Potter & Perry Chapter 29 Vital Signs Questions with Answers, Exams of Nursing

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Potter & Perry Chapter 29 Vital Signs Questions with

Answers

Vital Signs (VS) - Correct Answer - Measurements taken and compared to national norms as well as the patient's normal values.

• Measurements of the body's most basic function , indicate the vital function. vital signs - Correct Answer Blood pressure (BP) Temperature (T) Pulse (P) Respiration (R) SpO Pain Safety Guidelines for Measuring Vital Signs - Correct Answer -On admission to a healthcare facility -When assessing a patient during home care visits -In a hospital on a routine schedule -Before, during, after medication and treatments -When a patient's general physical condition changes -Before, during, and after nursing interventions influencing a vital signs -When a patient reports nonspecific symptoms of physical distress body temperature - Correct Answer The difference between the amount of heat produced by body processes and the amount of heat lost to the external environment. Heat Produced - Heat Loss = Body Temperature Body Temperature Measurements - Correct Answer Oral Axillary Rectal Tympanic (Ear) Temporal Correct technique for using each temperature site? - Correct Answer Oral: in the mouth, under the tongue Axillary: under the armpit, the probe should be place in the middle straight upwards Rectal: inserted in the rectum, use lubrication Tympanic (Ear): inserted in the ear Temporal: on the forehead, place on one side of the temple and slide to the other side Factors influencing body temperature? - Correct Answer Age Exercise

Hormonal level Environment Circadian rhythm Temperature alterations Normal ranges for adults and older adults? - Correct Answer Adult average temperature: 36 to 38C (96.8F to 100.4F) Range oral for the Older Adult Average temperature 35-36.1 (95-97F) 35C (95F) in cold weather Differences in average temperatures with each temperature site - Correct Answer Average rectal 37.5C (99.5F) Average oral/ tympanic: 37C (98.6F) Average axillary 36.6C (97.6F) What do pulse measurements measure? - Correct Answer -The palpable bounding of blood flow in a peripheral artery. Tell us how much blood is circulating. -Pulse pressure wave caused by stroke volume (amount of blood pumped into aorta) Pulse Rate - Correct Answer Number of pulsing sensations in 1 minute Factors that influence pulse/heart rate - Correct Answer Exercise Temperature Emotions Medication Postural change Pulmonary condition Hemorrhage Pulse Rates for Adults - Correct Answer Normal heart beat is called Eucardia: 60 to 100 (bpm) Tachycardia - Correct Answer Tachycardia: above 100 beat per minutes Bradycardia - Correct Answer Bradycardia: below 60 beat per minutes Assessment of Radial Pulse - Correct Answer •Technique: palpation •Rate (beats/min) •Rhythm (steadiness/pattern) •Strength/Amplitude ** (3+, 2+, 1+, 0) •Equality** (even, same on all peripheries)

Technique to measure pulse rates - Correct Answer The technique used to measure pulse rates is through palpation, and the equipment required for this is just hands and watch. Most common place can be along the groove of the thumb. When should the pulse technique differ? - Correct Answer When there is not much pulse rate felt in one area. In this case, auscultation is another technique that involves listening to the sounds produced by the body organs, equipment needed for this is a stethoscope. Pulse count - Correct Answer Normal pulse count for 30sec then multiple by 2 Irregular pulse count for full minute Respirations - Correct Answer Respiration measures the ventilation, the movement of gas in and out of the lungs. Ventilation - Correct Answer the movement of gases in and out of the lungs Diffusion - Correct Answer movement of oxygen and CO2 between alveoli and RBC Perfusion - Correct Answer distribution of red blood cells to and from the pulmonary capillaries Factors that influence respirations - Correct Answer Exercise Acute pain Anxiety Smoking Body position Medications Neurological injury Hemoglobin function Respiratory rates for adults - Correct Answer Normal respiration is called Eupnea: acceptable range 12 to 20 breaths per minute Tachypnea - Correct Answer Tachypnea > 20 breaths per minute Bradypnea - Correct Answer Bradypnea < 12 breaths per minute Assessment of Respiration - Correct Answer Technique: observation and palpation Rate: number value Depth: deep, normal or shallow Rhythm: regular or irregular Effort: easy or hard to breathe

Blood pressure readings measures? - Correct Answer The force exerted on the walls of an artery by the pulsing blood under pressure from the heart. systolic pressure - Correct Answer The peak of the maximum pressure when ejection occurs. diastolic pressure - Correct Answer The minimal pressure exerted against the arterial walls at all times. What are the interrelationships to blood pressure. - Correct Answer Cardiac output Peripheral resistance Blood volume Viscosity Elasticity What are some factors that influence pulse/heart rate? - Correct Answer •Age •Stress •Ethnicity* •Gender •Daily variation •Medications •Activity & weight •Smoking What is a normal BP reading for adults? - Correct Answer >120 mmHg systolic and

80 mmHg diastolic What are common errors in BP measurements? - Correct Answer -Take BP when the person is anxious -Smoking or caffeine within 30 minutes -Position of arm (below/above heart) -Wrong cuff size (too big = low BP, too small = high BP) -Cuff wrapped too loose -Failure to wait 1-2 minutes before repeating the test. What is the proper technique to measure a palpatory? - Correct Answer Palpation: involves use of the sense of touch to gather information. Equipment: Hands You place the BP cuff on the patient and your index and middle finger on the radius. You pump the BP cough until you can no longer feel the patient pulse. Whatever number you no longer feel the pulse, go up 30 (ex: you stop feeling pulse at 120 go up to 150 when you take BP). What are the different Korotkoff sounds? - Correct Answer Phase 1: Appearance of tap sound, this marks systolic BP

Phase 2: Sound takes up the murmuring quality, auscultatory gap may appear within this phase. Phase 3: Sound become very loud and gauging in quality Phase 4: Sound suddenly becomes muffled Phase 5: All sounds disappear, DBP recorded here. What is an auscultatory gap and how do we avoid measuring one? What happens if we don't avoid one? - Correct Answer Auscultatory gap occurs between the first and second Korotkoff sounds. It causes an underestimation of SBP or overestimation of DBP. To avoid it, be sure to inflate the cuff high enough to hear the true SBP before gap. When should/should not an electronic blood pressure device be used? - Correct Answer Should not: hypertension, hypotension, irregular heart rhythm, peripheral vascular obstruction, shivering, seizures, excessive tremors, inability to participate. What are some patient precautions to take when taking blood pressures? - Correct Answer Avoid: hemodialysis patients with a AV shunt, mastectomy, central venous/PICC lines, open wounds When should a different blood pressure site be used and where are other sites that blood pressures can be taken instead? - Correct Answer Other areas: brachial artery, radial artery, popliteal artery, posterior tibial artery. What does oxygen saturation measure? - Correct Answer Oxygen saturation measures the amount of hemoglobin bound to oxygen in the arteries. factors that can affect accurate oxygen saturation levels - Correct Answer Interference with light transmission Ex. patient motion, nail polish, artificial nails. Interference with arterial pulsation Ex. Hypothermia, hypotension, peripheral edema, disease and medication that causes vasoconstriction. What are the expected normal SpO2 ranges? - Correct Answer 95 to 100% normal When is it a clinical emergency SpO2 range? - Correct Answer 90% and below is clinical emergency A 52 year old woman is admitted with pneumonia, dyspnea, and discomfort in her left chest when taking deep breaths. She has smoked for 35 years and recently lost over 10lb. She is started on intravenous antibiotics, high-protein shakes, and 2 L O2 via nasal cannula. Her most recent vital signs are HR 112, BP 138/82, RR 22, tympanic temperature 37.9 C (100.2 F), and oxygen saturation 94%. Which vital signs reflect a positive outcome of the treatment interventions? (Select all that apply.)

1. Temperature 37 C (98.6 F)

2. Radial pulse: 98
3. Respiratory rate: 18
4. Oxygen saturation: 96%
5. Blood pressure: 134/78 - Correct Answer 1. Temperature 37 C (98.6 F)
6. Radial pulse: 98
7. Respiratory rate: 18
8. Oxygen saturation: 96% The licensed practical nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient does the nurse need to asses first?
9. 84 year old man recently admitted with pneumonia, RR 28, SpO2 89%
10. 54 year old woman admitted after surgery for repair of a fractured arm, BP 160/ mm Hg, HR 72.
11. 63 year old man with venous ulcers from diabetes, temperature 37.3 C (99.1 F), HR
13. 77 year old woman with left mastectomy 2 days ago, RR 22, BP 148/62. - Correct Answer 1. 84 year old man recently admitted with pneumonia, RR 28, SpO2 89% A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical records indicates tympanic temperatures of 38.7 C (101.6 F) at 0400, 36.6 C (97.9 F) at 0800, 36.9 C (98.4 F) at 1200, 37.6 C (99.6 F) at 1600, and 38.3 C (100.9 F) at 2000. How would the nurse describe this pattern of temperature measurements?
14. Usual range of circadian rhythm measurements.
15. Sustained fever pattern.
16. Intermittent fever pattern.
17. Resolving fever pattern. - Correct Answer 3. Intermittent fever pattern. A patient presents in the clinic with dizziness and fatigue. The assistive personnel (AP) reports a slow but regular radial pulse of 44. Places the following care activities in priority order.
18. Direct the AP to obtain a blood pressure.
19. Request that the patient lie on the clinical stretcher.
20. Assess the patient's apical pulse for a full minute.
21. Prepare to administer cardiac-stimulating medications. - Correct Answer 2, 1, 3, 4 Which of the following patients are at most risk for tachypnea? (Select all that apply.)
22. Patient just admitted with four rib fractures
23. Woman who is 9 months' pregnant
24. A patient admitted with hypothermia
25. Postoperative patient waking from general anesthesia
26. Three-pack-per-day smoker with pneumonia - Correct Answer 1. Patient just admitted with four rib fractures

2. Woman who is 9 months' pregnant
3. Three-pack-per-day smoker with pneumonia During admission of an obese patient with heart failure the assistive personnel (AP) reports to the nurse that the blood pressure (BP) is 140/76 on the left arm and 128/ on the right arm. What actions do you take on the basis of this information? (Select all that apply.)
4. Notify the health care provider immediately
5. Repeat the measurements on both arms using a stethoscope.
6. Ask the patient if she has taken her blood pressure medications recently.
7. Obtain blood pressure measurements on lower extremities.
8. Verify that the correct cuff size was used during the measurements.
9. Review the patient's record for her baseline vital signs.
10. Compare right and left radial pulses for strength. - Correct Answer 2. Repeat the measurements on both arms using a stethoscope.
11. Review the patient's record for her baseline vital signs. The assistive personnel (AP) informs the nurse that the electronic BP machine on the patient who has recently returned from surgery after removal of her gallbladder is flashing a blood pressure of 65/46 and alarming. Place the care activities in priority order.
12. Press the start button of the electronic BP machine to obtain a new reading.
13. Obtain a manual BP with a stethoscope
14. Check the patient's pulse distal to the BP cuff.
15. Assess the patient's mental status.
16. Remind the patient not to bend her arm with the BP cuff. - Correct Answer 4, 1, 3, 2, 5 A healthy adult patient tells the nurse that he obtained his BP in "one of those quick machines in the mall" and was alarmed that it was 152/72 when his normal value ranges from 114/76 to 118/78. The nurse obtains a blood pressure of 116/76 What would account for the blood pressure of 152/92? (Select all that apply.)
17. Cuff too small
18. Arm positioned above heart level
19. Slow inflation of the cuff by the machine
20. Patient did not remove his long-sleeve shirt
21. Insufficient time between measurement - Correct Answer 1. Cuff too small
22. Insufficient time between measurement A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The assistive personnel reports his admitting vital signs to the nurse. Which measurements should the nurse reassess?

(Select all that apply.)

1. Right arm BP: 118/
2. Radial pulse rate: 72 and irregular
3. Temporal temperature: 37.4 C (99.3 F)
4. Respiratory rate: 28
5. Oxygen saturation: 99% - Correct Answer 2, 4, 5 Which location would a nurse check auscultate the point of maximal impulse (PMI)? - Correct Answer left side of the chest at the 5th intercostal space (ICS) at the midclavicular line. The apical pulse is the point of maximal impulse and is located at the apex of the heart. Apical pulse - Correct Answer pulse taken with a stethoscope and near the apex of the heart