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RNSG 1105 MODULE 7 VITAL SIGNS QUESTIONS WITH COMPLTE SOLUTIONS
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RNSG 1105 MODULE 7 VITAL SIGNS QUESTIONS WITH COMPLTE SOLUTIONS
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RNSG 1105 MODULE 7 VITAL SIGNS QUESTIONSWITH COMPLTE SOLUTIONS
______________ (assessing pulse)
use middle 2-3 fingers
count pulsations for 30 secs and multiply by 2 Correct Answer
palpation
______________ (assessing pulse)
Use of stethoscope to ausculate apical pulse
ea lub-dub counts as 1 pulsation
if regular, count for 30 sec and multiply by 2
if irregular, count for a full min Correct Answer auscultation
________________________ (assessing pulse)
used when pulses that are difficult to palpate or auscultate
produces high frequency sound waves Correct Answer Doppler
ultrasound
A 52-year-old woman is admitted with dyspnea and discomfort
in her left chest with deep breaths. She has smoked for 35 years
and recently lost over 10 lbs. Her vital signs on admission are:
HR 112, BP 138/82, RR 22, tympanic temperature 36.8° C
(98.2° F), and oxygen saturation 94%. She is receiving oxygen
at 2 L via a nasal cannula. Which vital sign reflects a positive
outcome of the oxygen therapy?
a. Temperature: 37° C (98.6° F)
b.Radial pulse: 112
c.Oxygen saturation: 96%
d.Blood pressure: 134/78
,e.Respiratory rate: 24 Correct Answer c.Oxygen saturation:
96%
(Oxygen saturation is an assessment of oxygen perfusion.
Respiratory rate assesses ventilation, radial pulse and blood
pressure, assess the cardiovascular system, and temperature is an
assessment of thermal regulation.)
A 55-year-old female patient was in a motor vehicle accident
and is admitted to a surgical unit after repair of a fractured left
arm and left leg. She also has a laceration on her forehead. An
intravenous (IV) line is infusing in the right antecubital fossa,
and pneumatic compression stockings are on the right lower leg.
She is receiving oxygen via a simple face mask. Which sites do
you instruct the nursing assistant to use for obtaining the
patient's blood pressure and temperature?
A. Right antecubital and tympanic membrane
B.Right popliteal and rectal
C. Left antecubital and oral
D. Left popliteal and temporal artery Correct Answer A. Right
antecubital and tympanic membrane
IV in right arm can be turned off while blood pressure is
obtained. Blood pressure should not be measured on fractured
extremities that have compromised circulation. Sequential
stocking should remain on all the time while the patient is in bed
to promote blood flow in lower right extremity. Tympanic
membrane temperature is not affected by oxygen; the oxygen
would need to be removed to take an oral temperature. Forehead
laceration excludes temporal measurement. Rectal temperature
is more invasive.
,A 55-year-old female patient was in a motor vehicle accident
and is admitted to a surgical unit after repair of a fractured left
arm and left leg. She also has a laceration on her forehead. An
intravenous (IV) line is infusing in the right antecubital fossa,
and pneumatic compression stockings are on the right lower leg.
She is receiving oxygen via a simple face mask. Which sites do
you instruct the nursing assistant to use for obtaining the
patient's blood pressure and temperature? Correct Answer
Right antecubital and tympanic membrane
(IV in right arm can be turned off while blood pressure is
obtained. Blood pressure should not be measured on fractured
extremities that have compromised circulation. Sequential
stocking should remain on all the time while the patient is in bed
to promote blood flow in lower right extremity. Tympanic
membrane temperature is not affected by oxygen; the oxygen
would need to be removed to take an oral temperature. Forehead
laceration excludes temporal measurement. Rectal temperature
is more invasive.)
A healthy adult patient tells the nurse that he obtained his blood
pressure in "one of those quick machines in the mall" and was
alarmed that it was 152/72 when his normal value ranges from
114/72 to 118/78. The nurse obtains a blood pressure of 116/76.
What would account for the blood pressure of 152/92?
A. cuff to small
b. Arm positioned above heart level
c. The insufficient time between measurements
d. Slow inflation of the cuff by the machine
e. Patient did not remove his long-sleeved shirt Correct Answer
A. cuff to small
, c. Insufficient time between measurements
(Using too small of a cuff and not allowing for insufficient time
between measurements will result in false-high readings. Arm
above heart level and slow inflation result in false low readings.)
A healthy adult patient tells the nurse that he obtained his blood
pressure in "one of those quick machines in the mall" and was
alarmed that it was 152/72 when his normal value ranges from
114/72 to 118/78. The nurse obtains a blood pressure of 116/76.
What would account for the blood pressure of 152/92?
A.Cuff too small
B.Arm positioned above heart level
C.Slow inflation of the cuff by the machine
D.Patient did not remove his long-sleeved shirt
E.Insufficient time between measurements Correct Answer
A.Cuff too small
E.Insufficient time between measurements
A patient has been admitted for a cerebrovascular accident
(stroke). She cannot move her right arm, and she has a right-
sided facial droop. She is able to eat with her dentures in place
and swallow safely. The nursing assistive personnel (NAP)
reports to you that the patient will not keep the oral thermometer
probe in her mouth. What direction do you provide to the NAP?
a. Direct the NAP to hold the thermometer in place with her
gloved hand
b. Direct the NAP to switch the thermometer probe to the left
sublingual pocket
c. Direct the NAP to obtain a right tympanic temperature
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