Chapter 20. Measuring Vital Signs

Chapter 20. Measuring Vital Signs

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. A client’s vital signs at the beginning of the shift are as follows: oral temperature 99.3°F (37°C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four hours later, the client’s oral temperature is 102.3°F (39.1°C). Based on the temperature change, the nurse should anticipate the client’s heart rate would be how many beats/min?

a)	62
b)	82
c)	102
d)	122

 

 

ANS:  C

Heart rate increases about 10 beats/min for each degree Fahrenheit of temperature to meet increased metabolic needs and compensate for peripheral dilation.

 

Difficulty: Moderate

Nursing Process: Assessment

Client Need: PHSI

Cognitive Level: Application

 

PTS:   1

 

2. The nurse is assessing vital signs for a client after a surgical procedure on the left leg. IV fluids are infusing. It would be most important for the nurse to:

a)	Compare the left pedal pulse with the right pedal pulse
b)	Count the client’s respiratory rate for 1 full minute
c)	Take the blood pressure in the arm without an IV
d)	Take an oral temperature with an electronic thermometer

 

 

ANS:  A

For a client having surgery on the leg, the most important data would be whether the circulation has been compromised because of the surgery. This assessment can be made only by comparing one leg with the other. The nurse would, of course, count the respiratory rate for 1 full minute and take the BP in the arm without the IV. Oral temperatures are commonly obtained using electronic thermometers.

 

Difficulty: Moderate

Nursing Process: Assessment

Client Need: PHSI

Cognitive Level: Analysis

 

PTS:   1

 

3. The nurse hears rhonchi when auscultating a client’s lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds?

a)	Have the client take several deep breaths.
b)	Request the client take a deep breath and cough.
c)	Take the client’s blood pressure and apical pulse readings.
d)	Count the client’s respiratory rate for 1 minute.

 

 

ANS:  B

Rhonchi are caused by secretions in the large airways and may clear with coughing. This is how you differentiate between rhonchi and other adventitious sounds. Deep breathing will not help to clear rhonchi. Taking the blood pressure and apical pulse readings and counting the respiratory rate are not effective for clearing rhonchi, and would not be sufficient for the nurse to identify whether the sounds were, indeed, rhonchi.

 

Difficulty: Moderate

Nursing Process: Assessment

Client Need: PHSI

Cognitive Level: Application

 

PTS:   1

 

4. Which of the following sets of vital signs are all within normal limits for patients at rest?

a)	Infant: T 98.8°F (rectal), HR 160, RR 16, BP 120/54
b)	Adolescent: T 98.2°F (oral), HR 80, RR 18, BP 108/68
c)	Adult: T 99.6°F (oral), HR 48, RR 22, BP 130/84
d)	Older adult: T 98.6°F (oral), HR 110, RR 28, BP 170/95

 

 

ANS:  B

All of the adolescent’s vital signs are within normal parameters for the age. The infant’s temperature is below normal for a rectal reading because the core temperature is approximately 1 degree higher than readings from other sites. The heart rate (HR) for an infant is high, the respiratory rate (RR) is low, and the blood pressure (BP) is high for the age. For the typical adult, the temperature is high, the HR is low, the RR is high, and the BP is elevated for the age. For the older adult, the temperature is high-end normal, the HR is high, the RR is high, and the BP is high for the age.

 

Difficulty: Difficult

Nursing Process: Assessment

Client Need: PHSI

Cognitive Level: Analysis