NR 224- Week 2 Edapts- Vitals Signs UPDATED ACTUAL Questions and
CORRECT Answers
After obtaining a set of vital signs on a -The client just returned from a walk in the hallway.
client, the nurse determines that the results -The client's room is very warm.
are abnormal for this client. Which factors -The blood pressure (BP) cuff used by the nurse might have been too small.
may have impacted the client's vital signs?
The nurse is measuring vital signs on a -Higher pulse than adults
pediatric client. When analyzing the data -Lower blood pressure than adults
obtained, the nurse considers that, -Higher respiratory rate than adults
compared with adults, children tend to
have which of the following?
Select all that apply.
-Lower respiratory rates than adults
-Higher blood pressure than adults
-Higher respiratory rate than adults
-Higher pulse than adults
-Lower blood pressure than adults
The nurse is delegating vital sign -Review the client's vital sign data obtained by the nursing assistant.
measurements to a nursing assistant. Which -Assess the client's stability prior to delegating vital signs.
actions should be completed by the nurse?
Select all that apply.
-Document the apical pulse the nursing
assistant measured.
-Review the client's vital sign data obtained
by the nursing assistant.
-Document the admission vital signs the
nursing assistant obtained from your client.
-Assess the client's stability prior to
delegating vital signs.
,In order to analyze vital signs data for signs -Does the client's diagnosis typically cause this type of change in vital signs?
of a problem or a change in condition, the -Is this measurement typical for the client?
nurse knows that there are several factors -Do the client's baseline vital signs usually run this high/low?
to consider before taking action. Which -Is the vital signs equipment working properly?
statements are true? Select all that apply.
-Does the client's diagnosis typically cause
this type of change in vital signs?
-Do these vital sign measurements impact
the upcoming medication administration?
-Is the vital signs equipment working
properly?
-Do the client's baseline vital signs usually
run this high/low?
-Is the client asleep?
-Is this measurement typical for the client?
The nurse is preparing to document the -Document the route used to obtain vital signs.
client's vital sign measurements in the -Document the follow-up actions taken after abnormal findings were obtained.
electronic health record (EHR). What are -Document the client's response to abnormal findings.
the correct statements? Select all that
apply.
-Document the follow-up actions taken
after abnormal findings were obtained.
-First document, then analyze the abnormal
vital sign findings.
-Document the client's response to
abnormal findings.
-First document, then inform the healthcare
provider of abnormal findings.
-The route used to obtain vital signs is not
typically necessary to document.
-Document the route used to obtain vital
signs.
The nurse is caring for a client and -After completing a nursing assessment and determining there are no other
obtaining a set of vital signs along with a concerns, the nurse administers the client's dose of antihypertensive medication.
nursing assessment. The client (preferred -The nurse completes the nursing assessment and analyzes any additional areas of
pronouns: he/him/his) has a history of concern.
hypertension for which he is taking
antihypertensive medication. The ordered
parameters are to administer the
medication for blood pressure above
130/75. His medication is now due for
administration. His current blood pressure
is 160/80, which is around what his baseline
blood pressure typically runs. What are the
correct statements?
,The nurse is assessing a client's vital signs -Assess the client for additional cues of respiratory distress
and obtains the following results: -Stabilize the client in regard to airway, breathing, and circulation (ABCs)
Blood pressure: 156/94 mmHg
Temperature: 99.8°F orally
Apical pulse: 104 beats/minute
Respirations: 25 breaths/minute and regular
Pulse oximetry: 95%
The nurse recognizes that these results are
not within the parameters of normal vital
signs. All of the following actions may be
appropriate with the cues the nurse has,
but what two (2) things does the nurse do
first?
-Immediately alert the healthcare provider
-Ask the client if they just had something
warm to drink
-Administer prescribed antihypertensive
medication
-Assess the client for additional cues of
respiratory distress
-Stabilize the client in regard to airway,
breathing, and circulation (ABCs)
The nurse has just started a shift and is -Review the results and analyze them for cues of a possible problem.
receiving a report from the previous shift -Complete the nursing assessment, including apical pulse.
nurse. The previous shift nurse reports that
the client is stable, and they have,
therefore, delegated the vital signs to the
Unlicensed Assistive Personnel (UAP) as
this is the practice in the unit. As the new
shift nurse is reviewing the client's
electronic health record (EHR) at the
nurse's station to prepare for the nursing
assessment, the nursing assistant reports
the following results:
Blood pressure: 110/60, Apical pulse rate:
72, Respirations: 12/minute, Temperature:
98.0°F, SpO2: 99%.
Identify the correct statements below and
put them in the correct sequence.
Step 1______________________
Step 2 ____________________
, The nurse is obtaining a set of vital signs. -Has the client recently been active (walking in the hallway, etc.)?
The results indicate an elevated pulse rate. -Are there cues in the client's health status and history that are contributing to this
What other information is needed to finding?
determine a course of action? Select all -What is the client's normal baseline pulse rate range?
that apply.
-No other information is needed beyond
this result in order to take action.
-Has the client recently been active
(walking in the hallway, etc.)?
-What is the client's normal baseline pulse
rate range?
-Are there cues in the client's health status
and history that are contributing to this
finding?
-If the client is over the age of 65, this
finding would not be of concern as this is
typical with this age group.
The nurse is obtaining a client's vital signs. -Obtain the vital signs at the beginning of the nursing assessment.
In order to ensure accurate results, which -Assess vital signs at the same time at set intervals.
actions would the nurse need to complete? -Use cues obtained from vital signs in addition to nursing assessment to determine
Select all that apply. the response to an intervention.
-Use cues obtained from vital signs in addition to nursing assessment to identify
-Use careful technique. priority hypotheses and to generate solutions.
-Use only vital signs to provide the basis -Use careful technique.
for problem solving.
-Assess vital signs at the same time at set
intervals.
-Use cues obtained from vital signs in
addition to nursing assessment to
determine the response to an intervention.
-Use cues obtained from vital signs in
addition to nursing assessment to identify
priority hypotheses and to generate
solutions.
-Obtain the vital signs at the beginning of
the nursing assessment.
-Use only vital signs as the basis for
indications of body functioning.
CORRECT Answers
After obtaining a set of vital signs on a -The client just returned from a walk in the hallway.
client, the nurse determines that the results -The client's room is very warm.
are abnormal for this client. Which factors -The blood pressure (BP) cuff used by the nurse might have been too small.
may have impacted the client's vital signs?
The nurse is measuring vital signs on a -Higher pulse than adults
pediatric client. When analyzing the data -Lower blood pressure than adults
obtained, the nurse considers that, -Higher respiratory rate than adults
compared with adults, children tend to
have which of the following?
Select all that apply.
-Lower respiratory rates than adults
-Higher blood pressure than adults
-Higher respiratory rate than adults
-Higher pulse than adults
-Lower blood pressure than adults
The nurse is delegating vital sign -Review the client's vital sign data obtained by the nursing assistant.
measurements to a nursing assistant. Which -Assess the client's stability prior to delegating vital signs.
actions should be completed by the nurse?
Select all that apply.
-Document the apical pulse the nursing
assistant measured.
-Review the client's vital sign data obtained
by the nursing assistant.
-Document the admission vital signs the
nursing assistant obtained from your client.
-Assess the client's stability prior to
delegating vital signs.
,In order to analyze vital signs data for signs -Does the client's diagnosis typically cause this type of change in vital signs?
of a problem or a change in condition, the -Is this measurement typical for the client?
nurse knows that there are several factors -Do the client's baseline vital signs usually run this high/low?
to consider before taking action. Which -Is the vital signs equipment working properly?
statements are true? Select all that apply.
-Does the client's diagnosis typically cause
this type of change in vital signs?
-Do these vital sign measurements impact
the upcoming medication administration?
-Is the vital signs equipment working
properly?
-Do the client's baseline vital signs usually
run this high/low?
-Is the client asleep?
-Is this measurement typical for the client?
The nurse is preparing to document the -Document the route used to obtain vital signs.
client's vital sign measurements in the -Document the follow-up actions taken after abnormal findings were obtained.
electronic health record (EHR). What are -Document the client's response to abnormal findings.
the correct statements? Select all that
apply.
-Document the follow-up actions taken
after abnormal findings were obtained.
-First document, then analyze the abnormal
vital sign findings.
-Document the client's response to
abnormal findings.
-First document, then inform the healthcare
provider of abnormal findings.
-The route used to obtain vital signs is not
typically necessary to document.
-Document the route used to obtain vital
signs.
The nurse is caring for a client and -After completing a nursing assessment and determining there are no other
obtaining a set of vital signs along with a concerns, the nurse administers the client's dose of antihypertensive medication.
nursing assessment. The client (preferred -The nurse completes the nursing assessment and analyzes any additional areas of
pronouns: he/him/his) has a history of concern.
hypertension for which he is taking
antihypertensive medication. The ordered
parameters are to administer the
medication for blood pressure above
130/75. His medication is now due for
administration. His current blood pressure
is 160/80, which is around what his baseline
blood pressure typically runs. What are the
correct statements?
,The nurse is assessing a client's vital signs -Assess the client for additional cues of respiratory distress
and obtains the following results: -Stabilize the client in regard to airway, breathing, and circulation (ABCs)
Blood pressure: 156/94 mmHg
Temperature: 99.8°F orally
Apical pulse: 104 beats/minute
Respirations: 25 breaths/minute and regular
Pulse oximetry: 95%
The nurse recognizes that these results are
not within the parameters of normal vital
signs. All of the following actions may be
appropriate with the cues the nurse has,
but what two (2) things does the nurse do
first?
-Immediately alert the healthcare provider
-Ask the client if they just had something
warm to drink
-Administer prescribed antihypertensive
medication
-Assess the client for additional cues of
respiratory distress
-Stabilize the client in regard to airway,
breathing, and circulation (ABCs)
The nurse has just started a shift and is -Review the results and analyze them for cues of a possible problem.
receiving a report from the previous shift -Complete the nursing assessment, including apical pulse.
nurse. The previous shift nurse reports that
the client is stable, and they have,
therefore, delegated the vital signs to the
Unlicensed Assistive Personnel (UAP) as
this is the practice in the unit. As the new
shift nurse is reviewing the client's
electronic health record (EHR) at the
nurse's station to prepare for the nursing
assessment, the nursing assistant reports
the following results:
Blood pressure: 110/60, Apical pulse rate:
72, Respirations: 12/minute, Temperature:
98.0°F, SpO2: 99%.
Identify the correct statements below and
put them in the correct sequence.
Step 1______________________
Step 2 ____________________
, The nurse is obtaining a set of vital signs. -Has the client recently been active (walking in the hallway, etc.)?
The results indicate an elevated pulse rate. -Are there cues in the client's health status and history that are contributing to this
What other information is needed to finding?
determine a course of action? Select all -What is the client's normal baseline pulse rate range?
that apply.
-No other information is needed beyond
this result in order to take action.
-Has the client recently been active
(walking in the hallway, etc.)?
-What is the client's normal baseline pulse
rate range?
-Are there cues in the client's health status
and history that are contributing to this
finding?
-If the client is over the age of 65, this
finding would not be of concern as this is
typical with this age group.
The nurse is obtaining a client's vital signs. -Obtain the vital signs at the beginning of the nursing assessment.
In order to ensure accurate results, which -Assess vital signs at the same time at set intervals.
actions would the nurse need to complete? -Use cues obtained from vital signs in addition to nursing assessment to determine
Select all that apply. the response to an intervention.
-Use cues obtained from vital signs in addition to nursing assessment to identify
-Use careful technique. priority hypotheses and to generate solutions.
-Use only vital signs to provide the basis -Use careful technique.
for problem solving.
-Assess vital signs at the same time at set
intervals.
-Use cues obtained from vital signs in
addition to nursing assessment to
determine the response to an intervention.
-Use cues obtained from vital signs in
addition to nursing assessment to identify
priority hypotheses and to generate
solutions.
-Obtain the vital signs at the beginning of
the nursing assessment.
-Use only vital signs as the basis for
indications of body functioning.
