C HAPTER 29: V ITAL S IGNS
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. The nurse is working in the newborn nursery. In planning for temperature
measurement, the nurse will obtain the reading on the infants by using the:
A. Oral site
B. Rectal site
C. Axillary site
D. Tympanic site
ANS: C
The axillary site can be used with newborns and uncooperative clients.
The oral site should not be used with infants. The rectal site should not
be used for routine vital signs in newborns. The t ympanic site is
questioned as being accurate in newborns.
DIF: A REF: 515 OBJ: Co mprehension TOP: Nursing
Process: Planning MSC: NC LEX test plan designation:
Reduction of Risk Potential/Vital Signs
2. A client is being monitored with pulse oximetry. On review of the
following factors, the nurse suspects that the values will be influenc ed by:
A. The placement of the sensor on the extremit y
B. A diagnosis of peripheral vascular disease
, C. A reduced amount of artificial light in the room
D. The increased ambient temperature of the clients room
ANS: B
Peripheral vascular disease can reduce pulse volu me, which may affect
the pulse oximetry reading. The sensor should be placed on an
extremit y site (such as an earlobe or digit) with adequate local
circulation and the site should be free of moisture. Reduced light in the
room will not affect the oximetry reading. Outside light sources can
interfere with the oximeters abilit y to process reflected light. An
increased temperature of the room will not affect the oximetry reading.
If the room was very cold, the clients peripheral blood flow may
decrease, affecting the oximetry reading.
DIF: A REF: 533 OBJ: Comprehension TOP: Nursing
Process: Evaluation MSC: NC LEX test plan designation:
Reduction of Risk Potential/Vital Signs
3. An individual contacts the emergency department of the local hospital to
ask what to do for a skiing partner who appears to be suffering from
hypothermia. The victim is alert and able to respond to questions. The
nurse instructs the individual who has called to have the victim:
A. Take sips of brandy
B. Drink a bowl of warm soup
C. Drink a cup of very hot coffee
D. Run the affected extremities under hot water
ANS: B
, A conscious client benefits from drinking hot liquids such as soup.
Alcohol should be avoided. Caffeinated fluids should be avoided.
Extremities should be warmed graduall y. Tissue damage could occur if
placed under hot water. The entire body should be warmed, such as by
putting heating pads next to the head and neck that lose heat the
quickest.
DIF: B REF: 508 OBJ: Application TOP: Nursing Process:
Evaluation MSC: NC LEX test plan desig nation: Reduction of
Risk Potential/Vital Signs
4. A spouse assists the nurse evaluating the measurement of the clients blood
pressure. The nurse feels additional teaching is required if the spouse is
observed:
A. Deflating the cuff at 2 mm Hg/second
B. Having the client sit down for the measurement
C. Using the same time each day for the measurement
D. Taking the blood pressure after the client comes back from a walk
ANS: D
The clients blood pressure should not be measured after the client has
exercised, smoked, or in gested caffeine. The client should wait 30
minutes before assessment of the blood pressure. The cuff should be
deflated at a rate of 2 mm Hg per second. When possible, the client
should be sitting in a chair. The blood pressure should be assessed at
the same time each day.
, DIF: A REF: 537 OBJ: Comprehension TOP: Nursing
Process: Evaluation MSC: NC LEX test plan designation:
Reduction of Risk Potential/Vital Signs
5. The nurse measures the blood pressure in the leg due to the fact that the
client has bilater al casts on the upper extremities. The nurse palpates the
pulse before the measurement at the:
A. Popliteal fossa behind the knee
B. Inner side of the ankle below the medial malleolus
C. Top of the foot between the extension tendons of the great toe
D. Inguinal ligame nt midway between the symphysis pubis and the
anterior superior iliac spine
ANS: A
The popliteal artery, palpable behind the knee in the popliteal space, is
the site for auscultation when taking the blood pressure in the leg. The
inner side of the ankle, top of the foot, and inguinal ligament are not
the correct sites for assessment.
DIF: A REF: 546 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Reduction of Risk Potential/Vital Signs
6. The clients apical pulse wil l be taken by a student. According to the nurse
the stethoscope should be placed along the left clavicular line at the:
A. Second to third intercostal space
B. Third to fourth intercostal space
C. Fourth to fifth intercostal space
D. Fifth to sixth intercostal space
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. The nurse is working in the newborn nursery. In planning for temperature
measurement, the nurse will obtain the reading on the infants by using the:
A. Oral site
B. Rectal site
C. Axillary site
D. Tympanic site
ANS: C
The axillary site can be used with newborns and uncooperative clients.
The oral site should not be used with infants. The rectal site should not
be used for routine vital signs in newborns. The t ympanic site is
questioned as being accurate in newborns.
DIF: A REF: 515 OBJ: Co mprehension TOP: Nursing
Process: Planning MSC: NC LEX test plan designation:
Reduction of Risk Potential/Vital Signs
2. A client is being monitored with pulse oximetry. On review of the
following factors, the nurse suspects that the values will be influenc ed by:
A. The placement of the sensor on the extremit y
B. A diagnosis of peripheral vascular disease
, C. A reduced amount of artificial light in the room
D. The increased ambient temperature of the clients room
ANS: B
Peripheral vascular disease can reduce pulse volu me, which may affect
the pulse oximetry reading. The sensor should be placed on an
extremit y site (such as an earlobe or digit) with adequate local
circulation and the site should be free of moisture. Reduced light in the
room will not affect the oximetry reading. Outside light sources can
interfere with the oximeters abilit y to process reflected light. An
increased temperature of the room will not affect the oximetry reading.
If the room was very cold, the clients peripheral blood flow may
decrease, affecting the oximetry reading.
DIF: A REF: 533 OBJ: Comprehension TOP: Nursing
Process: Evaluation MSC: NC LEX test plan designation:
Reduction of Risk Potential/Vital Signs
3. An individual contacts the emergency department of the local hospital to
ask what to do for a skiing partner who appears to be suffering from
hypothermia. The victim is alert and able to respond to questions. The
nurse instructs the individual who has called to have the victim:
A. Take sips of brandy
B. Drink a bowl of warm soup
C. Drink a cup of very hot coffee
D. Run the affected extremities under hot water
ANS: B
, A conscious client benefits from drinking hot liquids such as soup.
Alcohol should be avoided. Caffeinated fluids should be avoided.
Extremities should be warmed graduall y. Tissue damage could occur if
placed under hot water. The entire body should be warmed, such as by
putting heating pads next to the head and neck that lose heat the
quickest.
DIF: B REF: 508 OBJ: Application TOP: Nursing Process:
Evaluation MSC: NC LEX test plan desig nation: Reduction of
Risk Potential/Vital Signs
4. A spouse assists the nurse evaluating the measurement of the clients blood
pressure. The nurse feels additional teaching is required if the spouse is
observed:
A. Deflating the cuff at 2 mm Hg/second
B. Having the client sit down for the measurement
C. Using the same time each day for the measurement
D. Taking the blood pressure after the client comes back from a walk
ANS: D
The clients blood pressure should not be measured after the client has
exercised, smoked, or in gested caffeine. The client should wait 30
minutes before assessment of the blood pressure. The cuff should be
deflated at a rate of 2 mm Hg per second. When possible, the client
should be sitting in a chair. The blood pressure should be assessed at
the same time each day.
, DIF: A REF: 537 OBJ: Comprehension TOP: Nursing
Process: Evaluation MSC: NC LEX test plan designation:
Reduction of Risk Potential/Vital Signs
5. The nurse measures the blood pressure in the leg due to the fact that the
client has bilater al casts on the upper extremities. The nurse palpates the
pulse before the measurement at the:
A. Popliteal fossa behind the knee
B. Inner side of the ankle below the medial malleolus
C. Top of the foot between the extension tendons of the great toe
D. Inguinal ligame nt midway between the symphysis pubis and the
anterior superior iliac spine
ANS: A
The popliteal artery, palpable behind the knee in the popliteal space, is
the site for auscultation when taking the blood pressure in the leg. The
inner side of the ankle, top of the foot, and inguinal ligament are not
the correct sites for assessment.
DIF: A REF: 546 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Reduction of Risk Potential/Vital Signs
6. The clients apical pulse wil l be taken by a student. According to the nurse
the stethoscope should be placed along the left clavicular line at the:
A. Second to third intercostal space
B. Third to fourth intercostal space
C. Fourth to fifth intercostal space
D. Fifth to sixth intercostal space
