Potter & Perry Chapter. 29 Vital Signs NCLEX Questions with Answers Latest Update 2024 Tes, Exams of Nursing

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Potter & Perry Chapter. 29 Vital Signs NCLEX Questions with

Answers Latest Update 2024 Test

1. The posterior hypothalamus helps control temperature by a) Causing vasoconstriction. b) Shunting blood to the skin and extremities. c) Increasing sweat production. d) Causing vasodilation. - Correct Answer a. Causing vasoconstriction. If the posterior hypothalamus senses that the body's temperature is lower than the set point, the body initiates heat conservation mechanisms. Vasoconstriction of blood vessels reduces blood flow to the skin and extremities. The anterior hypothalamus controls heat loss by inducing sweating, vasodilation of blood vessels, and inhibition of heat production.
2. Of the following mechanisms of heat loss by the body, identify the mechanism that transfers heat away by using air movement? a) Radiation b) Conduction c) Convection d) Evaporation - Correct Answer c. Convection Convection is the transfer of heat away from the body by air movement. Conduction is the transfer of heat from one object to another with direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas.
3. The patient has a temperature of 105.2° F. The nurse is attempting to lower his temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. The nurse is attempting to lower the patient's temperature through the use of a) Radiation.

b) Conduction. c) Convection. d) Evaporation. - Correct Answer b. Conduction. Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement.

5. The nurse is working the night shift on a surgical unit and is making 4 AM rounds. She notices that the patient's temperature is 96.8° F (36° C), whereas at 4 PM the preceding day, it was 98.6° F (37° C). What should the nurse do? a) Call the physician immediately to report a possible infection. b) Realize that this is a normal temperature variation. c) Provide another blanket to conserve body temperature. d) Provide medication to lower the temperature further. - Correct Answer b. Realize that this is a normal temperature variation. Body temperature normally changes 0.5° C to 1° C (0.9° F to 1.8° F) during a 24-hour period and is usually lowest between 1:00 and 4:00 AM, making this variation normal for the time of day. Unless the patient is complaining of being cold, there is no physiological need for providing an extra blanket or medication to lower the body temperature further. There is also no need to call a physician to report a normal temperature variation.
6. The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). His last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). The nurse should a) Call the physician and anticipate an order to treat the fever. b) Assume that the patient has an infection and order blood cultures. c) Wait an hour and recheck the patient's temperature. d) Be aware that temperatures this high are harmful and affect patient safety. - Correct Answer c. Wait an hour and recheck the patient's temperature. Waiting an hour and rechecking the patient's temperature would be the most appropriate action in this case. A fever usually is not harmful if it stays below 102.2° F

(39° C), and a single temperature reading does not always indicate a fever. In addition to physical signs and symptoms of infection, a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time. Mild temperature elevations enhance the body's immune system by stimulating white blood cell production. Usually, staff nurses do not order blood cultures, and nurses should base actions on knowledge, not on assumptions.

7. When heat loss mechanisms of the body are unable to keep pace with excess heat production, the result is known as a) Pyrexia. b) The plateau phase. c) The set point. d) Becoming afebrile. - Correct Answer a. Pyrexia. Pyrexia, or fever, occurs because heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature. The set point is the temperature point determined by the hypothalamus. When pyrogens trigger immune system responses, the hypothalamus reacts to raise the set point, and the body produces and conserves heat. During the plateau phase, chills subside and the person feels warm and dry as heat production and loss equilibrate at the new level. When the fever "breaks," the patient becomes afebrile.
8. The nurse is caring for a patient who has an elevated temperature. The nurse understands that a) Fever and hyperthermia are the same thing. b) Hyperthermia occurs when the body cannot reduce heat loss. c) Hyperthermia is an upward shift in the set point. d) Hyperthermia occurs when the body cannot reduce heat production. - Correct Answer d. Hyperthermia occurs when the body cannot reduce heat production. Fever and hyperthermia are not the same things. An elevated body temperature related to the body's inability to promote heat loss or reduce heat production is hyperthermia. Fever is an upward shift in the set point. Hyperthermia is not a shift in the set point.
9. The patient is restless with a temperature of 102.2° F (39° C). One of the first things the nurse should do is a) Place the patient on oxygen.

b) Restrict fluid intake. c) Increase patient activity. d) Increase patient's metabolic rate. - Correct Answer a. Place the patient on oxygen. During a fever, cellular metabolism increases and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Interventions during a fever include oxygen therapy. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for fluid volume deficit. Fluids should not be restricted. Increasing activity would increase the metabolic rate further, which would not be advisable.

10. The patient requires temperatures to be taken every two hours. Which of the following cannot be delegated to nursing assistive personnel? a) Selecting appropriate route and device b) Obtaining temperature measurement at ordered frequency c) Being aware of the usual values for the patient d) Assessing changes in body temperature - Correct Answer d. Assessing changes in body temperature The nurse is responsible for assessing changes in body temperature. The nurse instructs nursing assistive personnel to select the appropriate route and device to measure temperature, to obtain temperature measurement at ordered frequency, and to be aware of the usual values for the patient.
11. The patient requires routine temperature assessment but is confused and easily agitated and has a history of seizures. The nurse's best option would be to take his temperature a) Orally. b) Tympanically. c) Rectally. d) By the axillary method. - Correct Answer b. Tympanically. The tympanic route is easily accessible, requires minimal patient repositioning, and often can be used without disturbing the patient. It also has a very rapid measurement time. Oral temperatures require patient cooperation and are not recommended for

patients with a history of epilepsy. Rectal temperatures require positioning and may increase patient agitation. Axillary temperatures need long measurement times and continuous positioning by the nurse. The patient's agitation state may not allow for long periods of attention.

12. The patient is being admitted to the emergency department following a motor vehicle accident. His jaw is broken, and he has several broken teeth. He is ashen, and his skin is cool and diaphoretic. To obtain an accurate temperature, the nurse uses which of the following routes? a) Oral b) Axillary c) Rectal d) Temporal - Correct Answer c. Rectal The rectal route is argued to be more reliable when oral temperature cannot be obtained. Oral temperatures are not used for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills. Axillary temperature is affected by exposure to the environment, including time to place the thermometer. It also requires a long measurement time. Temporal artery temperature is affected by skin moisture such as diaphoresis or sweating.
13. The patient is found to be unresponsive and not breathing. To determine the presence of central blood circulation and circulation of blood to the brain, the nurse checks the patient's _____ pulse. a) Radial b) Brachial c) Posterior tibial d) Carotid - Correct Answer d. Carotid The heart continues to deliver blood through the carotid artery to the brain as long as possible. The carotid pulse is easily accessible during physiological shock or cardiac arrest. The radial pulse is used to assess peripheral circulation or to assess the status of circulation to the hand. The brachial site is used to assess the status of circulation to lower arm. The posterior tibial pulse is used to assess the status of circulation to the foot.
14. The nurse needs to obtain a radial pulse from a patient. To obtain the correct measure, what must the nurse do?

a) Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist. b) Place the thumb over the groove along the thumb side of the patient's wrist. c) Apply a very light touch so that the pulse is not obliterated. d) Apply very strong pressure to detect the pulse. - Correct Answer a. Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist. Place the tips of the first two or middle three fingers of the hand over the groove along the radial or thumb side of the patient's inner wrist. Fingertips are the most sensitive parts of the hand to palpate arterial pulsation. The thumb has a pulsation that interferes with accuracy. The pulse is more accurately assessed with moderate pressure. Too much pressure occludes the pulse and impairs blood flow.

16. While the nurse is assessing the patient's respirations, it is important for the patient to a) Be aware of the procedure being done. b) Not know that respirations are being assessed. c) Understand that respirations are estimated to save time. d) Not be touched until the entire process is finished. - Correct Answer b. Not know that respirations are being assessed. Do not let a patient know that respirations are being assessed. A patient who is aware of the assessment can alter the rate and depth of breathing. Respirations are the easiest of all vital signs to assess, but they are often the most haphazardly measured. Do not estimate respirations. Accurate measurement requires observation and palpation of chest wall movement.
17. The patient's blood pressure is 140/60. The nurse realizes that this equates to a pulse pressure of a) 140 b) 60 c) 80 d) 200 - Correct Answer c. 80.

The difference between the systolic pressure and the diastolic pressure is the pulse pressure. For a blood pressure of 140/60, the pulse pressure is 80 (140 - 60 = 80). 140 is the systolic pressure. 60 is the diastolic pressure. 200 is the systolic (140) added to the diastolic (60), but this has no clinical significance.

18. The thickness or viscosity of the blood affects the ease with which blood flows through small vessels. The nurse examines what value, which might help determine the amount of blood viscosity? a) Hematocrit b) Cardiac output c) Arterial size d) Blood volume - Correct Answer a. Hematocrit The hematocrit, or the percentage of red blood cells in the blood, determines blood viscosity. Blood pressure also depends on the cardiac output or volume pumped by the heart, but cardiac output does not affect viscosity. Arterial size helps to modify blood pressure. The smaller lumen of a vessel increases vascular resistance but does not affect viscosity. Blood volume also affects blood pressure, but it does not directly affect viscosity.
19. The patient is being admitted to the emergency department with complaints of shortness of breath. The patient has had chronic lung disease for many years but still smokes. The nurse should a) Administer high levels of oxygen. b) Use oxygen cautiously in this patient. c) Place a paper bag over the patient's face to allow rebreathing of carbon dioxide. d) Administer CO2 via mask. - Correct Answer b. Use oxygen cautiously in this patient. Because low levels of arterial O2 provide the stimulus that allows the patient to breathe, administration of high oxygen levels will be fatal for patients with chronic lung disease. Oxygen must be used cautiously in these types of patients. Patients with chronic lung disease have ongoing hypercarbia (elevated CO2 levels) and do not need to have CO administered or "rebreathed."
20. Which statement is true of the ovulation phase? a) Progesterone levels are below normal.

b) Body temperature is below baseline levels. c) Body temperature is at previous baseline levels or higher. d) Intense body heat and sweating occur. - Correct Answer c. Body temperature is at previous baseline levels or higher. Progesterone levels rise and fall cyclically during the menstrual cycle. When progesterone levels are low, the body temperature is a few tenths of a degree below the baseline. The lower temperature persists until ovulation occurs. During ovulation, greater amounts of progesterone enter the circulatory system and raise the body temperature to previous baseline levels or higher. These temperature variations help to predict a woman's most fertile time to achieve pregnancy. Women who undergo menopause (cessation of menstruation) often experience periods of intense body heat and sweating lasting from 30 seconds to 5 minutes (hot flashes).

21. The nurse is caring for a patient who has a pulse rate of 44. His blood pressure is within normal limits. In trying to determine the cause of the patient's low heart rate, the nurse would suspect a) That the patient would have a fever. b) Possible hemorrhage or bleeding. c) Calcium channel blockers or digitalis medications. d) Chronic obstructive pulmonary disease (COPD). - Correct Answer c. Calcium channel blockers or digitalis medications. Negative chronotropic drugs such as digitalis, beta-adrenergic agents, and calcium channel blockers can slow down pulse rate. Fever, bleeding, hemorrhage, and COPD all increase the body's need for oxygen, leading to an increased heart rate.
22. The patient was found unresponsive in her apartment and is being brought to the emergency department. She has arm, hand, and leg edema, her temperature is 95.6° F, and her hands are cold secondary to her history of peripheral vascular disease. It is reported that she has a latex allergy. To quickly measure the patient's oxygen saturation, what should the nurse do? a) Attach a finger probe to the patient's index finger. b) Place a nonadhesive sensor on the patient's ear lobe. c) Attach a disposable adhesive sensor to the bridge of the patient's nose.

d) Place the sensor on the same arm that the electronic blood pressure cuff is on. - Correct Answer b. Place a nonadhesive sensor on the patient's ear lobe. Select ear or bridge of nose if an adult patient has a history of peripheral vascular disease. Do not attach sensor to finger, ear, or bridge of nose if area is edematous or skin integrity is compromised. Do not use disposable adhesive probes if the patient has latex allergy. Do not attach probe to fingers that are hypothermic. Do not place sensor on the same extremity as electronic blood pressure cuff because blood flow to finger will be temporarily interrupted when cuff inflates.

23. The patient is admitted with shortness of breath and chest discomfort. Which of the following laboratory values could account for the patient's symptoms? a) Hemoglobin level of 8. b) Hematocrit level of 45% c) Red blood cell count of 5.0 million/mm d) Pulse oximetry of 90% - Correct Answer a. Hemoglobin level of 8. The concentration of hemoglobin reflects the patient's capacity to carry oxygen. Normal hemoglobin levels range from 10 to 18 g/100 mL in males and from 12 to 16 g/100 mL in females. Hemoglobin of 8.0 is low and indicates a decreased ability to deliver oxygen to meet bodily needs. All other values in the selection are considered normal.
24. Of the following values, which value would be considered prehypertension? a) 98/50 in a 7-year-old child b) 115/70 in an infant c) 140/90 in an older adult d) 120/80 in a middle-aged adult - Correct Answer d. 120/80 in a middle-aged adult An adult's blood pressure tends to rise with advancing age. The optimal blood pressure for a healthy, middle-aged adult is less than 120/80. Values of 120 to 139/80 to 89 mm Hg are considered prehypertension. Blood pressure greater than 140/90 is defined as hypertension. Blood pressure of 98/50 is normal for a child, whereas 115/70 can be normal for an infant.
25. The incidence of hypertension is greater in which of the following? a) Non-Hispanic Caucasians

b) African Americans c) Asian Americans d) Native Americans - Correct Answer b. African Americans The incidence of hypertension is greater in diabetic patients, older adults, and African Americans.

26. A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before she assesses the patient's blood pressure? a) Neither caffeine nor smoking affects blood pressure. b) She needs to insist that the patient stop smoking for at least 3 hours. c) The nurse should have the patient perform mild exercises. d) Caffeine and smoking can cause false BP elevations. - Correct Answer d. Caffeine and smoking can cause false BP elevations. Smoking immediately increases BP, and this increase lasts up to 15 minutes. Caffeine increases BP for up to 3 hours. Both affect a patient's blood pressure. The patient should rest at least 5 minutes before BP is measured.
27. When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. The nurse realizes that his rate is a) Normal for an infant. b) The proper rate for a toddler. c) Too slow for an infant. d) The same as that of a normal adult. - Correct Answer a. Normal for an infant. The normal rate for an infant is 120 to 160 beats/min. The rate obtained (145 beats/min) is within the normal range for an infant. The normal rate for a toddler is between 90 and 140 beats/min. The normal rate for an adult is between 60 and 100 beats/min.
28. The nurse is caring for an elderly patient and notes that his temperature is 96.8° F (36° C). She understands that this patient is a) Suffering from hypothermia. b) Expressing a normal temperature.

c) Hyperthermic relative to his age. d) Demonstrating the increased metabolism that accompanies aging. - Correct Answer b. Expressing a normal temperature. The average body temperature of older adults is approximately 96.8° F (36° C). This is not hypothermia or hyperthermia. Older adults have poor vasomotor control, reduced amounts of subcutaneous tissue, and reduced metabolism. The end result is lowered body temperature.

34. One benefit of using a stationary automatic blood pressure device is that the cuff a) Fits over clothing. b) Is extremely reliable. c) Is the method of choice for irregular heart rhythms. d) Is more reliable when pressure is less than 90 mm Hg systolic. - Correct Answer a. Fits over clothing. The cuff fits over clothing. However, the reliability of stationary machines is limited. Electronic blood pressure measurement is not recommended with irregular heart rates or when blood pressure is less than 90 mm Hg systolic.
35. The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take his blood pressure three times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. The nurse also instructs the patient that the a) Patient can apply the cuff in any manner he chooses because the machine is designed to be used by nonprofessionals. b) Machine requires frequent calibration to ensure accuracy. c) Cuff can be placed over clothing if necessary. d) Machine is accurate when blood pressures are low. - Correct Answer b. Machine requires frequent calibration to ensure accuracy. Electronic devices are easier to manipulate but require frequent recalibration—more than once a year. Because of their sensitivity, improper cuff placement or movement of the arm causes electronic devices to give incorrect readings. Stationary blood pressure devices are often found in public places, and the cuff fits over clothing. The same is not

true for portable devices. Electronic blood pressure measurement is not recommended when pressure is less than 90 mm Hg systolic.

36. The nurse is caring for a patient who complains of feeling light-headed and "woozy." The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do? a) Call the physician immediately. b) Perform an apical/radial pulse assessment. c) Apply more pressure to the radial artery to assess the pulse. d) Use his thumb to detect the patient's pulse. - Correct Answer b. Perform an apical/radial pulse assessment. If the pulse is irregular, do an apical/radial pulse assessment to detect a pulse deficit. If pulse count differs by more than 2, a pulse deficit exists, which sometimes indicates alterations in cardiac output. The nurse needs to gather as much information as possible before calling the physician. The radial pulse is more accurately assessed with moderate pressure. Too much pressure occludes the pulse and impairs blood flow. Fingertips are the most sensitive parts of the hand to palpate arterial pulsations. The thumb has a pulsation of its own that interferes with accuracy.
37. Of the following patients, which one is the best candidate to have his temperature taken orally? a) A 27-year-old postoperative patient with an elevated temperature b) A teenage boy who has just returned from outside "for a smoke" c) An 87-year-old confused male suspected of hypothermia d) A 20-year-old male with a history of epilepsy - Correct Answer a. A 27-year-old postoperative patient with an elevated temperature An elevated temperature needs to be evaluated, and there is no contraindication in this patient. Ingestion of hot/cold fluids or foods, smoking, or receiving oxygen by mask/cannula can require delays in taking oral temperature. Oral temperatures are not taken for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills, nor for infants, small children, or confused patients.
38. The physician order reads "Lopressor (metoprolol) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic." The patient's blood pressure is 92/66. The nurse does not give the medication and

a) Does not tell the patient what the blood pressure is. b) Documents only what the blood pressure was. c) Documents that the medication was not given owing to low blood pressure. d) Does not need to inform the health care provider that the medication was held. - Correct Answer c. Documents that the medication was not given owing to low blood pressure. The nurse must document any interventions initiated as a result of vital sign measurement such as holding an antihypertensive drug. The nurse should inform the patient of the blood pressure value and the need for periodic reassessment of the blood pressure. Documenting the blood pressure only is not sufficient. Any intervention must be documented as well. Abnormal findings must be reported to the nurse in charge or to the health care provider.

39. After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. Why is this done? a) Temperatures are the same regardless of the route used. b) Temperatures vary depending on the route used. c) Temperatures are cooler when taken rectally than when taken orally. d) Axillary temperatures are higher than oral temperatures - Correct Answer b. Temperatures vary depending on the route used. Temperatures obtained vary depending on the site used. Rectal temperatures are usually 0.5° C (0.9° F) higher than oral temperatures, and axillary temperatures are usually 0° C (0.9° F) lower than oral temperatures.
40. When temperature assessment is required, which of the following cannot be delegated to nursing assistive personnel? a) Temperature measurement b) Assessment of changes in body temperature c) Selection of appropriate route and device d) Consideration of factors that falsely raise temperature - Correct Answer b. Assessment of changes in body temperature

41. The nursing assistive person is taking vital signs and reports that a patient's blood pressure is abnormally low. The nurse should a) Have the nursing assistive person retake the blood pressure. b) Ignore the report and have it rechecked at the next scheduled time. c) Retake the blood pressure herself and assess the patient's condition. d) Have the nursing assistive person assess the patient's other vital signs. - Correct Answer c. Retake the blood pressure herself and assess the patient's condition. The nursing assistive person should report abnormalities to the nurse, who should further assess the patient. The nursing assistive person should not retake the blood pressure or other vital signs because the nurse needs to assess the patient. The report cannot be ignored. Assessment must be done by the nurse.
42. Of the following sites, which are used for obtaining a core temperature? (Select all that apply.) a) Oral b) Rectal c) Tympanic d) Axillary e) Pulmonary artery - Correct Answer c. Tympanic & e. Pulmonary artery Intensive care units use the core temperatures of the pulmonary artery, esophagus, and urinary bladder. Because the tympanic membrane shares the same arterial blood supply as the hypothalamus, the tympanic temperature is a core temperature. Oral, rectal, axillary, and skin temperature sites rely on effective blood circulation at the measurement site.
43. The patient has new-onset restlessness and confusion. His pulse rate is elevated, as is his respiratory rate. His oxygen saturation, however, is 94% according to the portable pulse oximeter. The nurse ignores the oximeter reading and calls the physician to obtain an order for an arterial blood gas (ABG). The nurse does this because many things can cause inaccurate pulse oximetry readings, including which of the following? (Select all that apply.) a) O2 saturations (SaO2) >70%

b) Carbon monoxide inhalation c) Nail polish d) Hypothermia at the assessment site e) Intravascular dyes - Correct Answer B, C, D, & E

3. The nurse is assessing the patient and his family for probable familial causes of the patient's hypertension. The nurse begins by analyzing the patient's personal history, as well as family history and current lifestyle situation. Which of the following issues would be considered risk factors? (Select all that apply.) a) Obesity b) Cigarette smoking c) Recent weight loss d) Heavy alcohol consumption e) Low blood cholesterol levels - Correct Answer A, B, & D
4. The patient is being encouraged to purchase a portable automatic blood pressure device so he can monitor his own blood pressure at home. What are some of the benefits of this? (Select all that apply.) a) Blood pressures can be obtained if pulse rates become irregular. b) Patients can provide information about patterns to health care providers. c) Patients can actively participate in their treatment. d) Self-monitoring helps with compliance and treatment. e) The risk of obtaining an inaccurate reading is decreased. - Correct Answer B, C, & D
5. When recording the patient's respiratory status, what must be recorded? (Select all that apply.) a) Respiratory rate b) Character of respirations c) Amount of oxygen therapy

d) Only normal findings e) Only in the graphic section - Correct Answer A, B, & C