Chapter 06: Vital Signs

Chapter 06: Vital Signs

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The patient’s oral temperature is 39° C. Which conclusion can the nurse make about the patient on the basis of this information?

a.	The patient is febrile.
b.	The patient is afebrile.
c.	An infection is present.
d.	Inflammation is present.

 

 

ANS:  A

A temperature of 39° C is above normal, and the patient with an above-average temperature is febrile. Afebrile indicates a lack of fever but does not necessarily imply a subnormal temperature. An infection often causes a fever in the patient, but a physical examination and laboratory work or culture are necessary before concluding that the patient has an infection. A patient with an inflammation can have a fever, but the patient can have an inflammation without being febrile.

 

DIF:    Cognitive Level: Comprehend          REF:   Page 112

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Diagnosis

 

2. The nurse is preparing to obtain a set of vital signs. Which is the most important factor for the nurse to consider when measuring patient vital signs?

a.	Documentation of vital signs requires timely and accurate recording.
b.	Normal limits are very narrow and are generally the same for all patients.
c.	Measuring equipment must be used correctly and appropriately.
d.	Environmental factors play a minor role on patient vital signs.

 

 

ANS:  C

It is important that each device be used correctly and appropriately to ensure patient safety and to obtain correct, complete patient information. Improper equipment distorts the results, increasing the risk of patient injury. If data are obtained with improper equipment and patient treatment is based on the faulty data, the people who use the improper equipment and the faulty data are liable for the results. This is especially important when assessing temperature and blood pressure since a variety of devices are available for measuring these vital signs. Documentation is an important part of taking vital signs; however, if the nurse uses improper equipment or technique to obtain vital signs, accurate and prompt recording is to no avail. Depending on the parameter, the normal limits are not relatively narrow. The benefit of a wider normal range is that the body is able to respond to stress and recover while remaining within normal limits. Environmental factors play a significant role on vital signs (e.g., an overly warm room affects patient temperature).

 

DIF:    Cognitive Level: Apply                   REF:   Page 99

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Implementation

 

3. A patient has a severe upper respiratory and ear infection and has been experiencing diarrhea. Assessment of the temperature would be most accurate if the nurse checked the temperature using which site?

a.	The rectum
b.	The axilla
c.	Under the tongue
d.	The tympanic membrane

 

 

ANS:  B

The axilla is the only area listed where there is no infection or health issue and where there is no interference to its accuracy. The rectum is an inappropriate site because of the diarrhea. The oral route, under the tongue, is an inappropriate site because of the severe upper respiratory infection. If the patient cannot breathe through the nose, mouth breathing occurs, and the mouth cannot be closed to create a seal for an accurate temperature measurement. The tympanic membrane is an inappropriate site because of the ear infection.

 

DIF:    Cognitive Level: Analyze                REF:   Page 101

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Assessment

 

4. The nurse is validating the measurement of an infant’s pulse by a nursing student. Which method should the nurse use to obtain the most accurate count?

a.	Compress the bell of the stethoscope over the apex of the heart.
b.	Locate the pulsations in the antecubital space.
c.	Palpate the superficial artery on the medial side of the wrist.
d.	Place the thumb and forefinger along the ridge on the outer side of the wrist.

 

 

ANS:  B

Counting the pulsations in the antecubital fossa from the brachial artery would give the most accurate count. Compressing the bell of the stethoscope turns it into a diaphragm; the bell is never compressed during use. Placing the thumb and forefinger along the ridge on the outer side of the wrist locates the radial artery, the preferred site for measuring an adult’s pulse.

 

DIF:    Cognitive Level: Apply                   REF:   Page 115

OBJ:    NCLEX: Physiological Integrity TOP:    Nursing Process: Implementation