Vital Signs Review Questions

If a client’s radial pulse is bradycardic at 40 with a regular rhythm, what is the best action of the nurse? \n \n 1) Count the pulse for 1 minute \n 2) Document it as a sinus arrhythmia \n 3) Check the blood pressure \n 4) Document the findings

Document the findings

When auscultating Ms. D’s BP, you begin to hear korotkoff sounds at 180. At 160, they disappear. You keep listening and begin to hear them again at 120. The korotkoff sounds continue until they disappear at 80. Which is correct based on this scenario? \n \n 1) Ms. D has a low pulse \n 2) Ms. D has a pulse pressure of 20 \n 3) Ms. D has an ausculatory gap \n 4) Ms. D has a low stroke volume

Ms. D has an auscultation gap

Which vital signs documentation note best adheres to CNO’s SOPs? \n \n 1) Client is hypotensive, P 56 \n 2) BP 117/53, P 62, regular rhythm \n 3) P 130, BP 98/54, regular \n 4) P 124 regular rhythm, BP 100/60

BP 117/53, P 62, regular rhythm

Mr H arrives out of breath having just ran 2 blocks so that he would not be late for his appointment. Which is the most expected bodily response? \n \n 1) increased cardiac output \n 2) increased viscosity \n 3) decreased pulse \n 4) presence of an ausculatory gap

Increased cardiac output

Which is the most accurate way to palpate a patient’s pulse?

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A. Place thumb on the radial bone at the wrist flexor, count for 1 minute if irregular

B. Place pads of three fingers 1 inch below antecubital fossa and count for 30 seconds

C. Place pads of three fingers on radial bone 1 inch above wrist flexor

D. Place pads of three fingers along radial bone at wrist flexor, count for 30 seconds

Place pads of 3 fingers along radial bone at wrist flexor, count for 30s

An 84 year-old patient who has an irregular and fast respiratory pattern and a shallow inspiratory phase. How should you assess her respirations?

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A. Count respirations for a full minute, noting rate and rhythm

B. Check pulse and respirations simultaneously for 30 seconds

C. Check respirations for 5 minutes in order to identify any variations in respiratory pattern

D. Count respirations for 15 seconds & multiply by four

Count respirations for a full minute, noting rate and rhythm

A client indicates that he/she is in pain. What should the nurse do? Choose all that apply.

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Take vital signs

Assess pain using visual analogue scale

Put head of bed at 45 degrees

Assess for guarding

Tell the client that you will make it better

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Take vital signs

Assess pain using visual analogue scale

Assess for guarding

**A 27 year old Arabian horse trainer arrived at your Emergency room after being kicked in the chest by her horse.**

 

(1) Which vital signs would be most apt to represent pain

a) Tachycardia and hypertension

b) Bradycardia and hypertension

c) Tachycardia and hypotension

d) Bradycardia and hypotension

 

Tachycardia and hypertentsion