Chapter 15: Vital Signs

Chapter 15: Vital Signs

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The nursing student is obtaining the patient’s vital signs. The patient has gone to the clinic seeking help because she is having chest pain. Which of the following vital signs are most important 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: Understanding (Comprehension)

REF:    270

OBJ:    Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.      TOP:            Nursing Process: Diagnosis

MSC:   NCLEX: Management of Care

 

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.	Have the NAP repeat the measurement if vital signs appear abnormal.
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

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 data, interpret their significance, and critically think through decisions about interventions. When vital signs appear abnormal, repeat the measurement. When caring for a patient, the nurse is responsible for vital sign monitoring.

 

PTS:    1                      DIF:    Cognitive Level: Understanding (Comprehension)

REF:    271

OBJ:    Correctly delegate vital sign measurement to nursing assistive personnel.

TOP:    Nursing Process: Diagnosis               MSC:   NCLEX: Management of Care

 

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 health care provider because the patient’s values differ from the standard range.
b.	Immediately call the health care provider and request antihypertensive medication.
c.	Ask the patient what his blood pressure normally measures for comparison.
d.	Do nothing; this is within a normal range for a patient with diabetic ketoacidosis.

 

 

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. A single measurement does not adequately reflect a patient’s blood pressure. Blood pressure trends, not individual measurements, guide your nursing interventions. Hypertension is defined as systolic blood pressure (SBP) greater than 140 mm Hg, diastolic blood pressure (DBP) greater than 90 mm Hg

 

PTS:    1                      DIF:    Cognitive Level: Understanding (Comprehension)

REF:    271 | 282

OBJ:    Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.      TOP:            Nursing Process: Diagnosis

MSC:   NCLEX: Management of Care

 

4. A nurse is working on a medical unit in an acute care hospital. One of the patients she is caring for has a fever of 100.6° F. Which of the following is the best reason why the patient should not receive an antipyretic at this time?

a.	A temperature of 100.3° F is within the normal range.
b.	Shivering is a more effective way to dissipate heat energy.
c.	Corticosteroids are safer to use than antipyretics.
d.	Mild fevers are an important defense mechanism of the body.

 

 

ANS:   D

Fever, or pyrexia, is an important defense mechanism. Therefore most health care providers will not treat an adult’s fever until it is higher than 39° C (102.2° F). For healthy young adults the average oral temperature is 37° C (98.6° F). In the elderly population, the average core temperature ranges from 35° to 36.1° C (95° to 97° F) because of decreased immunity. Shivering is counterproductive because of the heat produced by muscle activity. Although not used to treat fever, corticosteroids reduce heat production by interfering with the hypothalamic response. It is important to note that these drugs mask signs of infection by suppressing the immune system.

 

PTS:    1                      DIF:    Cognitive Level: Understanding (Comprehension)

REF:    173 | 174         OBJ:    Explain the principles and mechanisms of thermoregulation.

TOP:    Nursing Process: Diagnosis               MSC:   NCLEX: Management of Care