RN Vital Signs Assessment 2.0
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A nurse is planning care for a client who is experiencing tachycardia. Which of the following interventions should the nurse plan to include?
Instruct the client to increase exercise
Instruct the client to consume no more than four caffeinated beverages per day
Encourage the client to practice relaxation techniques each day
Encourage the client to engage in pattern paced breathing by panting
Encourage the client to practice relaxation techniques each day.
A nurse is providing teaching about thermoregulation to a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching?
"The body increases body temperature through the process known as vasodilation."
"The body loses heat through shivering."
"The body lowers body temperature through sweating."
"The body generates heat through evaporation."
"The body lowers body temperature through sweating."
A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. Which of the following statements should the charge nurse make?
"The first step in checking for orthostatic hypotension is obtaining a client's blood pressure while they are standing."
"An increase of 5 millimeters of mercury in the diastolic pressure with a position change indicates orthostatic hypotension."
"A decrease of 20 millimeters of mercury in the systolic pressure with a position change indicates orthostatic hypotension."
"Wait 5 minutes to check the client's blood pressure after each position change."
"A decrease of 20 millimeters of mercury in the systolic pressure with a position change indicates orthostatic hypotension."
A nurse on a pediatric unit is reviewing the medical records for a group of clients. Which of the following clients has a vital sign outside the expected reference range and requires intervention?
A 1-month-old infant who has a respiratory rate of 58/min
A 3-year-old preschooler who has an apical pulse rate of 144/min
An 8-year-old child who has a respiratory rate of 25/min
An 18-month-old toddler who has an apical pulse rate of 120/min
A 3-year-old preschooler who has an apical pulse rate of 144/min
A nurse is caring for a client who has a heart rate of 120/min. Which of the following actions should the nurse take?
Instruct the client to bear down like they are having a bowel movement.
Offer the client hot caffeinated tea to drink early in the morning.
Hold the client's thyroid medication.
Encourage the client to take a warm shower.
Instruct the client to bear down like they are having a bowel movement.
A nurse is reviewing documentation of vital signs by a newly licensed nurse for an assigned client. Which of the following entries in the chart requires follow up by the nurse?
BP 130/82 mm Hg left arm, lying. Client reports experiencing postoperative pain as 7 on a scale of 0 to 10. Prescribed analgesic administered and will re-evaluate BP in 30 min.
Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall.
SaO2 93% left index finger, client sleeping, nasal O2 dislodged. Nasal O2 readjusted and SaO2 increased to 95%.
Respiratory rate 18/min via observation, client sitting in chair.
Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall.
A nurse is reviewing the recent vital signs of a group of clients. Which of the following clients should the nurse see first?
A 45-year-old client who is postoperative and has a BP of 130/82 mm Hg
A 28-year-old client who runs marathons and has a heart rate of 54/min
A 52-year-old client who has an SaO2 of 92%
A 78-year-old client who has a temperature of 35.9° C (96.6° F)
A 52-year-old client who has an SaO2 of 92%
A nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings for vital signs. Which of the following findings requires follow up?
A client has an 8 mm Hg difference in systolic BP when moving from a sitting to a standing position.
A client has a radial pulse of +4 bilateral.
An older adult client has a tympanic temperature of 35.9° C (96.6° F).
A newborn has a respiratory rate of 56/min while sleeping.
A client has a radial pulse of +4 bilateral.
A charge nurse is reviewing the expected reference range of blood pressure in adult clients with a newly licensed nurse. Which of the following statements should the charge nurse include?
"Hypertension is diagnosed with two elevated measurements on two separate occasions."
"Successive blood pressure measurements of 126 over 78 is classified as stage I hypertension."
"Stage II hypertension is diagnosed when the blood pressure measurement is 132 over 86."
"A blood pressure measurement of 176 over 102 is classified as a hypertensive crisis."
"Hypertension is diagnosed with two elevated measurements on two separate occasions."
A nurse is evaluating the effectiveness of interventions used for clients who had alterations in vital signs. Which of the following clients' vital signs indicate that interventions were effective? (Select all that apply)
A preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min
An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min
A young adult who had hypotension after receiving an opioid analgesic and now has a blood pressure of 98/68 mm Hg
A toddler who was febrile 2 hr ago due to a viral infection and has a temporal temperature of 38.2° C (100.8° F)
An adult client who had tachycardia 1 hr ago due to postoperative pain and has an apical pulse rate of 106/min
A preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min
An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min is correct.
A young adult who had hypotension after receiving an opioid analgesic and now has a blood pressure of 98/68 mm Hg is correct.
A nurse is reviewing the vital signs for a group of clients. Which of the following clients should the nurse identify as exhibiting tachycardia?
An infant who has an apical pulse rate of 132/min
A preschooler who has an apical pulse rate of 108/min
A young adult who has an apical pulse rate of 104/min
An older adult who has an apical pulse rate of 96/min
A young adult who has an apical pulse rate of 104/min
A nurse is preparing an in-service about factors affecting respiratory rate for a group of assistive personnel. Which of the following information should the nurse include?
Anxiety can decrease a client's respiratory rate.
Opioid analgesics can increase a client's respiratory rate.
Pain can decrease a client's respiratory rate.
Fever can increase a client's respiratory rate.
Fever can increase a client's respiratory rate.
A nurse obtains a client's electronic blood pressure reading o 188/96 mm Hg. Which of the following actions should the nurse take next?
Provide client teaching regarding medications to control blood pressure.
Notify the provider of the client's blood pressure reading.
Provide client education on measures to decrease blood pressure.
Obtain a manual blood pressure reading from the client.
Obtain a manual blood pressure reading from the client.
A charge nurse is evaluating a newly licensed nurse's documentation of vital signs for several clients. Which of the following documentation should the charge nurse identify as being incomplete?
Radial pulse regular at 84/min
Respirations observed as even, nonlabored at 20/min with client in supine position
BP 124/82 mm Hg, lying in bed
Temporal temperature 36.9° C (98.4° F)
BP 124/82 mm Hg, lying in bed
A nurse is discussing the physiology of blood pressure with a group of assistive personnel. Which of the following information should the nurse include?
Diastolic blood pressure reflects the pressure exerted during contraction of the heart.
Blood pressure is measured and documented in millimeters of mercury.
Blood pressure decreases when the blood viscosity increases.
Systolic blood pressure reflects the pressure when the heart is relaxed.
Blood pressure is measured and documented in millimeters of mercury.
A nurse is observing an assistive personnel (AP) who is obtaining a blood pressure reading from a client. Which of the following actions by the AP requires follow up by the nurse?
The AP uses a cuff width that is 40% of the circumference of the client's arm.
The AP provides support for the client's arm while taking the BP.
The AP waits to take the client's BP 45 min after the client ambulates in the hallway.
The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second.
The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second.
A nurse is discussing the use of a client's thigh for blood pressure measurements with an assistive personnel (AP). Which of the following information should the nurse include?
Select a blood pressure cuff width that is 25% of the circumference of the client's thigh.
Palpate the femoral pulse when obtaining blood pressure in the thigh.
Expect blood pressure in the thigh to be 10 to 15 mm Hg less than in the arm.
Use the thigh to obtain blood pressure when a client has severe edema in their arms.
Use the thigh to obtain blood pressure when a client has severe edema in their arms.
A nurse is reviewing the vital signs obtained by an assistive personnel at 1200. For which of the following clients should the nurse plan to intervene?
Adult male who has a respiratory rate of 18/min
Toddler who has a respiratory rate of 44/min
Newborn who has a respiratory rate of 56/min
Adolescent female who has a respiratory rate of 16/min
Toddler who has a respiratory rate of 44/min
A nurse is planning for a group of clients. For which of the following clients should the nurse direct an assistive personnel (AP) to obtain a rectal temperature?
A toddler who has diarrhea
A client who is 1 day postoperative following a hemorrhoidectomy and receiving pain medications via PCA pump
An infant who is receiving intravenous fluids
A client who is diaphoretic and frequently chewing ice to relieve dry mouth
A client who is diaphoretic and frequently chewing ice to relieve dry mouth
A nurse is caring for a client who has an increase in cardiac output. Which of the following findings should the nurse expect?
Increase in blood pressure
Decrease in respiratory rate
Decrease in heart rate
Increase in stroke volume
Increase in blood pressure
A nurse is preparing an in-service for a group of newly hired assistive personnel (AP) about body temperature. Which of the following information should the nurse include?
Wait 5 min after a client has consumed a hot drink to obtain an oral temperature.
Place a tape or patch thermometer over a client's scapula.
A tympanic thermometer reflects a client's body surface temperature.
A temporal probe thermometer uses infrared scanning to determine a client's temperature.
A temporal probe thermometer uses infrared scanning to determine a client's temperature.
A nurse is evaluating the effectiveness of interventions provided to a client who has an SaO2 below the expected reference range. Which of the following manifestations requires follow up by the nurse?
Eupnea
Dyspnea
Heart rate of 84/min
SaO2 of 96%
Dyspnea
A nurse is caring for a group of clients. Which of the following clients is experiencing an alteration in their respiratory rate that requires intervention?
An adolescent who has a respiratory rate of 20/min
An older adult who has a respiratory rate of 16/min
An infant who has a respiratory rate of 52/min
A school-age child who has a respiratory rate of 14/min
A school-age child who has a respiratory rate of 14/min
A nurse is obtaining vital signs for a group of clients. Which of the following findings requires intervention?
A 17-year-old who has a respiratory rate of 16/min
A young adult who has a pulse rate of 98/min
An 11-year-old child who has a respiratory rate of 34/min
An older adult who has a pulse rate of 62/min
An 11-year-old child who has a respiratory rate of 34/min
A nurse is reviewing blood flow through the heart with a group of assistive personnel. The nurse should identify that blood flows to which of the following parts of the heart as it leaves the right ventricle?
Tricuspid valve
Pulmonary artery
Right atrium
Vena cava
Pulmonary artery
A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart?
Atrioventricular (AV) node
Left ventricle
Sinoatrial (SA) node
Right ventricle
Sinoatrial (SA) node
A nurse is evaluating the effectiveness of interventions used to address clients' vital signs that were outside of the expected reference ranges. Which of the following findings indicates the intervention was effective?
An older adult client who has pneumonia and a respiratory rate of 26/min after a position change
An adolescent who is postoperative and has an SaO2 of 93% after receiving an opioid analgesic
A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm Hg after using an inhaler
An older adult client who has an infection and a pulse rate of 110/min after using relaxation techniques
A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm Hg after using an inhaler
A nurse is observing an assistive personnel (AP) obtain vital signs from an adult client. Which of the following actions by the AP requires follow up by the nurse?
The AP pulls the pinna up and back when obtaining a tympanic temperature.
The AP informs the client when they are counting the respirations.
The AP gently presses down with the pads of two to three fingers over the radial pulse site.
The AP selects a blood pressure cuff width that is 40% the circumference of the client's arm.
The AP informs the client when they are counting the respirations.
A nurse is reviewing the vital signs for a group of clients to determine the effectiveness of interventions. Which of the following findings indicates an intervention was effective?
An adult client who received medication for pain 30 min ago now has a respiratory rate of 18/min.
A school-age child who received two units of packed red blood cells now has a BP of 76/54 mm Hg.
A toddler who received an antibiotic injection now has a heart rate of 148/min while sleeping in their parent's arms.
An older adult client who received an antipyretic medication 1 hr ago now has a temperature of 38.7° C (101.6° F).
An adult client who received medication for pain 30 min ago now has a respiratory rate of 18/min.
A nurse is caring for a recently admitted client and as part of the plan of care, two nurses obtained simultaneous pulse rates. The client's auscultated apical pulse was 106/min and the palpated radial pulse was 93/min. The nurse should document the findings as which of the following?
Pulse deficit less than 10
Radial pulse irregular
Apical pulse greater than radial
Pulse deficit of 13/min
Pulse deficit of 13/min
A nurse is evaluating the effectiveness of interventions provided to a client who was admitted for decreased circulation. Which of the following findings requires further intervention by the nurse?
Pulse deficit of 0
Left radial pulse is nonpalpable
Peripheral pulse +2 bilateral
Brachial pulses are symmetrical
Left radial pulse is nonpalpable
A charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. Identify the order of the steps the nurse should include. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Apply the sensor probe on the chosen site
Select the site for obtaining the measurement
Confirm the pulse rate displayed on the oximeter by palpating the radial pulse
Wait 15 second and observe the SaO2 percentage displayed on the pulse oximeter
Select the site for obtaining the measurement
Apply the sensor probe on the chosen site
Confirm the pulse rate displayed on the oximeter by palpating the radial pulse
Wait 15 second and observe the SaO2 percentage displayed on the pulse oximeter
A nurse is assessing a 3-month-old infant during a well-child visit. Which of the following actions should the nurse take when assessing the apical pulse?
Count the number of beats heard in 15 seconds and multiply by 4.
Notify the provider if the apical pulse rate is greater than 110/min.
Place the stethoscope over the 4th intercostal space to the left of the sternum.
Auscultate the apical pulse for an S4 heart sound.
Place the stethoscope over the 4th intercostal space to the left of the sternum.
A charge nurse is providing an in-service for a group of nurses about cardiac output. Which of the following statements should the nurse include?
"Cardiac output is the amount of blood flow through the heart in 1 minute."
"Cardiac output is the amount of blood ejected from the atria."
"Cardiac output is the ability of the muscle fibers in the ventricles to stretch."
"Cardiac output is the resistance of the ventricles to pump blood through the heart."
"Cardiac output is the amount of blood flow through the heart in 1 minute."
A charge nurse in a clinic is preparing an in-service about blood pressure measurements for a group of staff members. Which of the following information should the nurse include?
A client is diagnosed with an elevated blood pressure when the measurement is greater than 130/80 mm Hg.
A client is experiencing a hypertensive crisis when their blood pressure is greater than 150/90 mm Hg.
A client who has a blood pressure of 128/86 mm Hg has stage I hypertension.
A client who has a blood pressure of 162/102 mm Hg has stage II hypertension.
A client who has a blood pressure of 162/102 mm Hg has stage II hypertension.
A nurse is reviewing the vital signs for a group of clients obtained by an assistive personnel. The nurse should identify that which of the following clients requires a follow-up assessment due to bradycardia?
A school-age child who has an apical pulse rate of 78/min
A young adult who has a radial pulse rate of 56/min
An adolescent who has a radial pulse rate of 76/min
An older adult who has an apical pulse rate of 62/min
A young adult who has a radial pulse rate of 56/min
A nurse is preparing to obtain a young adult client's apical pulse. In which of the following locations should the nurse place their stethoscope to auscultate the client's pulse?
Apex of the heart
Right side of sternum
4th intercostal space
Midclavicular line below right clavicle
Apex of the heart
A nurse is providing care to a client who has an apical pulse rate of 54/min and is experiencing dizziness. Which of the following is the nurse's priority action?
Teach the client how to take their pulse so they can keep the provider informed of variations.
Inform the client to ask for assistance with getting out of bed.
Educate the client on medications, including therapeutic effects and potential adverse effects.
Ensure the client has been taking medications as prescribed.
Inform the client to ask for assistance with getting out of bed.
A nurse is assessing a client who has orthostatic hypotension. Which of the following actions should the nurse take?
Encourage the client to change positions slowly.
Restrict the client's oral intake of fluids.
Encourage the client to take a short walk.
Discontinue IV fluids.
Encourage the client to change positions slowly.
A nurse is caring for a client who has an increase in cardiac afterload. Which of the following findings should the nurse expect?
Increase in blood pressure
Increase in respiratory rate
Decrease in cardiac output
Decrease in preload
Increase in blood pressure
A nurse is caring for a client who asks about factors that could cause their pulse rate to increase. Which of the following factors should the nurse include in their response?
Hypothermia
Smoking
Sleeping
Aging
Smoking
A charge nurse is teaching a group of assistive personnel (AP) about the importance of documenting accurate vital signs. Which of the following information should the charge nurse include in the teaching?
Record vital signs at the end of each shift.
Recording vital signs provides critical information regarding a client's condition.
Obtaining and documenting baseline vital signs is the responsibility of the AP.
It is not necessary to record electronic blood pressure measurements.
Recording vital signs provides critical information regarding a client's condition.
A nurse is teaching a group of assistive personnel (AP) about techniques used to obtain BP. For which of the following clients should the nurse to instruct the AP to obtain an electric BP measurement?
A client who has a BP lower than the expected reference range
A school-age child
A client recovering from extensive abdominal surgery
A client who has stabilized BP measurements
A client who has stabilized BP measurements
A nurse is planning care for a group of clients and is reviewing the recent vital signs obtained by an assistive personnel. Which of the following clients should the nurse assess and recheck the vital signs prior to notifying the provider?
16-year-old female: respiratory rate 18/min, SaO2 98%
8-year-old male: respiratory rate 34/min, SaO2 97%
11-year-old male: respiratory rate 28/min, SaO2 99%
3-year-old female: respiratory rate 32/min, SaO2 96%
8-year-old male: respiratory rate 34/min, SaO2 97%
A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. Which of the following statements should the nurse include?
"Convection is the loss of body heat when a client is in contact with a cooler surface."
"Conduction is the loss of body heat when sweat dries from a client's skin."
"Evaporation is the loss of body heat when a client is near a current of cool air."
"Radiation is the loss of body heat when a client is in close proximity to a cooler surface."
"Radiation is the loss of body heat when a client is in close proximity to a cooler surface."
A nurse is teaching a group of newly licensed nurses about vital sign measurements. Which of the following factors should the nurse include in the teaching?
Anxiety can cause a decrease in respiratory rate.
Body temperature is typically lower in older adults.
Caffeine can cause a temporary decrease in pulse rate in adolescents.
Blood pressure slightly decreases immediately following the use of nicotine.
Body temperature is typically lower in older adults.
A nurse is caring for a client who is experiencing tachypnea due to an exacerbation of asthma. Which of the following medications should the nurse anticipate administering?
A nicotine product
An opioid antagonist
An antihypertensive
A bronchodilator
A bronchodilator
A nurse is preparing an in-service about peripheral pulses for a group of staff nurses. Which of the following information should the nurse include?
A pulse strength of +4 indicates that the pulse is of normal strength upon palpation.
A femoral pulse that is bounding upon palpation is an expected finding in a young adult.
A pulse strength of +1 indicates that the pulse is weak or diminished upon palpation.
A pedal pulse that is weak upon palpation is an expected finding in an older adult.
A pulse strength of +1 indicates that the pulse is weak or diminished upon palpation.
A nurse is preparing an in-service about vital signs for a group of newly hired assistive personnel. Which of the following information should the nurse include about measuring body temperature?
Tympanic temperature can be affected by environmental temperature.
Temporal temperature is inaccurate in children under 3 years of age.
Axillary temperature reflects rapid changes in a client's core body temperature.
Oral temperature is easily accessible despite a client's position.
Oral temperature is easily accessible despite a client's position.
A nurse working on a medical-surgical unit is caring for a group of clients. Which of the following clients' vital signs should the nurse identify is outside the expected reference range and notify the provider?
A client who has an apical pulse rate of 120/min
A client who has a blood pressure of 100/74 mm Hg
A client who has an apical pulse rate of 84/min
A client who has a blood pressure of 110/68 mm Hg
A client who has an apical pulse rate of 120/min
A nurse is discussing oxygen saturation with a client. Which of the following information should the nurse include?
Oxygen saturation is determined by the amount of oxygen bound to white blood cells.
Oxygen saturation reflects the amount of oxygen being delivered to body tissues.
The expected reference range for oxygen saturation is 90% to 100%.
A capillary refill time of less than 5 seconds ensures a reliable oxygen saturation measurement.
Oxygen saturation reflects the amount of oxygen being delivered to body tissues.
A nurse is reviewing the vital signs of four clients. The nurse should identify that which of the following clients has a vital sign outside the expected reference range
A 52-year-old client who has a fever due to a wound infection and a pulse rate of 100/min
A 76-year-old client who reports moderate pain and has a respiratory rate of 20/min
A 46-year-old client who is postoperative following a hysterectomy and has an SaO2 of 95%
A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg
A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg
A nurse is caring for a client who has hypotension. Which of the following factors should the nurse identify as a contributing factor to the client's condition?
Decrease in contractility
Increase in blood viscosity
Decrease in respiratory rate
Increase in preload
Decrease in contractility
A nurse is planning for a client who has hypertension. Which of the following interventions should the nurse include in the plan? (Select all that apply.)
Provide the client with low-sodium meals and snacks.
Encourage the client to participate in physical activity each day.
Instruct the client in the use of relaxation techniques.
Inform the client of the importance of abstaining from using products that contain nicotine.
Anticipate a prescription for a 1L IV fluid bolus.
Provide the client with low-sodium meals and snacks.
Encourage the client to participate in physical activity each day.
Instruct the client in the use of relaxation techniques.
Inform the client of the importance of abstaining from using products that contain nicotine.
A charge nurse is discussing a client's respiratory data with a newly licensed nurse. Which of the following statements should the nurse include?
"Clients will exhibit an increase in their respiratory rate after using a bronchodilator."
"Count the respiratory rate for 1 minute for clients who have a respiratory infection."
"Expect clients who have a brainstem injury to exhibit rapid respirations."
"Clients who are experiencing acute pain will have slow, deep respirations."
"Count the respiratory rate for 1 minute for clients who have a respiratory infection."
A nurse is planning care for a group of clients and is delegating to the assistive personnel (AP) to take the client's vital signs. For which of the following clients should the nurse obtain the vital signs rather than the AP?
A client who just received the fourth dose of an antibiotic for an infection
A client who has heart failure and is scheduled for discharge later in the day
A client who is 24 hr postoperative and is visiting with friends
A client who was recently admitted and reports chest pain
A client who was recently admitted and reports chest pain
A nurse is caring for a client who has a heart rate of 118/min. Which of the following actions should the nurse take to improve the client's heart rate?
Encourage the client to reduce intake of caffeinated soft drinks.
Inform the client to ambulate in the hallway for 10 min prior to taking vital signs.
Increase the room temperature and add blankets to warm the client.
Withhold the client's antianxiety medication.
Encourage the client to reduce intake of caffeinated soft drinks.
A charge nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct?
Pulse 52/min
Respiratory rate 24
SaO2 97% right index finger, room air
Blood pressure 132/86 mm Hg
SaO2 97% right index finger, room air