ATI: Vital Signs Question and Answers 100% Pass

ATI: Vital Signs Question and Answers 100% Pass Which of the following is true regarding assessing a patient's pulse? A. The human pulse is the palpable bounding of the blood flow in a peripheral artery. B. The normal pulse range for a resting adult is 50 to 110 beats/min. C. Three components that the nurse should include when documenting pulse (P) are the rate, rhythm, and depth. D. To calculate the pulse of a patient whose rhythm is irregular, the nurse should count the pulse rate for 30 seconds and multiply by two. A. When a peripheral artery can be compressed against an underlying bone or muscle, the pulsation created by the ejection of blood from the heart can be felt by palpating that site. Which of the following temperatures is within the normal range for adults and is documented correctly? A. T = 98.6º F B. T = 99.6º F (O) C. T = 101.0º F (O) B. Normal temperatures range from 96.8° F to 100.4° F. Appropriate documentation of temperature (T) includes degrees, scale (F), and assessment site: oral (O), tympanic (T), axillary (A), or rectal (R). Which of the following accurately describes body temperature? A. The difference between heat produced by and lost from the body B. The total amount of heat produced by the body C. The amount of heat produced by the body plus the amount of heat lost to the external environment A. Normal body temperature is the healthy balance between the amounts of heat the body produces as a byproduct of metabolism, muscle activity, thyroxine output, and sympathetic stimulation and the heat lost as a result of radiation, conduction, convection, and evaporation. The primary reason for assessing this patient's vital signs is to A. establish a baseline when the patient reports no specific health-related problem. B. determine the presence of any acute or chronic illness or disease process. C. initiate the nursing process. A. Vital signs are assessed for various reasons that include determining the patient's response to medical and nursing therapy as well as identifying clinical problems. However, the primary reason for such assessment at an initial visit of an apparently well patient is to document baseline data. This information will be useful for comparison with vital-sign data obtained at subsequent visits. Will your assessment of respiration provide information about your patient's ability to intake carbon dioxide and to expel oxygen? A. Yes B. No B. Respiration is the mechanism a person uses to introduce oxygen into the body while expelling carbon dioxide into the atmosphere. Which of the following is true regarding assessing a patient's respiration? A. It is best to inform the patient that you are assessing her respiration. B. "R = 14/min, normal, regular" is an appropriate documentation of a patient's respiration. C. Occurrence or periods of apnea in an older adult is a normal respiratory finding. D. Anxiety and acute pain are two factors that should not affect a patient's respiratory rate. B. Appropriate documentation of respiration includes rate, rhythm (regular, irregular), and depth (deep, normal, shallow). Which of the following describes systolic pressure? A. The force blood exerts on the wall of a blood vessel during both the contraction and relaxation phases of the heart B. The pressure exerted by the blood during the heart's contraction phase C. The pressure exerted by the blood during the heart's relaxation phase B. Systolic pressure describes the pressure exerted by the blood during the hearts contraction phase. The contraction of the heart forces the blood under high pressure into the aorta. The peak of maximum pressure when ejection occurs is the systolic pressure. You recorded your patient's blood pressure as 166/88. Is this within the normal range for an adult? A. Yes. B. No. B. While 120/80 mm Hg is considered a normal blood pressure for an adult, older adults may experience a rise as a result of decreased elasticity of the vessels; 140/90 is considered hypertension while a systolic pressure of 90 mm Hg or less is considered hypotension. In any case, 166/88 exceeds the normal range. Your patient's blood pressure exceeds the upper limit of the normal range for an adult, so you measure it again. Which of the following questions would be appropriate to ask your patient before you reassess her blood pressure? A. What is your usual blood-pressure reading? B. Have you eaten anything within the last hour? C. Did you drink any tea, coffee, or soda within the last half hour? D. Are you currently experiencing any emotional stress such as fear or anxiety? E. Have you smoked within the last 15 to 30 minutes? A, C, D, E How long would you wait before reassessing your patient's blood pressure on the same arm? A. 2 to 3 minutes B. 10 to 15 minutes A. Waiting 2 to 3 minutes before reassessing blood pressure in the same extremity allows time for the venous congestion caused by the previous blood pressure measurement to subside. Your patient is seated comfortably. You measure her blood pressure in her right arm and obtain a reading of 160/90. You ask her to return to have her blood pressure reassessed in 2 weeks since this reading indicates a blood pressure above the normal adult range. The most appropriate way for you to document this patient's blood pressure is A. blood pressure is 160/90 B. BP = 160/90; right arm, sitting C. BP = hypertensive at 160/90 B. Appropriate documentation of blood pressure includes the abbreviation for blood pressure (BP), the systolic pressure separated from the diastolic pressure by a slash mark, plus the assessed limb and general position of the patient. A 56-year-old female had her initial visit with a primary care provider (PCP) 2 weeks ago. At that appointment, her blood-pressure (BP) reading was above normal (160/90), so she returned today to have her BP evaluated. You escort the patient to an examination room and prepare to measure her vital signs, including temperature, pulse, respiration, and BP. You determine that the patient has not smoked or ingested any caffeine within the last 30 minutes. She is comfortably seated on the examining table. You prepare to check the patient's temperature using a tympanic thermometer. She denies any ear pain or drainage. You then inspect her ear canal for A. symmetry. B. sensitivity. C. cerumen. C. The visible presence of earwax can minimize the amount of tympanic membrane the thermometer probe can access, thus altering the accuracy of the reading. To facilitate straightening the natural curvature of the adult ear canal, you gently pull the patient's pinna (top of the ear) A. back, up, and out. B. forward, up, and out. C. back, down, and out. A. Manipulating the ear lobe in this fashion straightens the adult ear canal, thus providing better exposure of the tympanic membrane and allowing for optimal assessment. When using a tympanic membrane thermometer, correctly position the speculum probe with respect to the ear canal to ensure A. an appropriate seal is created to prevent the ear canal from being exposed to ambient temperature. B. that the risk of transmission of micro-organisms is reduced. A. Gentle pressure seals the ear canal from ambient temperature, which can alter readings as much as 2.8° C (5° F). You prepare to assess the patient's pulse and respiratory rate. You support her arm and palpate her wrist to locate the radial pulse along a groove located A. on the lateral aspect of the wrist. B. down the center of the wrist. C. on the thumb side of the wrist. C. The radial artery lies in a groove that runs down the medial or thumb side of the wrist. To assess the patient's pulse accurately, you compress the radial artery with A. the pads of your fingers. B. the tips of your fingers. C. the pad of your thumb. A. The finger pads are most sensitive and thus best suited for detecting the pulse, while the thumb pulsates strongly enough for you to mistake it for the patient's pulse.