CHAPTER 19: Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford

Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford Chapter 19: Vital Signs Multiple Choice Questions 1. What is the nurse's best initial action when noting a patient has abnormal vital signs? A. Document the findings B. Notify the provider C. Compare with prior readings D. Retake the vital signs in 15 minutes Answer: C Explanation: Trends in vital signs provide more clinically relevant information than isolated readings. Comparing current results with prior measurements helps determine if the abnormality reflects the patient's baseline or indicates a new concern. Why Other Options Are Wrong: A is insufficient without clinical analysis. B is premature without trend evaluation. D delays necessary assessment if readings are significantly abnormal. 2. A patient's blood pressure drops from 132/82 mm Hg to 90/66 mm Hg in one hour. What is the nurse's priority action? A. Wait to retake vitals in one hour B. Document the findings C. Have another nurse verify the readings D. Increase vital sign monitoring frequency Answer: D Explanation: A significant blood pressure drop requires more frequent monitoring to detect continued decline or stabilization, guiding timely interventions. Why Other Options Are Wrong: A delays necessary surveillance. B is inadequate for acute changes. C is unnecessary if initial measurements were accurate. 3. Which finding correlates with the term "afebrile" in a hand-off report? A. Blood pressure 152/98 mm Hg B. Temperature 98.4°F (36.8°C) C. Apical pulse 82 beats/min D. Respirations 16 breaths/min Answer: B Explanation: "Afebrile" indicates a normal body temperature, exemplified by 98.4°F (36.8°C). Why Other Options Are Wrong: A, C, and D are unrelated to temperature status. 4. Which technique uses conduction to reduce a patient's elevated temperature? A. Cooling fan in the room B. Ice packs in the axillae C. Mist spray on the skin D. Lowering room temperature Answer: B Explanation: Conduction transfers heat through direct contact (e.g., ice packs), unlike convection (fan), evaporation (mist), or radiation (room cooling). Why Other Options Are Wrong: A uses convection. C employs evaporation. D involves radiation. 5. How should a nurse proceed when needing to take an oral temperature after a patient drinks coffee? A. Have the patient drink room-temperature water B. Wait 30 minutes before measuring C. Take a rectal temperature instead D. Document inability to obtain reading Answer: B Explanation: Hot beverages alter oral mucosa temperature; waiting 30 minutes ensures accuracy without resorting to less comfortable routes. Why Other Options Are Wrong: A doesn't resolve temperature distortion. C is unnecessarily invasive. D avoids obtaining needed data. 6. Which student action requires correction when taking a tympanic temperature? A. Hand hygiene before patient contact B. Pulling the pinna down and back C. Explaining the procedure D. Pulling the pinna up and back Answer: B Explanation: Adults require pinna elevation (up and back); pulling down is for pediatric patients. Why Other Options Are Wrong: A, C, and D are correct techniques. 7. A patient's radial pulse is 110 beats/min and regular. What should the nurse do next? A. Assess for causes of tachycardia B. Compare with apical pulse C. Document the findings D. Notify the provider Answer: A Explanation: Tachycardia may stem from pain, fever, or dehydration; assessment identifies actionable causes before escalating. Why Other Options Are Wrong: B is unnecessary with a regular pulse. C is incomplete without assessment. D is premature without etiology. 8. Which student pulse assessment requires intervention? A. Apical pulse at 5th-6th intercostal space B. Dorsalis pedis pulse behind the knee C. Radial pulse on the wrist D. Brachial pulse at the inner elbow Answer: B Explanation: Dorsalis pedis is palpated on the foot's dorsum, not behind the knee. Why Other Options Are Wrong: A, C, and D are correct assessment sites. 9. What should the nurse assess when a pulse is hard to obliterate? A. Fluid volume overload B. Fluid volume deficit C. Apical heart rate D. Pulse deficit Answer: A Explanation: A bounding pulse suggests fluid overload, requiring evaluation for edema or respiratory distress. Why Other Options Are Wrong: B causes weak pulses. C and D are unrelated to pulse amplitude. 10. Which carotid pulse assessment error requires correction? A. Counting for 30 seconds B. Performing hand hygiene C. Compressing both carotids simultaneously D. Assessing one side at a time Answer: C Explanation: Bilateral carotid compression risks cerebral ischemia; assess one side at a time. Why Other Options Are Wrong: A, B, and D are appropriate practices. 11. What intervention best assists a patient with orthopnea? A. Encouraging deep breathing B. Administering pain medication C. Elevating the head of the bed D. Monitoring apnea duration Answer: C Explanation: Orthopnea (breathlessness when supine) is relieved by upright positioning to reduce pulmonary congestion. Why Other Options Are Wrong: A doesn't address positional dyspnea. B is irrelevant. D misinterprets orthopnea. 12. A hypothermic patient's pulse oximeter fails. What action is best? A. Move the probe to another finger B. Assess peripheral circulation C. Document the failure D. Remove nail polish Answer: B Explanation: Hypothermia impairs peripheral perfusion; assess circulation before attempting alternate sites. Why Other Options Are Wrong: A and D won't help if perfusion is poor. C is insufficient without troubleshooting. 13. A patient's blood pressure is 142/76 mm Hg. What is the pulse pressure? A. 28 B. 42 C. 58 D. 66 Answer: D Explanation: Pulse pressure = systolic − diastolic (142 − 76 = 66). Why Other Options Are Wrong: A, B, and C are incorrect calculations. 14. A patient's BP drops from 148/76 mm Hg (lying) to 110/60 mm Hg (standing). What action is priority? A. Instruct to call for assistance when rising B. Document and continue monitoring C. Reassure this is normal D. Recheck in 1 hour Answer: A Explanation: Orthostatic hypotension increases fall risk; safety measures are prioritized. Why Other Options Are Wrong: B is insufficient for acute risk. C is false reassurance. D delays safety intervention. 15. What action is needed for a patient with a right-sided mastectomy 2 years ago? A. "No BPs on right arm" sign B. "No continuous BPs on right arm" sign C. "BPs in legs only" sign D. No action required Answer: A Explanation: Mastectomy increases lymphedema risk; avoid all BP measurements on the affected side. Why Other Options Are Wrong: B and C are unnecessary restrictions. D ignores lymphedema risk. 16. Which assessment finding requires further evaluation? A. 40-year-old woman: pulse 68 B. 65-year-old man: respirations 10 C. 12-year-old: pulse 92 post-ambulation D. 50-year-old man: BP 112/60 upon waking Answer: B Explanation: Adult respirations 12 breaths/min indicate bradypnea needing assessment. Why Other Options Are Wrong: A, C, and D are within normal ranges. 17. Which hand-off report finding requires immediate assessment? A. SpO₂ 96% B. BP 102/62 mm Hg C. Pulse 42 beats/min D. Respirations 18 breaths/min Answer: C Explanation: A pulse of 42 beats/min (bradycardia) may compromise perfusion and requires urgent evaluation. Why Other Options Are Wrong: A, B, and D are normal findings. 18. Why does metabolic acidosis cause increased respirations? A. Increased metabolic rate B. Lungs eliminating excess CO₂ C. Temperature regulation D. Acute illness effect Answer: B Explanation: Kussmaul respirations compensate for acidosis by exhaling excess CO₂ to raise blood pH. Why Other Options Are Wrong: A, C, and D misinterpret the pathophysiology. Multiple Response Questions 1. What are the purposes of measuring vital signs? (Select all that apply.) A. Monitor body system function B. Detect early problems C. Evaluate intervention efficacy D. Confirm disease cure E. Establish baseline data Answer: A, B, C, E Explanation: Vital signs assess system function, identify deviations, evaluate treatments, and provide baselines—not confirm cures. Why Other Options Are Wrong: D is incorrect because vital signs alone cannot confirm cure. 2. What instructions should the nurse give a UAP delegated to take vital signs? (Select all that apply.) A. "Report if Mr. Smith's BP is low" B. "Take Mrs. Jones' BP every 15 minutes" C. "Notify me if Ms. Walsh's systolic BP 100 mm Hg" D. "Demonstrate the electronic cuff use" E. "I'll take Mr. Derby's BP—he's unstable" Answer: B, C, D, E Explanation: Clear parameters (B, C), competency verification (D), and stability assessments (E) ensure safe delegation. Why Other Options Are Wrong: A is too vague for actionable reporting. 3. Which factors increase blood pressure? (Select all that apply.) A. Head injury B. Hypovolemia C. Aging D. Recent meal E. Pain Answer: A, C, D, E Explanation: Head trauma, age-related vessel stiffness, postprandial state, and pain raise BP; hypovolemia lowers it. Why Other Options Are Wrong: B decreases BP. 4. Which organ dysfunctions directly affect respiration? (Select all that apply.) A. Brain B. Lungs C. Heart D. Liver E. Skeletal muscle Answer: A, B, C Explanation: Brain (respiratory center), lung (gas exchange), and heart (circulatory) pathologies impair respiration. Why Other Options Are Wrong: D and E do not directly control respiration. 5. What hypertension self-care topics should nurses teach? (Select all that apply.) A. Exercise most days B. Maintain healthy weight C. Avoid all alcohol D. Limit sodium to 2.4 g/day E. Follow DASH diet Answer: B, D, E Explanation: Weight management, sodium restriction, and DASH diet are key; alcohol moderation (not avoidance) and regular exercise are also recommended. Why Other Options Are Wrong: C is overly restrictive; A is incomplete without specifying "aerobic." 6. Which factors influence pulse assessment? (Select all that apply.) A. Age B. Gender C. Religion D. Exercise E. Medications Answer: A, B, D, E Explanation: Pulse varies with age, gender, activity, and medications (e.g., beta-blockers); religion is irrelevant. Why Other Options Are Wrong: C does not affect pulse. 7. Which findings indicate dyspnea? (Select all that apply.) A. Occasional productive cough B. SpO₂ 89% C. Orthopneic position D. Respirations 26/shallow E. Temperature 100.1°F Answer: B, C, D Explanation: Dyspnea involves hypoxia (B), positional breathing difficulty (C), and tachypnea (D). Why Other Options Are Wrong: A and E are unrelated to dyspnea.