General Inspection And Measurement Of Vital Signs

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Question 1

Free

Multiple Choice

Which body system does the nurse assess primarily by inspection?

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Respiratory

Gastrointestinal

Skin

Cardiovascular

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Question 2

Free

Multiple Choice

A patient is sitting slightly forward bracing his arms on his knees in a tripod position. This position is associated with which symptom?

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Abdominal pain

Spinal deformity

Back pain

Breathing difficulty

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Question 3

Free

Multiple Choice

The temperature of a patient is measured every 6 hours at 6 AM, 12 PM, 6 PM, and 12 AM. Which temperature reading is expected to be low due to a normal variation?

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The measurement at 6 AM

The measurement at 12 PM

The measurement at 6 PM

The measurement at 12 AM

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Question 4

Free

Multiple Choice

Which statement is correct regarding taking or interpreting axillary temperatures?

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Axillary temperatures should not be used in patients less than 2 years of age.

Readings may be less accurate.

The thermometer is left in place for no more than 3 minutes.

The thermometer is placed in the axilla with the shoulder abducted.

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Question 5

Free

Multiple Choice

A temperature of 99.8° F taken in the axilla is equivalent to which temperature value taken orally?

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100.8° F

99.8° F

98.8° F

97.8° F

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Question 6

Multiple Choice

The nurse suspects an irregularity in the rhythm of the patient's radial pulse. What is the most appropriate action for this nurse to take at this time?

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Document this rhythm as normal for the patient.

Use a Doppler to check the brachial pulse.

Count the patient's apical pulse for a full minute.

Count the radial pulse again for 15 seconds and multiply by 4.

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Question 7

Multiple Choice

Which of these respiratory rates are within normal limits?

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16-month-old; 42

6-year-old; 20

14-year-old; 26

40-year-old; 10

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Question 8

Multiple Choice

A nurse is taking vital signs of an adult patient whose oxygen saturation is 96%. The patient's temperature is 102° F, blood pressure is 130/86, pulse is 100 beats/min, and respiratory rate is 26 breaths/min. Which factor may be contributing to the elevated respiratory rate?

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The patient's temperature

The patient's oxygen saturation

The patient's pulse rate

The patient's blood pressure

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Question 9

Multiple Choice

Nurses understand that a patient's diastolic pressure represents which physiologic function?

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The pressure needed to open the aortic and pulmonic valves

The pressure in blood vessels when the ventricles contract

The pressure of the blood returning to the heart from the venous system

The pressure in blood vessels when the ventricles are relaxed

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Question 10

Multiple Choice

According to research findings, which site is preferred for measuring blood pressure when the nurse is unable to use the patient's upper arms?

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Ankle

Thigh

Calf

Wrist

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Question 11

Multiple Choice

A patient's blood pressure has been averaging 120/72 when using the upper arms. Today, the nurse uses this patient's thigh to measure the blood pressure. What is the expected systolic pressure using the thigh that is equivalent to a systolic pressure of 120?

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A systolic reading of 110 mm Hg

A systolic reading of 120 mm Hg

A systolic reading of 140 mm Hg

A systolic reading of 170 mm Hg

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Question 12

Multiple Choice

A nurse notices that the patient has gained 11 lb. If this increase in weight is related to fluid retention, the patient is retaining approximately how many liters of fluid?

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1 L

5 L

11 L

24 L

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Question 13

Multiple Choice

Which method of temperature measurement indirectly reflects inner core temperature? (Select all that apply.)

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Axillary temperature

Oral temperature

Tympanic temperature

Rectal temperature

Temporal artery temperature

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Question 14

Multiple Choice

Which method of temperature measurement does a nurse choose when assessing school-aged children in a wellness clinic? (Select all that apply.)

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Axillary temperature

Rectal temperature

Temporal artery temperature

Oral temperature

Tympanic membrane temperature

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Question 15

Multiple Choice

Which action by the nurse results in the patient's blood pressure measurement being falsely high? (Select all that apply.)

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Using a blood pressure cuff that is too narrow for the patient's upper arm

Deflating the blood pressure cuff too rapidly

Wrapping the blood pressure cuff too loosely

Reinflating the blood pressure cuff before it completely deflates

Positioning the patients arm above the level of the heart

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Question 16

Multiple Choice

Which action by the nurse results in the patient's blood pressure measurement being falsely low? (Select all that apply.)

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Using a blood pressure cuff that is too wide for the patients arm

Not inflating the blood pressure cuff enough

Positioning the patient's arm above the level of the heart

Wrapping the cuff too loosely around the arm

Deflating the cuff too rapidly

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Question 17

Multiple Choice

The nurse taking a patient's blood pressure recognizes that several factors may cause an increased blood pressure reading. Which factors below can increase blood pressure? (Select all that apply.)

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The patient rates pain at a level of 7 on a scale of 0 to 10.

The cuff was reinflated before being completely deflated.

The patient drank cold milk just before the reading.

The time of day is late afternoon.

The cuff is too wide for the extremity.

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Question 18

Essay

A female patient admitted with fluid retention has been in diuretic therapy to remove fluid. She weighed 187 lb on admission. Today she weighs 179 lb. Since admission, this patient has lost _____ L from fluid loss.

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