Fundamentals Nursing Active Learning 1st Edition Yoost Crawford
Fundamentals Nursing Active Learning 1st Edition Yoost Crawford
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Chapter 19: Vital Signs
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
MULTIPLE CHOICE
| a. | Document the findings. |
| b. | Notify the provider. |
| c. | Compare with prior readings. |
| d. | Retake the vital signs. |
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
| 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 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
| a. | Blood pressure 152/98 mm Hg |
| b. | Temperature 98.4° F (36.8° C) |
| c. | Pulse 82 beats/min |
| d. | Respirations 16 breaths/min |
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
| 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 REF: p. 289 OBJ: 19.02 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Thermoregulation
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