BSN 205-10 Final (Vital Signs)
Which of the following patients would require follow-up?
A. A newborn with a RR of 40 breaths per minute
B. A child with a RR of 20 breaths per minute
C. An adolescent with a RR of 16 breaths per minute.
D. An adult with a RR of 10 breaths per minute. - answerD
Normal RR for a newborn - answer30 to 60 breaths per minute
Normal RR for a child - answer20 breaths per minute
Normal RR for a teenager - answer16 to 20 breaths per minutte
Normal RR for an adult - answer12 to 20 breaths per minute
Which of the following vital signs recorded for an older adult would be considered
acceptable (within normal limits)?
A. Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%.
B. Temp 98.0 °F (36.7 °C), P-76, R-22, BP 110/70, O2 sat 88%.
C. Temp 98.6 °F (37 °C), P-56, R-20, BP 120/80, O2 sat 91%.
D. Temp 96.8° F (36 °C), P-60, R-18, BP 160/90, O2 sat 93%. - answerA.
Normal values for an older adult: average body temperature - answerapproximately 36°
C (96.8° F)
Normal values for an older adult: heart rate - answer60 to 100 beats per minute
Normal values for an older adult: RR - answerrespiratory rate 16 to 25 breaths per
minute
Normal values for an older adult: BP - answeraverage BP less than 120 over 80
Normal values for an older adult: Pulse Oximetry - answerpulse oximetry 95% to 100%
The nurse has delegated the task of temperature assessment to the NAP. Which
information should be provided to the NAP? (Select all that apply)
A. The frequency for taking or monitoring the temperature.
B. The type of temperature required.
C. What changes to report immediately to the nurse.
D. The patient's age.
E. The patient's diagnosis. - answerA, B, C
, Which of the following situations may affect a patient's vital signs? (Select all that
apply.)
A. Occupation.
B. Pain rated as a 7 on 0-10 pain scale.
C. Moving from lying to standing position.
D. Isolation precautions.
E. Time of Day - answerB, C, E
Factors that may alter vital signs include: - answertime of day
stress (emotional and physical)
temperature alterations/weather conditions
exercise/activity
emotions
medication
postural changes
acute pain
smoking
disease/injury status
noise
food/liquid consumption
odors
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?
(Select all that apply.)
A. To verify the patient is not experiencing any complications that may contraindicate
surgery or require intervention.
B. To determine whether the patient is "feeling funny" or "different".
C. To ensure the equipment is appropriately calibrated and functional.
D. To provide a set of vital signs to use for comparison during and after surgery.
E. To provide the patient with reassurance that he or she is being cared for by a
competent staff. - answerA, D
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?
A. Instruct the NAP to obtain a full set of vital signs.
B. Assess the patient s blood pressure.
C. Document this as a normal finding in an elderly adult.
D. Ask the NAP if the patient is nauseous. - answerB.
This is out of range. If there is a question regarding a patient's vital signs or a suspected
change in the patient's condition that may require further assessment, the nurse should
take the patient's vital signs rather than delegating the task.
Which patient would it be appropriate for the nurse to delegate vital signs?
A. Patient with recent complaint of headache.
Which of the following patients would require follow-up?
A. A newborn with a RR of 40 breaths per minute
B. A child with a RR of 20 breaths per minute
C. An adolescent with a RR of 16 breaths per minute.
D. An adult with a RR of 10 breaths per minute. - answerD
Normal RR for a newborn - answer30 to 60 breaths per minute
Normal RR for a child - answer20 breaths per minute
Normal RR for a teenager - answer16 to 20 breaths per minutte
Normal RR for an adult - answer12 to 20 breaths per minute
Which of the following vital signs recorded for an older adult would be considered
acceptable (within normal limits)?
A. Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%.
B. Temp 98.0 °F (36.7 °C), P-76, R-22, BP 110/70, O2 sat 88%.
C. Temp 98.6 °F (37 °C), P-56, R-20, BP 120/80, O2 sat 91%.
D. Temp 96.8° F (36 °C), P-60, R-18, BP 160/90, O2 sat 93%. - answerA.
Normal values for an older adult: average body temperature - answerapproximately 36°
C (96.8° F)
Normal values for an older adult: heart rate - answer60 to 100 beats per minute
Normal values for an older adult: RR - answerrespiratory rate 16 to 25 breaths per
minute
Normal values for an older adult: BP - answeraverage BP less than 120 over 80
Normal values for an older adult: Pulse Oximetry - answerpulse oximetry 95% to 100%
The nurse has delegated the task of temperature assessment to the NAP. Which
information should be provided to the NAP? (Select all that apply)
A. The frequency for taking or monitoring the temperature.
B. The type of temperature required.
C. What changes to report immediately to the nurse.
D. The patient's age.
E. The patient's diagnosis. - answerA, B, C
, Which of the following situations may affect a patient's vital signs? (Select all that
apply.)
A. Occupation.
B. Pain rated as a 7 on 0-10 pain scale.
C. Moving from lying to standing position.
D. Isolation precautions.
E. Time of Day - answerB, C, E
Factors that may alter vital signs include: - answertime of day
stress (emotional and physical)
temperature alterations/weather conditions
exercise/activity
emotions
medication
postural changes
acute pain
smoking
disease/injury status
noise
food/liquid consumption
odors
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?
(Select all that apply.)
A. To verify the patient is not experiencing any complications that may contraindicate
surgery or require intervention.
B. To determine whether the patient is "feeling funny" or "different".
C. To ensure the equipment is appropriately calibrated and functional.
D. To provide a set of vital signs to use for comparison during and after surgery.
E. To provide the patient with reassurance that he or she is being cared for by a
competent staff. - answerA, D
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?
A. Instruct the NAP to obtain a full set of vital signs.
B. Assess the patient s blood pressure.
C. Document this as a normal finding in an elderly adult.
D. Ask the NAP if the patient is nauseous. - answerB.
This is out of range. If there is a question regarding a patient's vital signs or a suspected
change in the patient's condition that may require further assessment, the nurse should
take the patient's vital signs rather than delegating the task.
Which patient would it be appropriate for the nurse to delegate vital signs?
A. Patient with recent complaint of headache.
