Chapter 5 Vital Signs

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Chapter 5  Vital Signs

 

 

Complete Chapter Questions And Answers
 

Sample Questions

 

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: Analysis REF: 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: Analysis REF: 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: Analysis REF: 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: Synthesis REF: 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: Comprehension REF: 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

 

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