Vital Signs

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Question 1
Free
Multiple Choice

A nurse notes a patient has abnormal vital signs. What action by the nurse is best?

Choose correct answer/s
A

Document the findings.

B

Notify the provider.

C

Compare with prior readings.

D

Retake the vital signs.

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Question 2
Free
Multiple Choice

A patient returned from a procedure and has vital sign measurements ordered every hour. The patient's blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg. What action by the nurse is most appropriate?

Choose correct answer/s
A

Take the vital signs again in another hour.

B

Document the findings in the patient's chart.

C

Have another nurse recheck the vital signs.

D

Plan to take the vital signs more often.

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Question 3
Free
Multiple Choice

A nurse is told in the hand-off report that a patient is afebrile. What assessment finding correlates with this statement?

Choose correct answer/s
A

Blood pressure 152/98 mm Hg

B

Temperature 98.4° F (36.8° C)

C

Pulse 82 beats/min

D

Respirations 16 breaths/min

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Question 4
Free
Multiple Choice

A nurse is caring for a patient who has a high temperature. The nurse plans to help the patient regain a normal temperature through conduction. What technique does the nurse use?

Choose correct answer/s
A

Placing a cooling fan in the patient's room

B

Putting ice packs in the patient's axillae

C

Spraying the patient with a fine mist of water

D

Turning the temperature down in the room

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Question 5
Free
Multiple Choice

A nurse is going to take a patient's oral temperature. The patient has been drinking coffee. What action by the nurse is best?

Choose correct answer/s
A

Have the patient drink room temperature water.

B

Return in 30 minutes to take the patient's temperature.

C

Take the patient's temperature rectally instead.

D

Document that temperature is unable to be obtained.

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Question 6
Multiple Choice

A nurse observes a student taking an adult patient's tympanic temperature. What action by the student requires the nurse to intervene?

Choose correct answer/s
A
Student washes hands prior to patient contact
B
Student pulls the pinna of the patient's ear down and back
C
Student explains the procedure to the patient
D
Student pulls the pinna of the patient's ear up and back
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Question 7
Multiple Choice

A nurse assesses a patient's radial pulse rate to be 110 beats/min and regular. What action by the nurse is best?

Choose correct answer/s
A
Assess the patient for causes of tachycardia.
B
Take an apical heart rate and compare the two.
C
Document the findings in the patient's chart.
D
Notify the patient's health care provider.
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Question 8
Multiple Choice

The student nurse is assessing a patient's pulses. What action by the student requires the nurse to intervene?

Choose correct answer/s
A
Assessing apical pulse between the fifth and sixth intercostal spaces
B
Assessing the doralis pedis pulse by palpating behind the patient's knee
C
Assessing the radial pulse on the patient's wrist
D
Assessing the brachial pulse on the patient's inner elbow
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Question 9
Multiple Choice

The nurse assesses a patient's pulse and finds it hard to obliterate with palpation. What action by the nurse is best?

Choose correct answer/s
A
Assess the patient for fluid volume overload.
B
Assess the patient for fluid volume deficit.
C
Assess the patient's apical heart rate.
D
Assess the patient's pulse deficit.
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Question 10
Multiple Choice

The nursing faculty member is observing a student taking a patient's carotid pulse. What action by the student requires intervention by the faculty member?

Choose correct answer/s
A
Counts pulse for 30 seconds and multiplies by two.
B
Performs hand hygiene prior to patient contact.
C
Compares pulses in both carotid arteries at the same time.
D
Assesses pulse on one side then assesses the other side.
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Question 11
Multiple Choice

A nurse is caring for a patient who has orthopnea. What action by the nurse is most appropriate?

Choose correct answer/s
A
Encourage deep breathing and coughing.
B
Medicate the patient for pain as needed.
C
Keep the head of the bed elevated.
D
Monitor the length of time the patient doesn't breathe.
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Question 12
Multiple Choice

The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The pulse oximeter does not provide a good reading. What action by the nurse is best?

Choose correct answer/s
A
Move the oximeter probe to another finger.
B
Assess the fingers for good circulation.
C
Document that the reading cannot be obtained.
D
Remove any fingernail polish present on the fingernail.
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Question 13
Multiple Choice

A patient's blood pressure is 142/76 mm Hg. What does the nurse chart as the pulse pressure?

Choose correct answer/s
A
28
B
42
C
58
D
66
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Question 14
Multiple Choice

A nurse performs orthostatic blood pressure readings on a patient with the following results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best?

Choose correct answer/s
A
Instruct the patient not to get up without help.
B
Document the findings and continue to monitor.
C
Reassure the patient that these findings are normal.
D
Reassess the blood pressures in 1 hour.
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Question 15
Multiple Choice

The nurse is caring for a woman who had a right-sided mastectomy 2 years ago. What action by the nurse is most appropriate?

Choose correct answer/s
A
Place a sign above the bed: "No blood pressures on the right arm."
B
Place a sign above the bed: "No continuous blood pressures on the right arm."
C
Place a sign above the bed: "Blood pressures in legs only."
D
No specific action is needed for this situation.
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Question 16
Multiple Choice

A nurse works on a postoperative care unit and sees many patients who have orthopedic surgery. One patient complains of significantly more pain than the other postoperative patients usually do. What action by the nurse is best?

Choose correct answer/s
A
Explain to the patient that so much pain is not reasonable.
B
Ask the patient to rate and describe the pain.
C
Give the patient pain medications as prescribed.
D
Call the provider and request an extra dose of pain medication.
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Question 17
Multiple Choice

The nurse receives a handoff report on four patients. Which patient should the nurse assess first?

Choose correct answer/s
A
Pain rating 4/10 after pain medication
B
Blood pressure 102/62 mm Hg
C
Pulse 42 beats/min
D
Respiratory rate 18 breaths/min
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Question 18
Multiple Choice

A nursing student is caring for a patient with metabolic acidosis. The student asks the registered nurse why the patient's respiratory rate is so high. What response by the nurse is best?

Choose correct answer/s
A
"The patient's metabolic rate is increased from being ill."
B
"The lungs are trying to rid the body of extra carbon dioxide."
C
"The patient is trying to reduce his temperature through panting."
D
"Patients who are acutely ill often have abnormal vital signs."
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Question 19
Multiple Choice

The nursing student learns that the purpose of measuring vital signs includes which rationale? (Select all that apply.)

Choose correct answer/s
A
Monitor body systems functioning.
B
Identify early signs of problems.
C
Evaluate effectiveness of interventions.
D
Determine if a cure has been obtained.
E
Provide a baseline to compare against.
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Question 20
Multiple Choice

The nurse is delegating taking vital signs to an unlicensed assistive personnel (UAP). What instructions does the nurse provide the UAP? (Select all that apply.)

Choose correct answer/s
A
"Let me know if Mr. Smith's blood pressure is low."
B
"Take Mrs. Jones' blood pressure every 15 minutes."
C
"Call me if Ms. Walsh's systolic blood pressure drops to under 100 mm Hg."
D
"Do you want me to demonstrate using the electronic blood pressure cuff?"
E
"I'll take Mr. Derby's blood pressure since he is not stable."
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