Chapter 19: Vital Signs

Chapter 19: Vital Signs

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. A nurse notes a patient has abnormal vital signs. What action by the nurse is best?

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.

DIF:    Applying        REF:   p. 286 | p. 288                                 OBJ:   19.01

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 action by the nurse is most appropriate?

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        REF:   pp. 287-288 | p. 299                         OBJ:   19.01

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?

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                                 REF:   p. 289             OBJ:   19.02

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 a high temperature. The nurse plans to help the patient regain a normal temperature through conduction. What technique does the nurse use?

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        REF:   p. 289            OBJ:   19.02             TOP:   Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

NOT:  Concepts: Thermoregulation