BSN 206 - Vital Signs post tests and exam
Which of the following patients would require follow-up? - correct answer An adult with a
respiratory rate of 10 breaths per minute.
Which of the following vital signs recorded for an older adult would be considered acceptable
(within normal limits)? - correct answer Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat
95%
The nurse has delegated the task of temperature assessment to the NAP. Which information
should be provided to the NAP? - correct answer What changes to report immediately to the
nurse.
The frequency for taking or monitoring the temperature.
The type of temperature required.
Which of the following situations may affect a patient's vital signs? - correct answer Moving
from lying to standing position.
Pain rated as a 7 on 0-10 pain scale.
Time of day.
The nurse will take the patient's vital signs preoperatively and record them as part of the
patient's preparation for surgery. Why is it necessary to take vital signs preoperatively? -
correct answer To verify the patient is not experiencing any complications that may
contraindicate surgery or require intervention.
To provide a set of vital signs to use for comparison during and after surgery.
The NAP reports to the nurse a 65-year-old patient s blood pressure is 160/98. What is the
appropriate initial response of the nurse? - correct answer Assess the patient s blood pressure.
Which patient would it be appropriate for the nurse to delegate vital signs - correct answer
Elderly nursing home resident
Which person would be expected to have the lowest body temperature - correct answer An 80-
year-old who walked half a mile
80-year-old would have a lower starting temperature and therefore, would most likely have the
lowest body temperature although it may take longer to return to baseline after exercise.
The NAP is preparing to measure a patient's vital signs. The patient reports having eaten a bowl
of warm soup. The NAP asks the RN what he should do. What is the best response - correct
, answer Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's
oral temperature.
The temperature of food or liquid could impair the accuracy of the reading.
For which patient would a tympanic thermometer be the preferred thermometer to use -
correct answer A tachypneic patient who is receiving oxygen by nasal cannula.
Which of the following patients would require frequent assessment of their temperature -
correct answer A young adult with a white blood count of 15,000/mm
A patient receiving a blood transfusion for chronic anemia.
An adult female in the recovery room following a hysterectomy.
The NAP reports that the patient's temperature is 39° C (102.2 °F). Which of the following are
appropriate nursing actions? - correct answer Remove the patient's blankets
Administer an antipyretic to the patient as ordered.
Which of the following actions, if made by the NAP, would require intervention and further
instruction by the nurse? - correct answer The NAP wipes the single-use chemical dot
thermometer and places it back in the patient's drawer for future use.
The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after
applying a probe cover.
Identify the factors that may have an effect on an elderly patient's temperature - correct
answer Drinking a cold glass of water.
Infection
Room temperature.
Participation in physical therapy exercises.
If a 52-year-old patient has a normal temperature, what range should the patient's temperature
fall within - correct answer 96.8-100.4 °F (36-38 °C)
A newborn patient's temperature has been rising rapidly and the baby has been crying. Which
of the following thermometers would be the best to use in measuring this patient's
temperature - correct answer Temporal artery
The task of pulse assessment could be delegated to the NAP for which of the following patients
- correct answer A radial pulse on a patient with a 1200 mL fluid restriction.
The temporal pulse of a child.
Which of the following patients would require follow-up? - correct answer An adult with a
respiratory rate of 10 breaths per minute.
Which of the following vital signs recorded for an older adult would be considered acceptable
(within normal limits)? - correct answer Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat
95%
The nurse has delegated the task of temperature assessment to the NAP. Which information
should be provided to the NAP? - correct answer What changes to report immediately to the
nurse.
The frequency for taking or monitoring the temperature.
The type of temperature required.
Which of the following situations may affect a patient's vital signs? - correct answer Moving
from lying to standing position.
Pain rated as a 7 on 0-10 pain scale.
Time of day.
The nurse will take the patient's vital signs preoperatively and record them as part of the
patient's preparation for surgery. Why is it necessary to take vital signs preoperatively? -
correct answer To verify the patient is not experiencing any complications that may
contraindicate surgery or require intervention.
To provide a set of vital signs to use for comparison during and after surgery.
The NAP reports to the nurse a 65-year-old patient s blood pressure is 160/98. What is the
appropriate initial response of the nurse? - correct answer Assess the patient s blood pressure.
Which patient would it be appropriate for the nurse to delegate vital signs - correct answer
Elderly nursing home resident
Which person would be expected to have the lowest body temperature - correct answer An 80-
year-old who walked half a mile
80-year-old would have a lower starting temperature and therefore, would most likely have the
lowest body temperature although it may take longer to return to baseline after exercise.
The NAP is preparing to measure a patient's vital signs. The patient reports having eaten a bowl
of warm soup. The NAP asks the RN what he should do. What is the best response - correct
, answer Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's
oral temperature.
The temperature of food or liquid could impair the accuracy of the reading.
For which patient would a tympanic thermometer be the preferred thermometer to use -
correct answer A tachypneic patient who is receiving oxygen by nasal cannula.
Which of the following patients would require frequent assessment of their temperature -
correct answer A young adult with a white blood count of 15,000/mm
A patient receiving a blood transfusion for chronic anemia.
An adult female in the recovery room following a hysterectomy.
The NAP reports that the patient's temperature is 39° C (102.2 °F). Which of the following are
appropriate nursing actions? - correct answer Remove the patient's blankets
Administer an antipyretic to the patient as ordered.
Which of the following actions, if made by the NAP, would require intervention and further
instruction by the nurse? - correct answer The NAP wipes the single-use chemical dot
thermometer and places it back in the patient's drawer for future use.
The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after
applying a probe cover.
Identify the factors that may have an effect on an elderly patient's temperature - correct
answer Drinking a cold glass of water.
Infection
Room temperature.
Participation in physical therapy exercises.
If a 52-year-old patient has a normal temperature, what range should the patient's temperature
fall within - correct answer 96.8-100.4 °F (36-38 °C)
A newborn patient's temperature has been rising rapidly and the baby has been crying. Which
of the following thermometers would be the best to use in measuring this patient's
temperature - correct answer Temporal artery
The task of pulse assessment could be delegated to the NAP for which of the following patients
- correct answer A radial pulse on a patient with a 1200 mL fluid restriction.
The temporal pulse of a child.
