Exam (elaborations)
Chapter 19 Vital Signs
- Course
- Fundamentals of Nursing
- Institution
- Oxford College Of Emory University
Chapter 19 Vital Signs
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DAWITChapter 19: Vital Signs
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative
Practice, 3RD Edition
MULTIPLE CHOICE
1. A nurse notes a patient has abnormal vital signs. What action by the nurse is best?
a. Document the findings.
b. Notify the provider.
c. Compare with prior readings.
d. Retake the vital signs in 15 minutes.
ANS: C
Individual vital signs are not as important as the trends. For instance, a patient may have a
blood pressure higher than ―normal‖ that is normal for the patient. Trends give more useful
information than a single reading. Documentation is important, but the nurse needs to do
more. If the readings are significantly abnormal, the provider should be notified. The nurse
may retake the vital signs if he/she is not confident of the first set of measurements, but
should not wait for time to pass.
DIF: Applying OBJ: 19.1 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Perfusion, Gas Exchange
2. A patient returned from a procedure and has vital sign measurements ordered every hour. The
patient‘s blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg. What
NUost
priority action by the nurse is m
RSapp
INrop
GTriate?
B.CO M
a. Take the vital signs again in another hour.
b. Document the findings in the patient‘s chart.
c. Have another nurse recheck the vital signs.
d. Plan to take the vital signs more often.
ANS: D
The nurse uses clinical judgment to determine how often the patient‘s vital signs should be
checked when there is a change in patient condition. The nurse should plan to assess vital
signs more often in this patient. Since this is a significant change, the nurse should not wait
another hour even though this is what the provider prescribed. It is not necessary for another
nurse to double-check the vital signs. Documentation needs to occur, but the priority is to plan
to take the vitals more often.
DIF: Applying OBJ: 19.1 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Perfusion, Gas Exchange
3. A nurse is told in the hand-off report that a patient is afebrile. What assessment finding
correlates with this statement?
a. Blood pressure 152/98 mm Hg
b. Temperature 98.4 °F (36.8 °C)
c. Apical pulse 82 beats/min
d. Respirations 16 breaths/min
NURSINGTB.COM
, DAWIT
ANS: B
A temperature of 98.4 °F is normal. ―Afebrile‖ means having a normal temperature. The other
readings are not related to this term.
DIF: Remembering OBJ: 19.2 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Thermoregulation
4. A nurse is caring for a patient who has an elevated temperature. The nurse plans to help the
patient regain a normal temperature through conduction. What technique does the nurse use?
a. Placing a cooling fan in the patient‘s room
b. Putting ice packs in the patient‘s axillae
c. Spraying the patient with a fine mist of water
d. Turning the temperature down in the room
ANS: B
Conduction is the transfer of heat through direct contact with another object, such as an ice
pack. A cooling fan would help lower temperature by convection. Spraying the patient with a
mist of water would lead to evaporative cooling. Turning the temperature down is an example
of radiation.
DIF: Applying OBJ: 19.2 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Thermoregulation
5. A nurse is going to take an oral temperature on a patient who has just consumed a cup of
coffee. What action by the nurse is best? B.C M
N R I G
a. Have the patient drink roomUteS mpeNratuTre wateO
r.
b. Return in 30 minutes to take the patient‘s temperature.
c. Take the patient‘s temperature rectally instead.
d. Document that temperature is unable to be obtained.
ANS: B
Oral temperatures will be inaccurate if the patient has been drinking or eating hot or cold
foods. The nurse instructs the patient not to continue drinking the coffee and returns in 30
minutes to take the temperature. Drinking room temperature water will not ―even out‖ the
patient‘s mouth temperature. The rectal route is not preferred by patients and should not be
used in this situation. The nurse needs a temperature and so should not document that it was
not obtained.
DIF: Applying OBJ: 19.2 TOP: Assessment
MSC: NCLEX Client Needs Category: Health Promotion and Management
NOT: Concepts: Thermoregulation
6. A nurse observes a student taking an adult patient‘s tympanic temperature. What action by the
student requires the nurse to intervene?
a. Student washes hands prior to patient contact.
b. Student pulls the pinna of the patient‘s ear down and back.
c. Student explains the procedure to the patient.
d. Student pulls the pinna of the patient‘s ear up and back.
NURSINGTB.COM
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