Chapter 20 Measuring Vital Signs

Chapter 20  Measuring Vital Signs

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. A client’s vital signs at the beginning of the shift are as follows: oral temperature 99.3°F (37°C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four hours later, the client’s oral temperature is 102.3°F (39.1°C). Based on the temperature change, the nurse should anticipate the client’s heart rate would be how many beats/min?
a)
62
b)
82
c)
102
d)
122

ANS: C
Heart rate increases about 10 beats/min for each degree Fahrenheit of temperature to meet increased metabolic needs and compensate for peripheral dilation.

Difficulty: Moderate
Nursing Process: Assessment
Client Need: PHSI
Cognitive Level: Application

PTS: 1

2. The nurse is assessing vital signs for a client after a surgical procedure on the left leg. IV fluids are infusing. It would be most important for the nurse to:
a)
Compare the left pedal pulse with the right pedal pulse
b)
Count the client’s respiratory rate for 1 full minute
c)
Take the blood pressure in the arm without an IV
d)
Take an oral temperature with an electronic thermometer

ANS: A
For a client having surgery on the leg, the most important data would be whether the circulation has been compromised because of the surgery. This assessment can be made only by comparing one leg with the other. The nurse would, of course, count the respiratory rate for 1 full minute and take the BP in the arm without the IV. Oral temperatures are commonly obtained using electronic thermometers.

Difficulty: Moderate
Nursing Process: Assessment
Client Need: PHSI
Cognitive Level: Analysis

PTS: 1

3. The nurse hears rhonchi when auscultating a client’s lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds?
a)
Have the client take several deep breaths.
b)
Request the client take a deep breath and cough.
c)
Take the client’s blood pressure and apical pulse readings.
d)
Count the client’s respiratory rate for 1 minute.

ANS: B
Rhonchi are caused by secretions in the large airways and may clear with coughing. This is how you differentiate between rhonchi and other adventitious sounds. Deep breathing will not help to clear rhonchi. Taking the blood pressure and apical pulse readings and counting the respiratory rate are not effective for clearing rhonchi, and would not be sufficient for the nurse to identify whether the sounds were, indeed, rhonchi.

Difficulty: Moderate
Nursing Process: Assessment
Client Need: PHSI
Cognitive Level: Application

PTS: 1

4. Which of the following sets of vital signs are all within normal limits for patients at rest?
a)
Infant: T 98.8°F (rectal), HR 160, RR 16, BP 120/54
b)
Adolescent: T 98.2°F (oral), HR 80, RR 18, BP 108/68
c)
Adult: T 99.6°F (oral), HR 48, RR 22, BP 130/84
d)
Older adult: T 98.6°F (oral), HR 110, RR 28, BP 170/95

ANS: B
All of the adolescent’s vital signs are within normal parameters for the age. The infant’s temperature is below normal for a rectal reading because the core temperature is approximately 1 degree higher than readings from other sites. The heart rate (HR) for an infant is high, the respiratory rate (RR) is low, and the blood pressure (BP) is high for the age. For the typical adult, the temperature is high, the HR is low, the RR is high, and the BP is elevated for the age. For the older adult, the temperature is high-end normal, the HR is high, the RR is high, and the BP is high for the age.

Difficulty: Difficult
Nursing Process: Assessment
Client Need: PHSI
Cognitive Level: Analysis

PTS: 1

5. The nurse assesses the following changes in a client’s vital signs. Which client situation should be reported to the primary care provider?
a)
Decreased blood pressure (BP) after standing up
b)
Decreased temperature after a period of diaphoresis
c)
Increased heart rate after walking down the hall
d)
Increased respiratory rate when the heart rate increases

ANS: A
A decrease in the client’s blood pressure when standing indicates orthostatic hypotension, and the cause should be investigated. The changes in vital signs indicated in the other options are normal changes for the situations.

Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Analysis

PTS: 1