Question: The best way to determine the depth of a patient's respiration is to

Answer: Observe the degree of chest-wall movement during inspiration and expiration*You determine the depth of respiration subjectively by evaluating how much chest-wall movement you can observe. The movement is generated by the movements of the diaphragm and intercostal muscles as the patient breathes. With shallow respiration, for example, you will observe very little movement. Deep respiration involves full expansion of the lungs, which is usually quite visible.

Question: When taking a patient's blood pressure, why is it important to notice the pressure on the manometer when you hear the fourth Korotkoff sound or phase?

Answer: You might not hear a fifth Korotkoff sound*Most clinicians consider the fifth Korotkoff sound, which is actually the disappearance of sound, an adult patient's diastolic blood pressure. However, with some patients, there is no distinct fifth sound. You hear sounds all the way to 0 mm Hg. For these patients, you would record the fourth Korokoff sound as the diastolic blood pressure.

Question: When auscultating a patient's apical pulse, you listen until you hear the S1 and S2 heart sounds clearly and regularly. S2 is produced when the

Answer: semilunar valves close*The second heart sound, S2, is generated by the closure of the semilunar valves (the aortic and pulmonic valves) and signals the start of diastole. S2 is the "dub" heard in the normal "lub-dub" sound.

Question: You are assessing a patient's vital signs. The patient has a temperature of 102 °F (39 °C). Which of the following do you expect to find?

Answer: An elevated pulse rate*A fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate.

Question: You are assessing the vital signs of a newly admitted patient. To establish an accurate baseline of the patient's respiration, you

Answer: Observe the patient's chest movements while appearing to assess his pulse*You are most likely to observe the true respiratory pattern (rate, rhythm, and depth) when the patient is unaware that he is being assessed. When patients know their respiration is being observed, it is common for them to alter respiratory pattern either voluntarily or involuntarily.

Question: When taking an adult patient's temperature rectally, it is important to

Answer: Insert the probe about an inch and a half into the patient's anus*An insertion depth of 1.5 inches (3.5 centimeters) ensures sufficient exposure of the probe to the blood vessels in the rectal wall. Positioning the probe against the blood vessels enables it to measure heat maximally and accurately.

Question: The difference between a patient's systolic and diastolic blood pressures is called

Answer: The pulse pressure*The difference between the systolic and diastolic pressures is the pulse pressure; if the patient's blood pressure is 130/85 mm Hg, the pulse pressure is 45/min. Pulse pressure can be a predictor of heart problems, especially in older adults. For example, an elevated pulse pressure usually reflects stiffness and reduced elasticity of the aorta, most often due to hypertension or atherosclerosis.

Question: When preparing to measure the vital signs of a patient, you should recognize that which of the following will affect the methods that you will use? (Select all that apply)

Answer: -The patient is 60 pounds overweight -The patient is reporting a "stuffy" nose-The patient is taking digoxin (Lanoxin)-The patient had a mastectomy 2 years ago*It is likely that a patient who is 60 pounds (27.3 kilograms) overweight would have a larger-than-average upper-arm circumference. If so, you would have to use a large-blood pressure cuff (instead of a regular-sized cuff) to assure an accurate blood-pressure reading. *A patient who has nasal congeston might resort to "mouth breathing", which would alter a temperature measurement obtained orally. This condition would also require that you assess the patient's respiration for a full 60 seconds. *The presnce of a cardiovascular problem that warrants pharmacological digoxin therapy would require that you assess the patient's apical pulse for a full 60 seconds. *Lymphatic drainage might be altered in the affected arm post mastectomy. The application of pressure from the assessment of blood pressure could result in a painful condition called lymphedema.

Question: You have assessed a 45-year-old patient's vital signs. Which of the following assessment values requires immediate attention?

Answer: A respiratory rate of 30/min*A respiratory rate of 30/min is above the normal range and indicates a respiratory problem that requires immediate attention. An adult breathing at that rate might be experiencing shortness of breath or dyspnea and, without intervention, this could become a life-threatening situation.

Question: The most important factor in measuring blood pressure accurately is

Answer: Using a cuff of the appropriate size for the patient*Using the wrong cuff size for the patient will result in an erroneous reading. A cuff that is too small will result in a reading that is falsely high while a cuff that is too big will record a false low. One way to select a cuff is to make sure that the width of the cuff is 40% of the arm circumference where the cuff will be wrapped. The bladder (inside the cuff) should surround 80% of the arm circumference.

Question: You are preparing to use a tympanic thermometer. Which of the following steps has the highest priority in the accurate use of this piece of equipment for measuring body temperature?

Answer: Gently pulling the pinna back and upward*This position helps straighten the ear canal and provides optimal access to the tympanic membrane. Good contact with sufficient tympanic membrane is essential for an accurate tympanic temperature measurement.

Question: When assessing a patient's respiration, it is recommended that the patient

Answer: Have the head of the bed elevated 45 to 60°*This is a comfortable position for most patients and it allows for full ventilatory movement. Also, any type of discomfort can increase respiratory rate.

Question: You are measuring a patient's temperature orally. You place the covered probe

Answer: In the posterior lingual pocket lateral to the midline*The heat produced by superficial blood vessels in the right and the left posterior sublingual pocket is what generates an accurate oral temperature reading. Inserting the probe "sideways" into the back of the area under the tongue on the left or the right will access this area.

Question: To auscultate a patient's apical pulse accurately, you position the bell or the diaphragm of your stethoscope over the point of maximal impulse, which is located

Answer: At the fifth intercostal space at the left midclavicular line*To locate the point of maximal impulse, first locate the angle of Louis - a bony prominence just below the suprasternal notch. Slide your fingers down each side of the angle of Louis to locate the second intercostal space. Gently move your fingers down the left side of the sternum to the fifth intercostal space and laterally to the left midclavicular line. You have found the PMI.