Question 1

The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement?

Accepted Answer

Place the tips of the first two or middle three fingers of the hand over the groove along the radial or thumb side of the patient's inner wrist. Fingertips are the most sensitive parts of the hand to palpate arterial pulsation. The thumb has a pulsation that interferes with accuracy. The groove along the little finger is the ulnar pulse.

Question 2

The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take?

Accepted Answer

Interventions during a fever include oxygen therapy. During a fever, cellular metabolism increases and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for fluid volume deficit. Fluids should not be restricted, even though the patient has heart failure; the patient needs fluids at this time due to the fever. Increasing the metabolic rate further would not be advisable. Coughing will increase muscular activity, which will increase fever.

Question 3

The patient requires temperatures to be taken every 2 hours. Which task will the nurse assign to an RN?

Accepted Answer

The nurse is responsible for assessing changes in body temperature. The nursing assistive personnel can use the appropriate route and device to measure temperature, obtain temperature measurement at ordered frequency, and be aware of the usual values for the patient.

Question 4

The patient is being admitted to the emergency department following a motor vehicle accident. The patient's jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature reading?

Accepted Answer

The tympanic route is the best choice in this situation. Oral temperatures are not used for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills. Axillary temperature is affected by exposure to the environment, including time to place the thermometer. It also requires a long measurement time. Temporal artery temperature is affected by skin moisture such as diaphoresis or sweating.

Question 5

The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The nurse notices that the patient's temperature is 96.8° F (36° C), whereas at 4:00 PM the preceding day, it was 98.6° F (37° C). What should the nurse do?

Accepted Answer

Body temperature normally changes 0.5° to 1° C (0.9° to 1.8° F) during a 24-hour period and is usually lowest between 1:00 and 4:00 AM, with a maximum temperature at 4:00 PM, making this variation normal for the time of day. Unless the patient reports being cold, there is no physiological need for providing an extra blanket or medication to lower the body temperature further. There is also no need to call a health care provider to report a normal temperature variation.

Question 6

The nurse is caring for an infant and is obtaining the patient's vital signs. Which artery will the nurse use to best obtain the infant's pulse?

Accepted Answer

The brachial or apical pulse is the best site for assessing an infant's or a young child's pulse because other peripheral pulses such as the radial, femoral, and popliteal arteries are deep and difficult to palpate accurately.

Question 7

The nurse is assessing the patient's respirations. Which action by the nurse is most appropriate?

Accepted Answer

Do not let a patient know that you are assessing respirations. A patient aware of the assessment can alter the rate and depth of breathing. Assess respirations immediately after measuring pulse rate, with your hand still on the patient's wrist as it rests over the chest or abdomen. Respirations are the easiest of all vital signs to assess, but they are often the most haphazardly measured. Do not estimate respirations.

Question 8

The patient's blood pressure is 140/60. Which value will the nurse record for the pulse pressure?

Accepted Answer

The difference between the systolic pressure and the diastolic pressure is the pulse pressure. For a blood pressure of 140/60, the pulse pressure is 80 (140 - 60 = 80). 140 is the systolic pressure. 60 is the diastolic pressure. 200 is the systolic (140) added to the diastolic (60), but this has no clinical significance.

Question 9

The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). The patient's last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). Which action will the nurse take?

Accepted Answer

Waiting 30 minutes and rechecking the patient's temperature would be the most appropriate action in this case. A fever is usually not harmful if it stays below 102.2° F (39° C), and a single temperature reading does not always indicate a fever. In addition to physical signs and symptoms of infection, a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time. Nurses should base actions on knowledge, not on assumptions. Encouraging the patient to increase muscular activity will cause heat production to increase up to 50 times normal. The temperature has decreased and a symptom of infection would be an increase in temperature.

Question 10

A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely?

Accepted Answer

Disease or trauma to the hypothalamus or the spinal cord, which carries hypothalamic messages, causes serious alterations in temperature control. The hypothalamus does not control pulse, respirations, or blood pressure.

Question 11

The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do?

Accepted Answer

Oxygen must be used cautiously in these types of patients. Hypoxemia helps to control ventilation in patients with chronic lung disease. Because low levels of arterial O₂ provide the stimulus that allows a patient to breathe, administration of high oxygen levels may be fatal for patients with chronic lung disease. Patients with chronic lung disease have ongoing hypercarbia (elevated CO₂ levels) and do not need to have CO₂ administered or "rebreathed" with a paper bag.

Question 12

A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss?

Accepted Answer

Convection is the transfer of heat away from the body by air movement. Conduction is the transfer of heat from one object to another with direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas.

Question 13

The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient's temperature?

Accepted Answer

Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss because of the direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement.

Question 14

The nurse reviews the laboratory results for a patient and determines the viscosity of the blood is thick. Which laboratory result did the nurse check?

Accepted Answer

The hematocrit, or the percentage of red blood cells in the blood, determines blood viscosity. Blood cultures determine the causative agent of an infection. Abnormal potassium levels can cause dysrhythmias. Arterial blood gases determine acid-base balance or the pH levels of the blood.

Question 15

The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient's temperature?

Accepted Answer

The tympanic route is easily accessible, requires minimal patient repositioning, and often can be used without disturbing the patient. It also has a very rapid measurement time. Oral temperatures require patient cooperation and are not recommended for patients with a history of seizures. Rectal temperatures require positioning and may increase patient agitation. Axillary temperatures need long measurement times and continuous positioning. The patient's agitation state may not allow for long periods of attention.

Question 16

A patient is pyrexic. Which piece of equipment will the nurse obtain to monitor this condition?

Accepted Answer

Pyrexia, or fever, occurs because heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature; therefore, a thermometer is needed. A stethoscope is not used to take a temperature but can be used for apical pulse and blood pressure. A pulse oximeter is used to determine oxygen content in the blood. A sphygmomanometer and blood pressure cuff is used to determine blood pressure and will be used for blood pressure problems.

Question 17

The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient?

Accepted Answer

An elevated body temperature related to the inability of the body to promote heat loss or reduce heat production is hyperthermia. Whereas fever is an upward shift in the set point, hyperthermia results from an overload of the thermoregulatory mechanisms of the body.

Question 18

The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use?

Accepted Answer

The heart continues to deliver blood through the carotid artery to the brain as long as possible. The carotid pulse is easily accessible during physiological shock or cardiac arrest. The radial pulse is used to assess peripheral circulation or to assess the status of circulation to the hand. The brachial site is used to assess the status of circulation to the lower arm. The apical pulse is used to auscultate the apical area.

Question 19

A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take?

Accepted Answer

A newborn loses up to 30% of body heat through the head and therefore needs to wear a cap to prevent heat loss. Temperature control mechanisms in newborns are immature and respond drastically to changes in the environment; do not increase the room temperature to 90 degrees. Take extra care to protect newborns from environmental temperatures. Provide adequate clothing; do not double the clothing or apply just a diaper.

Question 20

A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up?

Accepted Answer

50 mm Hg is abnormal so the nurse will follow up. Normal capnography results are 35 to 45 mm Hg.

Quiz 30: Vital Signs