatment 
D)  Ask the NAP to obtain another set of vital signs in 4 hours

Question 20

The nurse documents a patient's radial pulse rate as 120 beats/min and regular.One hour later,the nurse rechecks the pulse and it is irregular at 120 beats/min.What is the most appropriate nursing action?

Accepted Answer

A)  Ask another nurse to check the pulse. 
B)  Place the patient on bedrest and administer fluids. 
C)  Place the patient on a cardiac monitor. 
D)  Check the pulse in the opposite arm.

Exam 20: Measuring Vital Signs