Chapter 14 Vital Signs

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Chapter 14  Vital Signs

 

 

Complete Chapter Questions And Answers
 

Sample Questions

 

MULTIPLE CHOICE

1. Lucas is a nursing student who is obtaining Mrs. Elliott’s vital signs. Mrs. Elliott has gone to the clinic seeking help because she is having chest pain. Which of the following vital signs are most important for Lucas to obtain?
A.
Temperature, pulse, respirations
B.
Temperature, pulse, respirations, oxygen saturation
C.
Temperature, pulse, respirations, blood pressure, oxygen saturation
D.
Temperature, pulse, respirations, blood pressure, oxygen saturation, pain

ANS: D
The cardinal vital signs are temperature, pulse, respiration, blood pressure, and oxygen saturation. A sixth vital sign, assessment of pain, is a standard of care in health care settings. Frequently pain and discomfort are the signs that lead a patient to seek health care. Therefore assessing a patient’s pain helps a nurse understand the patient’s clinical status and progress.

PTS: 1 DIF: Cognitive Level: Analysis REF: 260
OBJ: Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity

2. Upon a patient’s admission to the nursing unit, the registered nurse delegated to the nursing assistive personnel to take her vital signs. What is the registered nurse’s responsibility regarding delegating this task?
A.
This is inappropriate delegation, the nurse should always take the vital signs.
B.
The nurse should ask the nursing assistive personnel to report any abnormalities in the measurements.
C.
The nurse should review and interpret the vital sign measurements.
D.
This task has been delegated so the nurse is not responsible.

ANS: C
When caring for a patient, the nurse is responsible for vital sign measurement. A nurse may delegate the measurement of selected vital signs (e.g., stable patients) to nursing assistive personnel. However, it is the nurse’s responsibility to review vital sign measurements, interpret their significance, and make decisions about interventions.

PTS: 1 DIF: Cognitive Level: Analysis REF: 260
OBJ: Correctly delegate vital sign measurement to nursing assistive personnel
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment

3. A 36-year-old African American patient has been admitted to the hospital with diabetic ketoacidosis. The nurse who is admitting him notes that his blood pressure is 164/98. Which of the following should the nurse do next?
A.
Call the physician to report the blood pressure.
B.
Retake the blood pressure with an electronic device.
C.
Ask the patient what his blood pressure normally measures.
D.
Do nothing; this is within a normal range.

ANS: C
Know the patient’s usual range of vital signs. A patient’s usual values sometimes differ from the standard range for that age or physical state. Use the patient’s usual values as a baseline for comparison with findings taken later.

PTS: 1 DIF: Cognitive Level: Analysis REF: 260
OBJ: Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment

4. A man has been taken to the emergency department after passing out while repairing the roof on his house. The temperature outside is 96° F and his skin is warm and dry. How should the nurse obtain his temperature?
A.
Axillae
B.
Rectal
C.
Oral
D.
Temporal

ANS: B
Sites reflecting core temperature are more reliable indicators of body temperature than sites reflecting surface temperature, such as the armpit or axillae.

PTS: 1 DIF: Cognitive Level: Analysis REF: 265
OBJ: Explain variations in techniques used to assess vital signs in an infant, a child, and an adult TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment

5. Nancy is a 6-year-old who was taken into the hospital after having a seizure at home. Nancy’s mother tells the nurse that she has been ill for the past week and has had a fever with nausea and vomiting. Nancy’s mother believes that the seizure was caused by a fever of 99.5° F, which Nancy had during the course of her illness. What is the nurse’s best response?
A.
“It probably was a febrile seizure; let’s see what the health care provider thinks.”
B.
“Has Nancy ever had a seizure in the past?”
C.
“Febrile seizures are common in children Nancy’s age.”
D.
“Has Nancy been exposed to anyone with the flu?”

ANS: B
Dehydration and febrile seizures occur during rising temperatures of children between 6 months and 3 years of age. Febrile seizures are unusual in children older than 5 years of age.

PTS: 1 DIF: Cognitive Level: Analysis REF: 262
OBJ: Discuss physiological changes associated with fever
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment

 

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