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Vital Signs nclex questions

  1. a nurse assesses an oral temperature for a patient as 38.5°C (101.3°F).  What term would the nurse use to report this temperature?



    A. fever
  2. a nurse is assessing vital signs on several hospitalized children.  the nurse would plan to use the oral route to assess temperature for which patient?



    C. 15 year old healthy adolescent.
  3. when assessing a temperature rectally, the nurse would use extreme care when inserting the thermometer to prevent which of the following?



    A. decrease in heart rate.  insertion of a rectal thermometer may stimulate the vagus nerve, which in turn, would decrease heart rate.  This may potentially be harmful for patients with cardiac problems
  4. while taking an adult patient's pulse, a nurse finds the rate to be 140 bpm.  what should the nurse do next?



    C. report the rate.  a heart rate of 140 bpm in an adult is abnormal and should be reported to the instructor or the nurse in charge of the patient.
  5. a patient complains of severe abdominal pain.  when assessing the vital signs, the nurse would not be surprised to find what assessment?



    C. an increase in pulse rate.  pulse often increases when someone experiencing pain.  pain doesn't affect body temp, and may increase (not decrease) BP.  acute pain may increase respiratory rate, but decrease depth.
  6. two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 bpm.  the nurse would document this difference as which of the following?



    A. pulse deficit
  7. before assessing respirations, the nurse reviews normal rates for adults.  which rate would the nurse identify as normal?
    a. 1-6 br/m
    b. 12-20 br/m
    c. 60-80 br/m
    d. 100-120 br/m
    12-20 br/m
  8. a patient is having dyspnea.  what would the nurse do first?



    D. elevate the head of the bed.  elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm greater room for expansion and facilitating lung expansion.
  9. a student nurse is learning to assess BP.  what does the BP measure?



    C. force of blood against atrial walls.
  10. a nurse knows BP is often higher in older adults based on the understanding that which of the following occurs with aging?



    A. decreased elasticity in arterial walls
  11. a patient has a BP reading of 130/90 mmHg when visiting a clinic.  what would a nurse recommend to the patient?



    B. follow-up BP measurements.  a single reading of a mildly elevated BP is not significant, but measurement should be taken again over time to determine if hypertension is a problem.  the nurse would recommend a return visit to the clinic for a recheck.
  12. it is important to have the appropriate cuff size when taking the BP.  what error may occur when the cuff size is wrong?



    A. an incorrect reading
  13. a patient has intravenous fluids infusing in the right arm.  when taking a BP on this patient, what would the nurse do in this situation?



    A. take it in the left arm.
Author
ajax726
ID
233254
Card Set
Vital Signs nclex questions
Description
nclex vital sign questions
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