Fundamentals Final Reviewer Test bank - Questions and Answers Vital Signs.
MULTIPLE CHOICE
1. A nurse notes a patient has abnormal vital signs. What
... [Show More] action by the nurse is best?
2. 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?
d. Plan to take the vital signs more often.
3. A nurse is told in the hand-off report that a patient is afebrile. What assessment finding correlates with this statement?
4. 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?
5. A nurse is going to take a patient’s oral temperature. The patient has been drinking coffee. What action by the nurse is best?
6. A nurse observes a student taking an adult patient’s tympanic temperature. What action by the student requires the nurse to intervene?
7. A nurse assesses a patient’s radial pulse rate to be 110 beats/min and regular. What action by the nurse is best?
8. The student nurse is assessing a patient’s pulses. What action by the student requires the nurse to intervene?
b. Assessing the doralis pedis pulse by palpating behind the patient’s knee
9. The nurse assesses a patient’s pulse and finds it hard to obliterate with palpation. What action by the nurse is best?
a. Assess the patient for fluid volume overload.
10. 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?
c. Compares pulses in both carotid arteries at the same time.
11. A nurse is caring for a patient who has orthopnea. What action by the nurse is most appropriate?
12. 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?
b. Assess the fingers for good circulation.
13. A patient’s blood pressure is 142/76 mm Hg. What does the nurse chart as the pulse pressure?
d. 66
14. 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?
15. The nurse is caring for a woman who had a right-sided mastectomy 2 years ago. What action by the nurse is most appropriate?
a. Place a sign above the bed: “No blood pressures on the right arm.”
16. 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?
b. Ask the patient to rate and describe the pain.
17. The nurse receives a handoff report on four patients. Which patient should the nurse assess first?
c. Pulse 42 beats/min
18. 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?
b. “The lungs are trying to rid the body of extra carbon dioxide.”
1. The nursing student learns that the purpose of measuring vital signs includes which rationale? (Select all that apply.)
a. Monitor body systems functioning.
b. Identify early signs of problems.
c. Evaluate effectiveness of interventions.
e. Provide a baseline to compare against.
ANS: A, B, C, E
2. 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.)
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.”
3. The nurse understands that which factors can increase blood pressure? (Select all that apply.)
a. Head injury
c. Increasing age
d. Recent food intake
e. Pain
4. The nurse assessing respirations understands that problems in what organs can directly affect the process of respiration? (Select all that apply.)
a. Brain
b. Lungs
c. Heart
5. A nurse is teaching a patient and the patient’s family about self-care measures for hypertension. Which topics does the nurse include? (Select all that apply.)
b. Maintain a normal body weight
d. Reduce dietary sodium to 2.4 g/day
e. Follow the DASH diet
6. Which parameters does the nurse include when assessing pain? (Select all that apply.)
a. Facial expression
c. Shallow respirations [Show Less]