Clinical Nursing Skills and Techniques 8th Edition by Anne Griffin Perry – Test Bank

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Chapter 5: Vital Signs

MULTIPLE CHOICE

1.The patient is brought to the emergency department complaining of severe shortness of breath. She is cyanotic and her extremities are cold. In an attempt to quickly assess the patient’s respiratory status, the nurse should:

a.	remove the patient’s nail polish to get a pulse oximetry reading.
b.	use a forehead probe to get a pulse oximetry reading.
c.	use a finger probe to get a pulse oximetry reading.
d.	check the color of the patient’s nail polish before attempting a reading.

ANS: B

Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacologic vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Assess for factors that influence measurement of SpO₂ (e.g., oxygen therapy; respiratory therapy such as postural drainage and percussion; hemoglobin level; hypotension; temperature; nail polish [Cieck et al., 2010]; medications such as bronchodilators).

DIF:Cognitive Level: AnalysisREF:Text reference: p. 101

OBJ:Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.TOP:Pulse Oximetry

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2.A person’s core temperature is considered the most accurate since it is:

a.	reflective of the surrounding environment.
b.	the same for everyone.
c.	controlled by the hypothalamus.
d.	independent of external influences.

ANS: C

The core temperature, or the temperature of the deep body tissues, is under the control of the hypothalamus and remains within a narrow range. Skin or body surface temperature rises and falls as the temperature of the surrounding environment changes, and it fluctuates dramatically. Body tissues and cells function best within a relatively narrow temperature range, from 36° C to 38° C (96.8° F to 100.4° F), but no single temperature is normal for all people. For healthy young adults, the average oral temperature is 37° C (98.6° F). An acceptable temperature range for adults depends on age, gender, range of physical activity, hydration status, and state of health.

DIF:Cognitive Level: AnalysisREF:Text reference: p. 67

OBJ:Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.TOP:Core Temperature

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3.The nurse takes the patient’s temperature using a tympanic electronic thermometer. The temperature reading is 36.5° C (97.7° F). The nurse knows that this correlates with:

a.	37.0° C (98.6° F) rectally.
b.	37.0° C (98.6° F) orally.
c.	36.0° C (97.7° F) axillary.
d.	36.0° C (97.7° F) orally.

ANS: B

It generally is accepted that axillary and tympanic temperatures are usually 0.5° C (0.9° F) lower than oral temperatures. It generally is accepted that rectal temperatures are usually 0.5° C (0.9° F) higher than oral temperatures.

DIF:Cognitive Level: AnalysisREF:Text reference: p. 67

OBJ: Discuss factors involved in selecting temperature measurement sites.

TOP: Temperature Assessment KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4.The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette. The patient has just returned from his “cigarette break.” The nurse is about to take the patient’s temperature orally and should:

a.	wait about 15 minutes before taking his temperature.
b.	give him oral fluids to rinse the nicotine away before taking his temperature.
c.	give him a stick of chewing gum to chew and then take his temperature.
d.	take his oral temperature and record the findings.

ANS: A

The nurse should verify that the patient has not had anything to eat or drink and has not chewed gum or smoked within the 15 minutes before oral temperature is measured. Oral food and fluids and smoking and gum can alter temperature measurement.

DIF:Cognitive Level: SynthesisREF:Text reference: p. 71

OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Oral Temperature Assessment

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5.When evaluating the patient’s temperature levels, the nurse expects the patient’s temperature to be lower:

a.	in the morning.
b.	after exercising.
c.	during periods of stress.
d.	during the postoperative period.

ANS: A

Temperature is lowest during early morning. Muscle activity and stress raise heat production. Drugs may impair or promote sweating, vasoconstriction, or vasodilation, or may interfere with the ability of the hypothalamus to regulate temperature.

DIF:Cognitive Level: ComprehensionREF:Text reference: p. 70

OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Temperature Assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

6.When inserting a rectal thermometer, the nurse encounters resistance. The nurse should:

a.	apply mild pressure to advance.
b.	ask the patient to take deep breaths.
c.	remove the thermometer immediately.
d.	remove the thermometer and reinsert it gently.

ANS: C

If resistance is felt during insertion, withdraw the thermometer immediately. Never force the thermometer. This prevents trauma to the mucosa. With the nondominant hand, separate the patient’s buttocks to expose the anus. Ask the patient to breathe slowly and relax. This fully exposes the anus for thermometer insertion and relaxes the anal sphincter for easier thermometer insertion.

DIF:Cognitive Level: ApplicationREF:Text reference: p. 72

OBJ:Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures.TOP:Rectal Temperature Assessment

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7.An appropriate procedure for measurement of an adult’s temperature with a tympanic membrane sensor is:

a.	pulling the ear pinna down and back.
b.	moving into the ear in a figure-eight pattern.
c.	fitting the probe loosely into the ear canal.
d.	pointing the probe toward the mouth and chin.

ANS: B

Move the thermometer in a figure-eight pattern. Pull the ear pinna backward, up, and out for an adult; fit the speculum tip snugly in the canal and do not move; and point the speculum tip toward the nose.

DIF:Cognitive Level: ApplicationREF:Text reference: p. 75

OBJ:Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures.TOP:Rectal Temperature Assessment

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8.The patient is a 1-year-old male infant who is admitted with possible sepsis. The patient is irritable and agitates easily. What should the nurse do to assess the patient’s temperature?

a.	Take an oral temperature before doing anything else.
b.	Take an axillary temperature using the upper axilla.
c.	Place the child in Sims’ position for a rectal temperature.
d.	Take a rectal temperature as the last vital sign.

ANS: D

Critically ill children sometimes have cool skin but a high core temperature because of poor perfusion to the skin. Children may assume the prone position for rectal temperature measurement. With children who cry or are restless, it is best to take temperature as the last vital sign. Use axillary temperatures for screening purposes only, not to detect fevers in infants and young children. Use the lower axilla to record temperature in side-lying infants.

DIF:Cognitive Level: ApplicationREF:Text reference: p. 76

OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures. TOP: Temperature Assessment in Pediatric Patients

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

9.The patient is returning from a cardiac catheterization. The puncture site is in the right femoral artery. The patient is having vital signs assessed every 15 minutes. Along with vital signs, the nurse assesses the pedal pulses of the right and left feet. Which of the following would be of major concern?

a.	Both pedal pulses were bounding.
b.	The femoral artery could be palpated.
c.	The right pedal pulse was weaker than the left.
d.	The radial artery pulse was 88.

ANS: C

If a peripheral pulse distal to an injured or treated area of an extremity feels weak on palpation, the volume of blood reaching tissues below the affected area may be inadequate, and surgical intervention may be necessary. A full bounding pulse is an indication of increased volume. When the pulse wave reaches a peripheral artery, you can feel it by palpating the artery lightly against underlying bone or muscle. The pulse is the palpable bounding of the blood flow. The usual range for adults is 60 to 100 beats per minute.

DIF:Cognitive Level: AnalysisREF:Text reference: p. 77

OBJ:Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.TOP:Pulse Assessment

KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

10.The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette. The patient has just returned from his “cigarette break.” The nurse is about to take the patient’s radial pulse and should:

a.	wait about 15 minutes before taking his pulse.
b.	use her thumb to detect the pulse and get an accurate count.
c.	press hard to detect the pulse and get an accurate count.
d.	take his pulse for 15 seconds and multiply by 4.

ANS: A

If a patient has been smoking, wait 15 minutes before assessing pulse. Anxiety, activity, and smoking elevate heart rate. Assessing radial pulse rate at rest allows for objective comparison of values. Fingertips are the most sensitive parts of the hand for palpating arterial pulsation. The nurse’s thumb has pulsation that interferes with accuracy. Pulse assessment is more accurate when moderate pressure is used. Too much pressure occludes pulse and impairs blood flow. If the pulse is regular, count the rate for 30 seconds and multiply the total by 2. If the pulse is irregular, count the rate for a full 60 seconds. Assess the frequency and the pattern of irregularity.

DIF:Cognitive Level: AnalysisREF:Text reference: p. 78

OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Pulse Assessment

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

11.When evaluating the radial pulse measurement technique of the nursing assistant, the nurse identifies appropriate technique when the assistant:

a.	has the patient’s arm elevated.
b.	positions the patient supine or sitting.
c.	applies significant pressure to the pulse site.
d.	counts the pulse for 15 seconds and multiplies by 4.

ANS: B

Assist the patient to assume a supine or sitting position. If the patient is supine, place the patient’s forearm straight alongside or across the lower chest or upper abdomen with the wrist extended straight. If the patient is sitting, bend the patient’s elbow 90 degrees and support the lower arm on the chair or on the nurse’s arm. Slightly extend or flex the wrist with the palm down until the strongest pulse is noted. Lightly compress against the radius, obliterate the pulse initially, and then relax pressure so the pulse becomes easily palpable. Pulse is assessed more accurately with moderate pressure. Too much pressure occludes the pulse and impairs blood flow. If the pulse is regular, count the rate for 30 seconds and multiply the total by 2. If the pulse is irregular, count the rate for 60 seconds. Assess frequency and pattern of irregularity.

DIF:Cognitive Level: ComprehensionREF:Text reference: p. 79

OBJ: Appropriately delegate vital sign measurements to nursing assistive personnel (NAP).

TOP: Delegation of Pulse Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

12.The nurse is caring for an infant in the NICU. While taking vital signs, the nurse finds that the baby’s heart rate is 195. The nurse calls the physician, knowing that the normal heart rate should be:

a.	60 to 100 beats per minute.
b.	100 to 160 beats per minute.
c.	90 to 140 beats per minute.
d.	220 beats per minute or higher.

ANS: B

The infant’s heart rate at birth ranges from 100 to 160 beats per minute at rest. By adolescence, the heart rate varies between 60 and 100 beats per minute and remains so throughout adulthood. By age 2, the pulse rate slows to 90 to 140 beats per minute.

DIF:Cognitive Level: AnalysisREF:Text reference: p. 82

OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Assessing Apical Pulse

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

13.The patient has been in the hospital for several days for urosepsis. He has been responding favorably to treatment, and his vital signs have been “normal” for 2 days. When the nurse takes his vital signs, however, the patient’s apical pulse is 152 and regular. The nurse suspects that the:

a.	patient is having a reaction to his narcotic medication.
b.	patient may be suffering from hypothermia.
c.	patient’s fever may have returned.
d.	patient may be an athlete.

ANS: C

Fever or exposure to warm environments increases heart rate. Large doses of narcotic analgesics and hypothermia can slow heart rate. A well-conditioned patient may have a slower than usual resting heart rate, which returns more quickly to resting rate after exercise.

DIF:Cognitive Level: SynthesisREF:Text reference: p. 82

OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Assessing Apical Pulse

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

14.What steps should the nurse take to conduct an assessment of a possible pulse deficit?

a.	A nurse measures the pulse after the patient exercises.
b.	Two nurses check the same pulse on opposite sides of the body.
c.	Two nurses assess the apical and radial pulses and determine the difference.
d.	The current pulse is compared with previous pulse measurements for differences.

ANS: C

Locate apical and radial pulse sites. One nurse auscultates the apical pulse, and one nurse palpates the radial pulse. Both nurses count the pulse rate for 60 seconds simultaneously. Subtract the radial rate from the apical rate to obtain the pulse deficit. The pulse deficit reflects the number of ineffective cardiac contractions in 1 minute. If a pulse deficit is noted, assess for other signs and symptoms of decreased cardiac output.

DIF:Cognitive Level: ApplicationREF:Text reference: p. 85

OBJ: Explain the implications of a pulse deficit. TOP: Pulse Deficit

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

15.An appropriate method of assessing a patient’s respirations is for the nurse to:

a.	place the bed flat.
b.	remove all supplemental oxygen sources from documentation.
c.	explain to the patient that respirations are being assessed.
d.	gently place the patient’s hand in a relaxed position over the upper abdomen.

ANS: D

Place the patient’s arm in a relaxed position across the abdomen or lower chest, or place the nurse’s hand directly over the patient’s upper abdomen. Be sure the patient is in a comfortable position, preferably sitting or lying with the head of the bed elevated 45 to 60 degrees. Sitting erect promotes full ventilatory movement. A position of discomfort may cause the patient to breathe more rapidly. Documentation should include any supplemental oxygen that the patient is receiving. Inconspicuous assessment of respirations immediately after pulse assessment prevents the patient from consciously or unintentionally altering the rate and depth of breathing.

DIF:Cognitive Level: ApplicationREF:Text reference: p. 88

OBJ: Accurately assess a patient’s respirations. TOP: Respiratory Assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

16.The nurse is about to take vital signs on a newborn patient in the nursery. She should:

a.	assess respiratory rate after taking a rectal temperature.
b.	observe the child’s chest while the child is sleeping.
c.	call the physician if the rate is over 40.
d.	expect that the child will have short periods of apnea.

ANS: D

An irregular respiratory rate and short apneic spells are normal for newborns. Assess respiratory rate before other vital signs or assessments are taken. Children up to age 7 breathe abdominally, so respirations are observed by abdominal movement. Average respiratory rate (breaths per minute) for newborns is 30 to 60; for infants (6 months to 1 year), 30 to 50; for toddlers (2 years), 25 to 32; and for children from 3 to 12 years, 20 to 30.

DIF:Cognitive Level: AnalysisREF:Text reference: p. 90

OBJ: Accurately assess a patient’s respirations. TOP: Pediatric Considerations

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

17.The nurse should report an assessment of _____ respirations per minutes for a(n) _____.

a.	14; adult patient
b.	16; 8-year-old patient
c.	25; toddler
d.	38; newborn

ANS: B

Acceptable average respiratory rate (breaths per minute) for newborns is 35 to 40; for infants (6 months), 30 to 50; for toddlers (2 years), 22 to 32; and for children, 20 to 30. Adults average 12 to 20 respirations per minute.

DIF:Cognitive Level: ApplicationREF:Text reference: p. 90

OBJ: Identify ranges of acceptable vital sign values for infant, child, and adult.

TOP: Respiratory Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

18.During the normal cardiac cycle, blood pressure reaches a peak, followed by a trough, in the cycle. What is the peak known as?

a.	Pulse pressure
b.	Systole
c.	Diastole
d.	Korotkoff phase

ANS: B

Blood pressure is the force exerted by blood against the vessel walls. During a normal cardiac cycle, blood pressure reaches a peak, followed by a trough, or low point, in the cycle. The peak pressure occurs when the heart’s ventricular contraction, or systole, forces blood under high pressure into the aorta. The difference between systolic pressure and diastolic pressure is the pulse pressure. When the ventricles relax, the blood remaining in the arteries exerts a minimum or diastolic pressure. Diastolic pressure is the minimal pressure exerted against the arterial wall at all times. As the sphygmomanometer cuff is deflated, the five different sounds heard over an artery are called Korotkoff phases.

DIF:Cognitive Level: KnowledgeREF:Text reference: p. 90

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Systolic Blood Pressure KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

19.The patient is complaining of a severe headache. The nurse takes the patient’s blood pressure and finds it to be 240/110. What is the pulse pressure?

a.	110
b.	240
c.	130
d.	350

ANS: C

The difference between systolic pressure and diastolic pressure is the pulse pressure. For a blood pressure of 240/110, the pulse pressure is 130. The diastolic pressure is 110. The systolic pressure is 240. The sum of the systolic and diastolic pressures is 350.

DIF:Cognitive Level: AnalysisREF:Text reference: p. 90

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Pulse Pressure KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

20.During his initial screening, the patient’s blood pressure was noted to be elevated. Two months after the first assessment, he was noted to have a blood pressure of 150/92 and 166/96 at different times during the visit. It is now a month and a half later, and the nurse is concerned because the patient’s initial blood pressure on this visit was 154/94. She is preparing to take a second blood pressure, understanding that another reading in this range could lead to a diagnosis of:

a.	hypotension
b.	prehypertension
c.	hypertension
d.	orthostatic hypotension

ANS: C

Hypertension is defined as systolic blood pressure (SBP) of 140 mm Hg or greater, diastolic blood pressure (DBP) of 90 mm Hg or greater, or taking antihypertensive medication (NHBPEP, 2003). One blood pressure recording revealing a high SBP or DBP does not qualify as a diagnosis of hypertension. However, if you assess a high reading (e.g., 150/90 mm Hg), encourage the patient to return for another checkup within 2 months. The diagnosis of hypertension in adults requires an average of two or more readings taken at each of two or more visits after an initial screening. Hypotension occurs when the systolic blood pressure falls to 90 mm Hg or below. Prehypertension is a designation for patients at high risk for developing hypertension. In these patients, early intervention through adoption of healthy lifestyles reduces the risk of or prevents hypertension. Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., lightheadedness, dizziness) and low blood pressure when rising to an upright position.

DIF:Cognitive Level: SynthesisREF:Text reference: p. 91

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Hypertension KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

21.The patient is an 86-year-old woman who is being admitted for dehydration and pneumonia. The patient is lying in bed but tells the nurse that she needs to go to the bathroom. The nurse tells the patient that she will stay with her and will help her get there. The patient states, “That’s OK. I can make it on my own.” The nurse should:

a.	help the patient to the bathroom and stay with her.
b.	allow the patient to get up on her own and go to the bathroom.
c.	allow the patient to go to the bathroom and call for help if needed.
d.	insert a Foley catheter.

ANS: A

Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., lightheadedness, dizziness) and low blood pressure when rising to an upright position. Orthostatic changes in vital signs are good indicators of blood volume depletion. In severe cases of orthostatic hypotension, loss of consciousness may occur. Foley catheters are believed to be a major source or urinary tract infection.

DIF: Cognitive Level: Synthesis REF: Text reference: p. 91 |Text reference: p. 98

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Orthostatic Hypotension KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

22.The nurse chooses a sphygmomanometer that has a circular gauge and a needle that registers the millimeter calibrations. This type of device is known as a(n) _____ manometer.

a.	mercury
b.	electronic
c.	aneroid
d.	direct (invasive)

ANS: C

The aneroid manometer has a glass-enclosed circular gauge containing a needle that registers millimeter calibrations. Metal parts in the aneroid manometer are subject to temperature expansion and contraction and must be recalibrated at least every 6 months to verify their accuracy. Before using the aneroid manometer, make sure the needle is pointing to zero. With mercury manometers, pressure created by inflation of the compression cuff moves the column of mercury up the tube against the force of gravity. Millimeter calibrations mark the height of the mercury column. Electronic or automatic blood pressure machines consist of an electronic sensor positioned inside a blood pressure cuff attached to an electronic processor. You measure arterial blood pressure either directly (invasively) or indirectly (noninvasively). The direct method requires electronic monitoring equipment and the insertion of a thin catheter into an artery. The risks associated with invasive blood pressure monitoring require use in an intensive care setting.

DIF:Cognitive Level: KnowledgeREF:Text reference: p. 91

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP:ManometersKEY:Nursing Process Step: Diagnosis

MSC: NCLEX: Physiological Integrity

23.The nurse is working on the general surgical unit and is caring for a patient who has a right total mastectomy. To take the patient’s vital signs and to accurately assess the patient’s blood pressure, it will be necessary to:

a.	place the blood pressure cuff on the left upper arm.
b.	place the blood pressure cuff on the right upper arm.
c.	place the blood pressure cuff on the right lower arm.
d.	use direct (invasive) blood pressure measurement.

ANS: A

Determine the best site for blood pressure assessment. Avoid applying the cuff to an extremity when intravenous fluids are infusing, an arteriovenous shunt or fistula is present, or breast or axillary surgery has been performed on that side. The risks associated with invasive blood pressure monitoring require use in an intensive care setting.

DIF:Cognitive Level: ApplicationREF:Text reference: p. 93

OBJ: Describe factors involved in selecting an extremity to measure blood pressure.

TOP:ManometersKEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

24.Which site is used to auscultate blood pressure?

a.	Radial
b.	Ulnar
c.	Brachial
d.	Temporal

ANS: C

Place the stethoscope over the brachial artery to measure blood pressure. Use the radial site for the radial pulse, the ulnar site for the ulnar pulse, and the temporal site for the temporal pulse.

DIF:Cognitive Level: ApplicationREF:Text reference: p. 77

OBJ: Describe factors involved in selecting an extremity to measure blood pressure.

TOP: Brachial Pulse KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

25.The nurse is caring for a 2-year-old child who is admitted with croup and crying. To take the child’s vital signs, the nurse should:

a.	place the pediatric blood pressure cuff on the left arm.
b.	place the blood pressure cuff on the right thigh.
c.	skip the blood pressure measurement.
d.	place the blood pressure cuff on the left thigh.

ANS: C

Blood pressure is not a routine part of assessment in children younger than 3 years. The right arm is preferred for blood pressure measurement in children older than 3. Thigh blood pressure is the least preferred and the most uncomfortable method for children.

DIF:Cognitive Level: AnalysisREF:Text reference: p. 98

OBJ: Describe factors involved in selecting an extremity to measure blood pressure.

TOP: Teaching Considerations KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

26.When the benefits of the different types of blood pressure monitoring devices are compared, which of the following patients would be the best candidate for noninvasive electronic blood pressure measurement?

a.	A 49-year-old postsurgical patient with no history of heart disease on q15min vital signs
b.	A 22-year-old patient undergoing active grand mal seizures
c.	A 68-year-old patient with diagnosed peripheral vascular disease
d.	A 54-year-old patient with chronic atrial fibrillation

ANS: A

These devices are used when frequent assessment is required, as in critically ill or potentially unstable patients; during or after invasive procedures; or when therapies require frequent monitoring. Patients with irregular heart rate, peripheral vascular disease, seizures, tremors, and shivering are not candidates for this device.

DIF:Cognitive Level: AnalysisREF:Text reference: p. 99

OBJ: Discuss the benefits and disadvantages of using an automatic blood pressure machine.

TOP:Noninvasive Electronic Blood Pressure Measurement

KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

27.The patient was found in an alley on a cold winter night and is admitted with hypothermia from environmental exposure. She is elderly and is having difficulty breathing. Her breath sounds are diminished, and the tip of her nose is cyanotic. The nurse wants to assess the oxygen level in the patient’s blood. She decides to use the pulse oximeter. The best way to apply this to this patient would be with a(n):

a.	finger probe.
b.	earlobe sensor.
c.	forehead sensor.
d.	toe sensor.

ANS: C

In adults, you can apply reusable and disposable oximeter probes to the earlobe, finger, toe, bridge of the nose, or forehead. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacologic vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas.

DIF:Cognitive Level: AnalysisREF:Text reference: p. 101

OBJ: Accurately assess a patient’s oxygenation status using pulse oximetry.

TOP: Oxygen Saturation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

28.The patient is admitted in a near comatose state with a blood glucose level of 750. His respiratory rate is 42 breaths per minute, and his respiratory pattern is deep and regular. What is this type of breathing known as?

a.	Cheyne-Stokes respiration
b.	Biot’s respiration
c.	Bradypnea
d.	Kussmaul’s respiration

ANS: D

Respirations are abnormally deep, regular, and increased in rate. This is common in diabetic ketoacidosis. With Cheyne-Stokes respirations, respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. The respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses, and breathing slows and becomes shallow, climaxing in apnea before respiration resumes. With Biot’s respirations, respirations are abnormally shallow for two to three breaths followed by an irregular period of apnea. With bradypnea, the rate of breathing is regular but abnormally slow (fewer than 12 breaths per minute).

DIF:Cognitive Level: AnalysisREF:Text reference: p. 89

OBJ: Accurately assess a patient’s respirations. TOP: Breathing Patterns

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

29.What is a disadvantage of using the disposable sensor pad for pulse oximetry?

a.	It is less restrictive.
b.	It contains latex.
c.	It is less expensive to use.
d.	It is available in different sizes.

ANS: B

A disposable sensor pad can be applied to a variety of sites, including the earlobe of an adult and the nose bridge, palm, or sole of an infant. It is less restrictive for continuous SpO₂ monitoring. It is expensive and contains latex, which some patients may not be able to tolerate. The skin under the adhesive may become moist and may harbor pathogens. It is available in a variety of sizes, and the pad can be matched to infant weight.

DIF:Cognitive Level: ApplicationREF:Text reference: p. 101

OBJ: Accurately assess a patient’s oxygenation status using pulse oximetry.

TOP: Oxygen Saturation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1.The nurse is preparing to take the patient’s temperature. Which of the following may cause the temperature to fluctuate? (Select all that apply.)

a.	Age
b.	Stress
c.	Hormones
d.	Medications

ANS: A, B, C, D

Older adults have a narrower range of temperature than younger adults. A temperature within an acceptable range in an adult may reflect a fever in an older adult. Undeveloped temperature control mechanisms in infants and children cause temperature to rise and fall rapidly. Stress elevates temperature. Women have wider temperature fluctuations than men because of menstrual cycle hormonal changes; body temperature varies during menopause. Some drugs impair or promote sweating, vasoconstriction, or vasodilation, or interfere with the ability of the hypothalamus to regulate temperature.

DIF:Cognitive Level: AnalysisREF:Text reference: p. 70

OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Temperature Assessment

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2.Which of the following processes are involved in respiration? (Select all that apply.)

a.	Ventilation
b.	Diffusion
c.	Oximetry
d.	Perfusion

ANS: A, B, D

Three processes are involved in respiration: ventilation, mechanical movement of gases into and out of the lungs; diffusion, movement of O₂ and CO₂ between the alveoli and the red blood cells; and perfusion, distribution of red blood cells to and from the pulmonary capillaries.

DIF:Cognitive Level: ComprehensionREF:Text reference: p. 86

OBJ: Accurately assess a patient’s respirations. TOP: Respiratory Assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3.The nurse is about to teach the patient about risk factors for hypertension. Which of the following are risk factors for hypertension? (Select all that apply.)

a.	Obesity
b.	Cigarette smoking
c.	High blood cholesterol
d.	Renal disease

ANS: A, B, C, D

Persons with a family history of hypertension, premature heart disease, lipemia, or renal disease are at significant risk. Obesity, cigarette smoking, heavy alcohol consumption, high blood cholesterol and triglyceride levels, and continued exposure to stress from psychosocial and environmental conditions are factors linked to hypertension.

DIF:Cognitive Level: KnowledgeREF:Text reference: p. 93

OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Teaching Considerations

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

4.The nurse is about to take a patient’s blood pressure. Which of the following conditions would cause the nurse to obtain a false high reading? (Select all that apply.)

a.	Bladder or cuff too narrow
b.	Bladder or cuff too wide
c.	Patient’s arm below the level of the heart
d.	Inflating the cuff too slowly

ANS: A, C, D

Bladder or cuff too narrow or too short, arm below heart level, or inflating the cuff too slowly will give a false high reading. A bladder or cuff too wide will give a false low reading.

DIF:Cognitive Level: AnalysisREF:Text reference: p. 92

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP:Common Mistakes in Blood Pressure Assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

COMPLETION

1.___________, a subjective symptom, is also referred to as a vital sign, along with the physiological signs.

ANS:

Pain

Pain, a subjective symptom, is also referred to as a vital sign, along with the physiological signs.

DIF:Cognitive Level: ComprehensionREF:Text reference: p. 66

OBJ: Identify when it is appropriate to assess each vital sign. TOP: Pain as a Vital Sign

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

2.When heat loss mechanisms are unable to keep pace with heat production, ____________ is the result.

ANS:

fever

Fever occurs when heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature.

DIF:Cognitive Level: AnalysisREF:Text reference: p. 67

OBJ:Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.TOP:Core Temperature

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3.The nurse is taking a rectal temperature on an adult patient. She expects to insert the thermometer __________ inches.

ANS:

1.5

Gently insert the thermometer into the anus in the direction of the umbilicus 3.5 cm (1.5 inches) for an adult. Do not force the thermometer.

DIF:Cognitive Level: ApplicationREF:Text reference: p. 72

OBJ:Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures.TOP:Rectal Temperature Assessment

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4.The patient has been sleeping and has been lying on his right side. The nurse is ready to take his temperature using a tympanic thermometer. She needs to insert the thermometer into his ___________ ear.

ANS:

left

If the patient has been lying on one side, use the upper ear. Heat trapped in the ear facing down will cause a false high temperature reading.

DIF:Cognitive Level: ApplicationREF:Text reference: p. 74

OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures. TOP: Tympanic Membrane Temperature Assessment

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5.An irregular heartbeat, often found in children, that speeds up with inspiration and slows down with expiration is known as a sinus ___________.

ANS:

dysrhythmia

Children often have a sinus dysrhythmia, which is an irregular heartbeat that speeds up with inspiration and slows down with expiration.

DIF:Cognitive Level: AnalysisREF:Text reference: p. 80

OBJ:Accurately assess a patient’s radial and apical pulses.

TOP:Pulse Assessment—Pediatric Considerations

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

6.___________ is the sound of the tricuspid and mitral valves closing at the end of ventricular filling.

ANS:

S1

S1 is the sound of the tricuspid and mitral valves closing at the end of ventricular filling, just before systolic contraction begins.

DIF:Cognitive Level: ApplicationREF:Text reference: p. 81

OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Assessing Apical Pulse

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

7._________ is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction.

ANS:

S2

S2 is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction.

DIF:Cognitive Level: ApplicationREF:Text reference: p. 81

OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Assessing Apical Pulse

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

8.An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a ____________.

ANS:

pulse deficit

An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. Pulse deficits frequently are associated with dysrhythmias and warn of potentially decreased cardiac function.

DIF:Cognitive Level: ComprehensionREF:Text reference: p. 85

OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Pulse Deficit

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

9.To take a manual blood pressure, the nurse places the cuff of the _____________ around the patient’s upper arm.

ANS:

sphygmomanometer

The most common technique of measuring blood pressure is auscultation using a sphygmomanometer and stethoscope.

DIF:Cognitive Level: ComprehensionREF:Text reference: p. 90

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Sphygmomanometer KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

10.After applying the sphygmomanometer to the patient’s upper arm, the nurse inflates the cuff to the proper level, and then, using a stethoscope, listens for the __________________ sounds.

ANS:

Korotkoff

The most common technique used for measuring blood pressure is auscultation with a sphygmomanometer and stethoscope. As the sphygmomanometer cuff is deflated, the five different sounds heard over an artery are called Korotkoff phases. The sound in each phase has unique characteristics. Blood pressure is recorded with the systolic reading (first Korotkoff sound) before the diastolic reading (beginning of the fifth Korotkoff sound).

DIF:Cognitive Level: ApplicationREF:Text reference: p. 90

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Korotkoff Sounds KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

11._____________ occurs when the systolic blood pressure falls to 90 mm Hg or below.

ANS:

Hypotension

Hypotension occurs when the systolic blood pressure falls to 90 mm Hg or below. Although some adults normally have a low blood pressure, for most people, low blood pressure is an abnormal finding associated with illness.

DIF:Cognitive Level: KnowledgeREF:Text reference: p. 91

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP:HypotensionKEY:Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

12.The percent to which hemoglobin is filled with oxygen is known as _________________.

ANS:

arterial blood oxygen saturation

Pulse oximetry is the noninvasive measurement of arterial blood oxygen saturation—the percent to which hemoglobin is filled with oxygen.

DIF:Cognitive Level: KnowledgeREF:Text reference: p. 101

OBJ: Accurately assess a patient’s oxygenation status using pulse oximetry.

TOP: Oxygen Saturation KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity