Vital Sign Measurement and Interpretation, Exams of Nursing

Download Vital Sign Measurement and Interpretation and more Exams Nursing in PDF only on Docsity! Vital Signs Latest Exam Questions With Complete Updated Solutions. A nurse is planning care for a client who is experiencing tachycardia. Which of the following interventions should the nurse plan to make? a) instruct the client to increase exercise b) instruct the client to consume no more than four caffeinated beverages per day c) encourage the client to practice relaxation techniques each day d) encourage the client to engage in pattern paced breathing by panting - Answer c) encourage the client to practice relaxation techniques each day A nurse is teaching a group of AP about techniques used to obtain BP. For which of the following clients should the nurse to instruct the AP to obtain an electronic BP measurement? a) a client who has a BP lower than the expected reference range b) a school-age client c) a client recovering from extensive abdominal surgery d) a client who has stabilized BP measurements - Answer d) a client who has stabilized BP measurements A nurse is observing an AP obtain vital signs from an adult client. Which of the following actions by the AP requires follow up by the nurse? a) the AP pulls the pinna up and back when obtaining a tympanic temperature b) the AP informs the client when they are counting the respirations c) the AP gently presses down with the pads of two or three fingers over the radial pulse site d) the AP selects a blood pressure cuff that is 40% the circumference of the client's arm - Answer b) the AP informs the client when they are counting the respirations A charge nurse in a clinic is preparing an in-service about blood pressure measurements for a group of staff members. Which of the following should the nurse include? a) A client diagnosed with an elevated BP when the measurement is greater than 130/80 mm Hg b) A client us experiencing a hypertensive crisis when their BP is greater than 150/90 mm Hg c) A client who has a BP of 128/86 mm Hg has stage I hypertension d) A client who has a blood pressure of 162/102 mm Hg has stage II hypertension - Answer d) A client who has a blood pressure of 162/102 mm Hg has stage II hypertension A charge nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct? a) pulse 52/min b) RR 24 c) SaO2 97% right index finger, room air d) BP 132/86 mm Hg - Answer c) SaO2 97% right index finger, room air A nurse is assessing a three month old infant during a well-child visit. Which of the following actions should the nurse take when assessing the apical pulse? a) count the number of beats heard in 15 seconds and multiply by 4 b) notify the provider if the apical pulse rate is greater than 110/min c) place the stethoscope over the 4th intercostal space to the left of the sternum d) auscultate the apical pulse for an S4 heart sound - Answer c) place the stethoscope over the 4th intercostal space to the left of the sternum A nurse is caring for a group of clients. Which of the following clients is experiencing an alteration in their RR that requires intervention? a) an adolescent who has a RR of 20/min b) an older adult with RR of 16/min c) an infant with RR of 52/min d) a school-age child who has a RR of 14/min - Answer d) a school-age child who has a RR of 14/min A nurse is planning care for a group of clients. For which of the following clients should the nurse direct an AP to obtain a rectal temperature? a) a toddler who has diarrhea b) a client who is 1 day post op from hemorrhoid surgery c) an infant who is receiving IV fluids d) encourage the client to take a warm shower - Answer a) instruct the client to bear down like they are having a bowel movement A nurse is preparing an in-service about factors affecting RR for a group of APs. Which of the following information should the nurse include? a) anxiety can decrease a client's RR b) opioid analgesics can increase a client's RR c) pain can decrease a client's RR d) Fever can increase a client's RR - Answer d) Fever can increase a client's RR A nurse is caring for a client who has an increase in cardiac afterload. Which of the following findings should the nurse expect? a) increase in BP b) increase in RR c) decrease in cardiac output d decrease in preload - Answer a) increase in BP A nurse is planning care for a client who has hypertension. Which of the following interventions should the nurse include in the plan? Select all that apply a) provide the client with low-sodium meals and snacks b) encourage the client to participate in physical activity each day c) instruct the client in the use of relaxation techniques d) inform the client of the importance of abstaining from using products that contain nicotine e) anticipate a prescription for a 1L fluid bolus - Answer a) provide the client with low-sodium meals and snacks b) encourage the client to participate in physical activity each day c) instruct the client in the use of relaxation techniques d) inform the client of the importance of abstaining from using products that contain nicotine A nurse is reviewing the vital signs obtained by an AP at 1200. For which of the following clients should the nurse plan to intervene? a) adult male who has a RR of 18/min b) toddler who has a RR of 44/min c) newborn who has a RR of 56/min d) adolescent female who has a RR of 16/min - Answer b) toddler who has a RR of 44/min A nurse is discussing oxygen saturation with a client. Which of the following information should the nurse include? a) oxygen saturation is determined by the amount of oxygen bound to WBCs b) oxygen saturation reflects the amount of oxygen being delivered to body tissues c) the expected reference range for oxygen saturation s 90% to 100% d) a capillary refill time of less than 5 seconds ensures a reliable oxygen saturation measurement - Answer b) oxygen saturation reflects the amount of oxygen being delivered to body tissues A charge nurse is discussing a client's RR data with a newly licensed nurse. Which of the following statements should the nurse include? a) clients will exhibit an increase in their RR after using a bronchodilator b) count the RR for 1 min who have a respiratory infection c) expect clients who have a brainstem injury to exhibit rapid respirations d) clients who are experiencing acute pain will have slow, deep respirations - Answer b) count the RR for 1 min who have a respiratory infection A charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. Identify the order of the steps the nurse should include. - Answer 1) select the site for obtaining the measurement 2) apply the sensor probe on the chosen site 3) confirm the pulse rate displayed o the oximeter by palpating the radial pulse 4) wait 15 seconds and observer the SaO2 percentage displayed on the pulse oximeter A nurse is reviewing the vital signs fir four clients. The nurse should identify that which of the following clients has a vital sign outside of the reference range? a) a 52 year old client who has a fever due to a would infection and a pulse rate of 100/min b) a 76 year old client who reports moderate pain and has a RR of 20/min c) a 46 year old client who is postoperative following a hysterectomy and has an SaO2 of 95% d) a 23 year old client who runs marathons and has a BP of 82/54 mm Hg - Answer c) a 46 year old client who is postoperative following a hysterectomy and has an SaO2 of 95% A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. Which of the following statements should the charge nurse make? a) the first step in checking for checking orthostatic hypotension is obtaining a client's BP while they are standing b) an increase of 5 mm of Hg in the diastolic pressure with a position change indicates orthostatic hypotension c) a decrease of 20 mm of Hg in the diastolic pressure with a position change indicates orthostatic hypotension d) wait 5 minutes to check the client's BP after each position change - Answer c) a decrease of 20 mm of Hg in the diastolic pressure with a position change indicates orthostatic hypotension A nurse is preparing an in-service about vital signs for a group of newly hired APs. Which of the following information should the nurse include about measuring body temperature? a) tympanic temperature can be affected by environmental temperature b) temporal temperature is inaccurate in children under 3 years old c) axillary temperature reflects rapid changes in a client's core body temperature d) oral temperature is easily accessible despite a client's position - Answer d) oral temperature is easily accessible despite a client's position A charge nurse is evaluating a newly licensed nurse's documentation of vitals for several clients. Which of the following documentation should the charge nurse identify as being incomplete? a) radial pulse regular at 84/min b) respirations observed as even, nonlabored at 20/min with client in supine position c) BP 124/82 mm Hg lying in bed d) temporal temperature 36.9 degrees C (98.4 degrees F) - Answer c) BP 124/82 mm Hg lying in bed d) an adult client who had tachycardia 1 hr ago due to postoperative pain and has an apical pulse rate of 106/min - Answer a) a preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min b) an older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min c) a young adult who had hypotension after receiving an opioid analgesic now has a blood pressure of 98/68 mm Hg A nurse is reviewing vitals for a group of clients to determine the effectiveness of interventions. Which of the following findings indicates an intervention was effective? a) an adult client who received medication for pan 30 min ago now has a RR of 18/min b) a school-age child who received two units of packed RBCs now has a BP of 76/54 mm Hg c) a toddler who received an antibiotic injection has a heart rate of 148/min while sleeping in their parent's arms - Answer a) an adult client who received medication for pan 30 min ago now has a RR of 18/min A nurse working on a medical-surgical unit is caring for a group of clients. Which of the following clients' vitals should the nurse identify is outside the expected reference range and notify the provider? a) a client who has an apical pulse rate of 120/min b) a client who has a BP of 100/74 mm Hg c) a client who has an apical pulse rate of 84/min d) a client who has a BP of 110/68 mm Hg - Answer a) a client who has an apical pulse rate of 120/min A nurse is planning care for a group of clients and is reviewing the recent vitals obtained by an AP. Which of the following clients should the nurse assess and recheck the vital signs prior to notifying the provider? a) 16 year old female; RR 18/min, SaO2 98% b) 8 year old male; RR 34/min, SaO2 97% c) 11 year old male; RR 28/min, 99% d) 3 year old female; RR 32/min, SaO2 96% - Answer b) 8 year old male; RR 34/min, SaO2 97% A charge nurse is reviewing the expected reference ranges of BP in adult clients with a newly licensed nurse. Which of the following statements should the charge nurse include? a) hypertension is diagnosed with two elevated measurements on two separate occasions b) successive BP measurements of 126 over 78 is classified as stage I hypertension c) stage II hypertension is diagnosed when the BP measurement is 132 over 86 d) a BP measurement of 176 over 102 is classified as hypertensive crisis - Answer a) hypertension is diagnosed with two elevated measurements on two separate occasions A nurse is providing teaching about thermoregulation to a group of newly licensed nurses. Which of the following statements should the nurse include? a) the body increases body temperature through the process known as vasodilation b) the body loses heat through shivering c) the body lowers body temperature through sweating d) the body generates heat through evaporation - Answer c) the body lowers body temperature through sweating A nurse obtains a client's electronic BP reading of 188/96 mm Hg. Which of the following actions should the nurse take next? a) provide client teaching regarding medications to control BP b) notify the provider of the clients BP reading c) provide the client education on measurements to decrease BP d) obtain a manual BP reading from the client - Answer d) obtain a manual BP reading from the client A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart? a) AV node b) left ventricle c) SA node d) right ventricle - Answer c) SA node A nurse is reviewing the recent vitals of a group of clients. Which of the following clients should the nurse see first? a) a 45 year old client who is post-op and has a BP of 130/82 b) a 28 year old client who runs marathons and has a HR of 54/min c) a 52 year old client who has an SaO2 of 92% d) a 78 year old client who has a temperature of 35.9 degrees c (96.6 degrees f) - Answer c) a 52 year old client who has an SaO2 of 92% A nurse is reviewing blood flow through the heart with a group of APs. The nurse should identify that blood flows to which of the following parts of the heart as it leaves the right ventricle? a) tricuspid valve b) pulmonary artery c) right atrium d) vena cava - Answer b) pulmonary artery A nurse is preparing an in-service about peripheral pulses for a group of staff nurses. Which of the following information should the nurse include? a) a pulse strength of +4 indicates that the pulse is of normal strength upon palpation b) a femoral pules that is bounding upon palpation is an expected finding in a young adult c) a pulse strength of +1 indicates that the pulse is weak or diminished upon palpation d) a pedal pulse that is weak upon palpation is an expected finding in an older adult - Answer c) a pulse strength of +1 indicates that the pulse is weak or diminished upon palpation a nurse is planning care for a group of clients and is delegating to the AP to take the client's vitals. For which of the following clients should the nurse obtain the vitals signs rather than the AP? a) a client who just received the fourth dose of antibiotics for an infection b) a client who has heart failure and is scheduled for a discharge later in the day c) a client who is 24 hr post-op and is visiting with friends d) a client who was recently admitted and reports chest pain - Answer d) a client who was recently admitted and reports chest pain A nurse s caring for a client who has a HR of 118/min. Which of the following actions should the nurse take to improve the client's HR? a) encourages the client to reduce the amount of caffeinated soft drinks