Question: 1. A nurse assesses an oral temperature for an adult patient. The patient's temperature is 37.5°C (99.5°F). What term would the nurse use to report this temperature?

a. Febrile

b. Hypothermia

c. Hypertension

d. Afebrile

Answer: d. Afebrile

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Question: 2. A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variations in normal vital signs, which patients would the nurse document as having a normal vital sign? Select all that apply.

a. A 4-month old infant whose temperature is 38.1°C (100.5°F)

b. A 3-year old whose blood pressure is 118/80

c. A 9-year old whose temperature is 39°C (102.2°F)

d. An adolescent whose pulse rate is 70 bpm

e. An adult whose respiratory rate is 20 bpm

f. A 72-year old whose pulse rate is 42 bpm

Answer: a. A 4-month old infant whose temperature is 38.1°C (100.5°F)

d. An adolescent whose pulse rate is 70 bpm

e. An adult whose respiratory rate is 20 bpm

f. A 72-year old whose pulse rate is 42 bpm

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Question: 3. A patient who is febrile may lose body heat through perspiration. The nurse recognizes that this is an example of what mechanism of heat loss?

a. Evaporation

b. Convection

c. Radiation

d. Conduction

Answer: a. Evaporation

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Question: 4. The rectal temperature, a core temperature, is considered to be one of the most accurate routes. In which cases would taking a rectal temperature be contraindicated? Select all that apply.

a. A newborn who has hypothermia

b. A child who has pneumonia

c. An older patient who is post myocardial infarction (heart attack)

d. A teenager who has leukemia

e. A patient receiving erythropoietin to replace red blood cells

f. An adult patient who is newly diagnosed with pancreatitis

Answer: a. A newborn who has hypothermia

c. An older patient who is post myocardial infarction (heart attack)

d. A teenager who has leukemia

e. A patient receiving erythropoietin to replace red blood cells

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Question: 5. While taking an adult patient's pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next?

a. Check the pulse again in 2 hours.

b. Check the blood pressure.

c. Record the information.

d. Report the rate to the primary care provider.

Answer: d. Report the rate to the primary care provider.

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Question: 6. A patient complains of severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments? Select all that apply.

a. An increase in the pulse rate

b. A decrease in body temperature

c. A decrease in blood pressure

d. An increase in respiratory depth

e. An increase in respiratory rate

f. An increase in body temperature

Answer: a. An increase in the pulse rate

e. An increase in respiratory rate

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Question: 7. Two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 beats per minute. The nurse would document this difference as which of the following?

a. Pulse deficit

b. Pulse amplitude

c. Ventricular rhythm

d. Heart arrhythmia

Answer: a. Pulse deficit

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Question: 8. The nurse instructor is teaching student nurses about the factors that may affect a patient's blood pressure. Which statements accurately describe these factors? Select all that apply.

a. Blood pressure decreases with age.

b. Blood pressure is usually lowest on arising in the morning.

c. Women usually have lower blood pressure than men until menopause.

d. Blood pressure decreases after eating food.

e. Blood pressure tends to be lower in the prone or supine position.

f. Increased blood pressure is more prevalent in African Americans.

Answer: b. Blood pressure is usually lowest on arising in the morning.

c. Women usually have lower blood pressure than men until menopause.

e. Blood pressure tends to be lower in the prone or supine position.

f. Increased blood pressure is more prevalent in African Americans.

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Question: 9. A patient is having dyspnea. What would the nurse do first?

a. Remove pillows from under the head

b. Elevate the head of the bed

c. Elevate the foot of the bed

d. Take the blood pressure

Answer: b. Elevate the head of the bed

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Question: 10. A student nurse is learning to assess blood pressure. What does the blood pressure measure?

a. Flow of blood through the circulation

b. Force of blood against arterial walls

c. Force of blood against venous walls

d. Flow of blood through the heart

Answer: b. Force of blood against arterial walls

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Question: 11. Prioritization: Place the following descriptions of the phases of Korotkoff sounds in order from Phase I - Phase V.

a. Characterized by muffled or swishing sounds that may temporarily disappear; also known as the auscultatory gap

b. Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery

c. The last sound heard before a period of continuous silence, known as the second diastolic pressure

d. Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; known as the systolic pressure

e. Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; considered to be the first diastolic pressure

Answer: d. Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; known as the systolic pressure

a. Characterized by muffled or swishing sounds that may temporarily disappear; also known as the auscultatory gap

b. Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery

e. Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; considered to be the first diastolic pressure

c. The last sound heard before a period of continuous silence, known as the second diastolic pressure

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Question: 12. A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient?

a. Follow-up measurements of blood pressure

b. Immediate treatment by a physician

c. No action, because the nurse considers this reading is due to anxiety

d. A change in dietary intake

Answer: a. Follow-up measurements of blood pressure

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Question: 13. A nurse is documenting a blood pressure of 120/80 mm Hg. The nurse interprets the 120 to represent:

a. The rhythmic distention of the arterial walls as a result of increased pressure due to surges of blood with ventricular contraction

b. The lowest pressure present on arterial walls while the ventricles relax

c. The highest pressure present on arterial walls while the ventricles contract

d. The difference between the pressure on arterial walls with ventricular contraction and relaxation

Answer: c. The highest pressure present on arterial walls while the ventricles contract

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Question: 14. It is important to have the appropriate cuff size when taking the blood pressure. What error may result from a cuff that is too large or too small?

a. An incorrect reading

b. Injury to the patient

c. Prolonged pressure on the arm

d. Loss of Korotkoff sounds

Answer: a. An incorrect reading

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Question: 15. A patient has intravenous fluids infusing in the right arm. When taking a blood pressure on this patient, what would the nurse do in this situation?

a. Take the blood pressure in the right arm

b. Take the blood pressure in the left arm

c. Use the smallest possible cuff

d. Report inability to take the blood pressure

(Taylor 621-622)Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Answer: b. Take the blood pressure in the left arm

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