A patient's blood pressure is 118/82 mm Hg. He asks the nurse, What do the numbers mean? The nurse's best reply is:
a. The numbers are within the normal range and are nothing to worry about.
b. The bottom number is the diastolic pressure and reflects the stroke volume of the heart.
c. The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts.
d. The concept of blood pressure is difficult to understand. The primary thing to be concerned about is the top number, or the systolic blood pressure.
Question 2The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child's respirations?
a. Respirations should be counted for 1 full minute, noticing rate and rhythm.
b. Child's pulse and respirations should be simultaneously checked for 30 seconds.
c. Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern.
d. Patient's respirations should be counted for 15 seconds and then multiplied by 4 to obtain the number of respirations per minute.
Question 3The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature-36 C; pulse-48 beats per minute; respirations-14 breaths per minute; blood pressure-104/68 mm Hg.
Which statement is true concerning these results?
a.
The patient is experiencing tachycardia.
b.
These are normal vital signs for a healthy, athletic adult.
c.
The patient's pulse rate is not normalhis physician should be notified.
d.
On the basis of these readings, the patient should return to the clinic in 1 week.
Question 4When assessing the force, or strength, of a pulse, the nurse recalls that the pulse:
a. Is usually recorded on a 0- to 2-point scale.
b. Demonstrates elasticity of the vessel wall.
c. Is a reflection of the heart's stroke volume.
d. Reflects the blood volume in the arteries during diastole.
Question 5When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurse's next action would be to:
a. Immediately notify the physician.
b. Consider this finding normal in children and young adults.
c. Check the child's blood pressure, and note any variation with respiration.
d. Document that this child has bradycardia, and continue with the assessment.
Question 6When assessing a patient's pulse, the nurse should also notice which of these characteristics?
a. Force
b. Pallor
c. Capillary refill time
d. Timing in the cardiac cycle
Question 7Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for:
a. 1 minute, if the rhythm is irregular.
b. 15 seconds and then multiplied by 4, if the rhythm is regular.
c. 2 full minutes to detect any variation in amplitude.
d. 10 seconds and then multiplied by 6, if the patient has no history of cardiac abnormalities.
Question 8To assess a rectal temperature accurately in an adult, the nurse would:
a. Use a lubricated blunt tip thermometer.
b. Insert the thermometer 2 to 3 inches into the rectum.
c. Leave the thermometer in place up to 8 minutes if the patient is febrile.
d. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.
Question 9The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding use of the TMT?
a. A tympanic temperature is more time consuming than a rectal temperature.
b. The tympanic method is more invasive and uncomfortable than the oral method.
c. The risk of cross-contamination is reduced, compared with the rectal route.
d. The tympanic membrane most accurately reflects the temperature in the ophthalmic artery.
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