Potter-Perry Chapter 29 Vital Signs -2 Questions with Answers Latest Update 2024, Exams of Nursing

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Potter-Perry Chapter 29 Vital Signs -2 Questions with

Answers Latest Update 2024

A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 lbs. Her vital signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8° C (98.2° F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy? A. Temperature 98. B. Radial pulse 112 C. Respiratory rate 24 D. Oxygen saturation 96% E. BP 134/78 - Correct Answer D. Oxygen saturation 96% Oxygen saturation is an assessment of oxygen perfusion. Respiratory rate assesses ventilation, radial pulse and blood pressure assess the cardiovascular system, and temperature is an assessment of thermal regulation. The licensed practice nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first? A. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% B. 54-year-old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72 C. 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84 D. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62 - Correct Answer A. 84 yo man recently admitted with pneumonia, RR 28, SpO2 89% SpO2 89% is a critical value and requires immediate attention. Other values require attention but are not life threatening. A 55-year-old female patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. Which sites do you instruct the nursing assistant to use for obtaining the patient's blood pressure and temperature? A. Right antecubital and tympanic membrane B. Right popliteal and rectal C. Left antecubital and oral D. Left popliteal and temporal artery - Correct Answer A. Right antecubital and tympanic membrane IV in right arm can be turned off while blood pressure is obtained. Blood pressure should not be measured on fractured extremities that have compromised circulation.

Sequential stocking should remain on all the time while the patient is in bed to promote blood flow in lower right extremity. Tympanic membrane temperature is not affected by oxygen; the oxygen would need to be removed to take an oral temperature. Forehead laceration excludes temporal measurement. Rectal temperature is more invasive. The nurse observes a nursing student taking a blood pressure (BP) on a patient. The nurse notes that the student very slowly deflates the cuff in an attempt to hear the sounds. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. Which of the following BP readings made by the student is most likely caused by an incorrect technique? A. 96/40 mm Hg B. 110/66 mm Hg C. 130/90 mm Hg D. 156/82 mm Hg - Correct Answer C. 130/ Deflating the cuff too slowly will result in a false-high diastolic blood pressure. As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. What is the best response? A. Nail polish attracts microorganisms and contaminates the finger sensor. B. Nail polish increases oxygen saturation. C. Nail polish interferes with sensor function. D. Nail polish creates excessive heat in sensor probe. - Correct Answer C. Nail polish interferes with sensor function A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7° C (101.6° F) (0400), 36.6° C (97.9° F) (0800), 36.9° C (98.4° F) (1200), 37.6° C (99.6° F) (1600), and 38.3° C (100.9° F) (2000). How would you describe this pattern of temperature measurements? A.Usual range of circadian rhythm measurements B. Sustained fever pattern C. Intermittent fever pattern D. Resolving fever pattern - Correct Answer C. Intermittent fever pattern A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a slow but regular radial pulse of 44. What is your priority intervention? A. Request that the nursing assistant repeat the pulse check B. Call for a stat electrocardiogram (ECG) C. Assess the patient's apical pulse and evidence of a pulse deficit D. Prepare to administer cardiac-stimulating medications - Correct Answer C. Assess the patient's apical pulse and evidence of a pulse deficit

A radial pulse of 44 is a critical value and requires additional assessment by the nurse. Decreased peripheral pulse can indicate cardiac or vascular abnormality, which can be determined by apical pulse and pulse deficit assessment. Which patient is at highest risk for tachycardia? A. A healthy basketball player during warmup exercises B. A patient admitted with hypothermia C. A patient with a fever of 39.4° C (103° F) D. A 90-year-old male taking beta blockers - Correct Answer C. A patient with a fever Fever elevates metabolism by 10%, resulting in an increased heart rate to remove the heat produced. Hypothermia and beta blockers decrease heart rate. Healthy athletes have a lower heart rate as a result of conditioning. A patient has been admitted for a cerebrovascular accident (stroke). She cannot move her right arm, and she has a right-sided facial droop. She is able to eat with her dentures in place and swallow safely. The nursing assistive personnel (NAP) reports to you that the patient will not keep the oral thermometer probe in her mouth. What direction do you provide to the NAP? A. Direct the NAP to hold the thermometer in place with her gloved hand B. Direct the NAP to switch the thermometer probe to the left sublingual pocket C. Direct the NAP to obtain a right tympanic temperature D. Direct the NAP to use a temporal artery thermometer from right to left - Correct Answer D. Direct the NAP to use a temporal artery thermometer from right to left A temporal artery temperature verifies the forehead temperature in back of the left ear, which is the side not affected by the altered blood flow related to the stroke. Holding the thermometer or switching locations will not help the patient close her mouth during temperature assessment. The patient's right side has vascular changes related to the stroke. The nursing assistive personnel (NAP) informs you that the electronic blood pressure machine on the patient who has recently returned from surgery following removal of her gallbladder is flashing a blood pressure of 65/46 and alarming. What is the correct order for care activities?

1. Press the start button of the electronic blood pressure machine to obtain a new reading.
2. Obtain a manual blood pressure with a stethoscope.
3. Check the patient's pulse distal to the blood pressure cuff.
4. Assess the patient's mental status.
5. Remind the patient not to bend her arm with the blood pressure cuff. A. 5, 3, 1, 4, 2 B. 3, 2, 1, 4, 5 C. 4, 1, 3, 2, 5 D. 1, 2, 4, 3, 5 E. 2, 3, 1, 4, 5 - Correct Answer C. 4, 1, 3, 2, 5

First priority is to verify that the patient's blood pressure is providing adequate blood flow to the brain and critical organs. Movement interferes with electronic blood pressure measurement; recycling the machine will obtain a blood pressure while you are assessing the patient. Check the distal pulse to verify circulation to the extremity and then obtain manual blood pressure if needed. Patient education can prevent false values and decrease patient anxiety with alarms. Which of the following patients are at most risk for tachypnea? (Select all that apply.) A. Patient just admitted with four rib fractures B. Woman who is 9 months' pregnant C. Adult who has consumed alcoholic beverages D. Adolescent waking from sleep E. Three-pack-per-day smoker with pneumonia - Correct Answer A. Pt admitted with 4 rib fractures B. Woman who is 9 month's pregnant E. 3 pack per day smoker with pneumonia Patient with rib fractures is unlikely to breathe deeply and a large fetus restricts diaphragmatic movement, leading to decreased ventilatory volume. Pneumonia decreases gas exchange surface area. Tachypnea occurs to increase minute ventilation. Alcohol is a respiratory depressant. The nursing assistive personnel (NAP) reports to you that the blood pressure (BP) of the patient in Question 11 is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? (Select all that apply.) A. Notify the health care provider immediately B. Repeat the measurements on both arms using a stethoscope C. Ask the patient if she has taken her blood pressure medications recently D. Obtain blood pressure measurements on lower extremities E. Verify that the correct cuff size was used during the measurements F. Review the patient's record for her baseline vital signs G. Compare right and left radial pulses for strength - Correct Answer B. Repeat the measurements on both arms using a stethoscope F. Review the pt's record for vital signs The systolic BP measurements are significantly different and may reflect the vascular and muscular changes caused by the stroke. However, unexpected findings require reassessment by the nurse with a comparison to previous values. It is premature to notify the provider; differences are not caused by medications; inappropriate cuff size would reflect similar systolic pressures; pulse strength would be similar for these BP measurements. A healthy adult patient tells the nurse that he obtained his blood pressure in "one of those quick machines in the mall" and was alarmed that it was 152/72 when his normal

value ranges from 114/72 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.) A. Cuff too small B. Arm positioned above heart level C. Slow inflation of the cuff by the machine D. Patient did not remove his long-sleeved shirt E. Insufficient time between measurements - Correct Answer A. Cuff too small E. Insufficient time between measurements Using too small of a cuff and not allowing for insufficient time between measurements will result in false-high readings. Arm above heart level and slow inflation result in false low readings. A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant reports his admitting vital signs to the nurse. Which measurements should the nurse reassess? (Select all that apply.) A. Right arm BP: 118/ B. Radial pulse rate: 72 and irregular C. Temporal temperature: 37.4° C (99.3° F) D. Respiratory rate: 28 E. Oxygen saturation: 99% - Correct Answer B. Radial pulse rate: 72 or higher D. Respiratory rate: 28 E. O2 saturation: 99% Irregular pulse and elevated respiratory rate are outside of expected values and require further assessment by the nurse. Pneumonia and shortness of breath can cause low oxygen saturation; an assessment of 99% may be a false-high value. Blood pressure and temperature are within expected values for the patient history. What happens when you deflate the cuff too slowly? - Correct Answer Deflating the cuff too slowly will result in a false-high diastolic blood pressure. Normal Oral Temperature Ranges - Correct Answer 96.8-100. Normal Average Oral/Tympanic Temperature - Correct Answer 98. Normal Rectal Temperature Ranges - Correct Answer Usually 0.9 degrees F higher than oral Normal Average Rectal Temperature - Correct Answer 99. Normal Axillary Temperature ranges - Correct Answer Usually 0.9 degrees F lower than oral Normal Axillary Average Temperature - Correct Answer 97.

Normal adult pulse - Correct Answer 60- Normal Respiratory Rate - Correct Answer 12-20 breaths per min Normal Systolic BP - Correct Answer 90- Normal Diastolic BP - Correct Answer 60- Normal O2 Saturation - Correct Answer Above 95% Antipyretic - Correct Answer An agent that reduces fever Auscultation gap - Correct Answer Temporary disappearance of sounds usually heard over the brachial artery, occurring when the cuff pressure is high and gradually reduced, with the sounds again heard at a lower level pressure -Usually occurs in patients w/ hypertension Febrile - Correct Answer Feverish Oximetry - Correct Answer Determination of the oxygen saturation of arterial blood using a photoelectric device called an oximeter Pulse deficit - Correct Answer The difference between apical and radial pulse rates S1 - Correct Answer The first heart sound, heard with the AV (mitral and bicuspid) valve closing S2 - Correct Answer The second heart sound, heard with the semilunar (aortic and pulmonic) valves closing Sims' position - Correct Answer A side-lying position with the lowermost arm behind the body and the uppermost leg flexed Temporal Pulse Site - Correct Answer Location: Over temporal bone of head, above and lateral to the eye Assessment Criteria: easily accessible site used to assess pulse in children Carotid Pulse Site - Correct Answer Location: Along medial edge of sternocleidomastoid in neck Assessment Criteria: Easily accessible site used during physiological shock or cardiac arrest when other sites are not palpable Apical Pulse Site - Correct Answer Location: Fourth to fifth intercostal space at left midclavicular line Assessment Criteria: Site used to auscultate for apical pulse

Brachial Pulse Site - Correct Answer Location: Groove between biceps and triceps muscles at antecubital fossa Assessment Criteria: Site used to assess status of circulation to lower arm and auscultate blood pressure Radial Pulse Site - Correct Answer Location: Radial or thumb side of forearm at wrist Assessment Criteria: Common site used to assess character of pulse peripherally and status of circulation to hand Ulnar Pulse Site - Correct Answer Location: Ulnar or little finger side of forearm at wrist Assessment Criteria: Site used to assess status of circulation to hand Femoral Pulse Site - Correct Answer Location: Below inguinal ligament, midway between symphysis pubis and anterior superior iliac spine Assessment Criteria: Site used to assess character of pulse during physiological shock or cardiac arrest when other pulse aren't palpable; used to assess status of circulation to leg Popliteal Pulse Site - Correct Answer Location: Behind knee in popliteal fossa Assessment Criteria: Site used to assess status of circulation to lower leg Posterior Tibial Pulse Site - Correct Answer Location: Inner side of ankle, below medial malleolus Assessment Criteria: Site used to assess status of circulation to foot Dorsalis Pedis Pulse Site - Correct Answer Location: Along top of foot, between extension tendons of great and first toe Assessment Criteria: Site used to assess status of circulation to foot How does exercise effect pulse? - Correct Answer 1. Short term exercises increases pulse rate

2. Long-term exercise and conditioning of the heart results in a lower (decreased) resting pulse rate & and a quicker return to resting level after exercise How does temperature increase pulse rate? - Correct Answer Fever and heat How does temperature decrease pulse rate? - Correct Answer Hypothermia How do emotions increase pulse rate? - Correct Answer Sympathetic stimulation increased by acute pain and anxiety, affecting rate rate How do emotions decrease pulse rate? - Correct Answer Parasympathetic stimulation increased by unrelieved severe pain

How do medications increase pulse rate? - Correct Answer Positive chronotropic drugs (epinephrine) How do medications decrease pulse rate? - Correct Answer Negative chronotropic drugs (digitalis, beta-adrenergic and calcium channel blockers) How does hemorrhaging increase pulse rate? - Correct Answer Sympathetic stimulation increased by loss of blood How does postural change increase pulse rate? - Correct Answer Standing or sitting How does postural change decrease pulse rate? - Correct Answer Lying down How do pulmonary conditions increase heart rate? - Correct Answer Diseases causing poor oxygenation such as asthma or COPD What happens to BP if the bladder of the cuff is too wide? - Correct Answer False-low What happens to BP if the bladder/cuff is too narrow/short? - Correct Answer False-high What happens to BP if cuff is wrapped too loosely? - Correct Answer False-high What happens to BP if you deflate the cuff too slowly? - Correct Answer False-high diastolic What happens to BP if you deflate the cuff too quickly? - Correct Answer False-low systolic and false-high diastolic What happens to BP if the arm is below heart level? - Correct Answer False-high What happens to BP if the arm is above heart level? - Correct Answer False-low What happens to BP if the arm isn't supported? - Correct Answer False-high What happens to BP if the stethoscope impairs the examiner's hearing? - Correct Answer False-low systolic and false-high diastolic What happens to BP if the stethoscope is applied too firmly? - Correct Answer False- low diastolic What happens to BP if you inflate too slowly? - Correct Answer False-high diastolic What happens to BP if you repeat assessments too quickly? - Correct Answer False- high systolic

What happens to BP if there's an inadequate inflation level? - Correct Answer False-low systolic What happens to BP if multiple examiners use different sounds for each reading? - Correct Answer False-high systolic and false-low diastolic