n224 Vital signs review questions WITH
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CORRECT ANSWERS |\
The nurse assesses the following vital signs in a 78-year-old
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male: temperature 36.6°C, temporal; pulse 72 beats/min, regular,
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2+; respirations 18 breaths/min, regular, no use of accessory
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muscles; BP 142/92 mm Hg. Which of the findings is abnormal?
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a. Pulse
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b. BP|\
c. Respirations
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d. Temperature - CORRECT ANSWERS ✔✔B.
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Rationale: In older adults, both SBP and DBP increase due to
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increased stiffness of arterial walls. This finding is outside of the
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normal range. Temperature in the older adult tends to be at the
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lower range of normal.
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The best way to assess a client's respiration rate is by
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a. placing a hand over the client's chest and counting for 30
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seconds.
, b. observing and counting respirations for 30 seconds and
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multiplying by 2 without mentioning that you are observing the
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respirations.
c. asking the client to breathe normally for 1 minute.
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d. having the client rest for 10 minutes and then recounting if
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respirations are irregular. - CORRECT ANSWERS ✔✔B.
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Rationale: Do not make the patient aware that you are assessing
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respirations. Increased awareness may alter normal respiratory
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pattern.
The patient's radial pulse is weak and thready. The nurse's next
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action is to |\ |\
a. transfer the patient to a critical care unit.
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b. notify the primary care provider.
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c. compare findings with previous findings and opposite
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extremity.
d. |\
assess vital signs every 15 minutes. - CORRECT ANSWERS ✔✔C.
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Rationale: Comparing with previous findings and with the
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opposite extremity can help determine if any acute changes have
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occurred.
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CORRECT ANSWERS |\
The nurse assesses the following vital signs in a 78-year-old
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male: temperature 36.6°C, temporal; pulse 72 beats/min, regular,
|\ |\ |\ |\ |\ |\ |\
2+; respirations 18 breaths/min, regular, no use of accessory
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
muscles; BP 142/92 mm Hg. Which of the findings is abnormal?
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
a. Pulse
|\
b. BP|\
c. Respirations
|\
d. Temperature - CORRECT ANSWERS ✔✔B.
|\ |\ |\ |\ |\ |\
Rationale: In older adults, both SBP and DBP increase due to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
increased stiffness of arterial walls. This finding is outside of the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
normal range. Temperature in the older adult tends to be at the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
lower range of normal.
|\ |\ |\
The best way to assess a client's respiration rate is by
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
a. placing a hand over the client's chest and counting for 30
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
seconds.
, b. observing and counting respirations for 30 seconds and
|\ |\ |\ |\ |\ |\ |\ |\ |\
multiplying by 2 without mentioning that you are observing the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
respirations.
c. asking the client to breathe normally for 1 minute.
|\ |\ |\ |\ |\ |\ |\ |\ |\
d. having the client rest for 10 minutes and then recounting if
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respirations are irregular. - CORRECT ANSWERS ✔✔B.
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Rationale: Do not make the patient aware that you are assessing
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
respirations. Increased awareness may alter normal respiratory
|\ |\ |\ |\ |\ |\ |\
pattern.
The patient's radial pulse is weak and thready. The nurse's next
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
action is to |\ |\
a. transfer the patient to a critical care unit.
|\ |\ |\ |\ |\ |\ |\ |\
b. notify the primary care provider.
|\ |\ |\ |\ |\
c. compare findings with previous findings and opposite
|\ |\ |\ |\ |\ |\ |\ |\
extremity.
d. |\
assess vital signs every 15 minutes. - CORRECT ANSWERS ✔✔C.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Rationale: Comparing with previous findings and with the
|\ |\ |\ |\ |\ |\ |\ |\
opposite extremity can help determine if any acute changes have
|\ |\ |\ |\ |\ |\ |\ |\ |\
occurred.
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