EXAM 2 Vitalsigns - vitals
Nursing Skill Development (Goodwin University)
Downloaded by Paul Wilson ()
, EXAM 2 – VITAL SIGNS
1. A nurse is planning care for a client who is experiencing tachycardia. Which of the
following interventions should the nurse plan to include?
a) Instruct the client to increase exercise
b) Instruct the client to consume no more than four caffeinated beverages per
day
c) Encourage the client to practice relaxation techniques each day
d) Encourage the client to engage in pattern paced breathing by panting
2. A nurse is providing teaching about thermoregulation to a group of newly licensed
nurses. Which of the following statements should the nurse include in the teaching?
a) “The body increases body temperature through the process known as
vasodilation”
b) “The body loses heat through shivering”
c) “The body lowers body temperature through sweating”
d) “The body generates heat through evaporation”
3. A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nur
u u u u u u u u u u u u u
ses. Which of the following statements should the charge nurse make?
u u u u u u u u u u
a) “The first step in checking for orthostatic hypotension is obtaining a client’s blo
u u u u u u u u u u u u
od pressure while they are standing”
u u u u u
b) “An increase of 5 milliliters of mercury in the diastolic pressure with a position cha
u u u u u u u u u u u u u u
nge indicates orthostatic hypotension”
u u u
c) “A decrease of 20 milliliters of mercury in the systolic pressure with a position cha
u u u u u u u u u u u u u u
nge indicates orthostatic hypotension”
u u u
d) “Wait 5 minutes to check the client’s blood pressure after each position cha
u u u u u u u u u u u u
nge”
4. A nurse on a pediatric unit is reviewing the medical records for a group of clients. Which
u u u u u u u u u u u u u u u u u
of the following clients has a vital sign outside the expected reference range and requir
u u u u u u u u u u u u u u
es intervention?
u
a) A 1-month old infant who has a respiratory rate of 58/min
u u u u u u u u u u
b) A 3-year old preschooler who has an apical pulse rate of 144/min
u u u u u u u u u u u
c) An 8-year old child who has a respiratory rate of 25/min
u u u u u u u u u u
d) An 18-month old toddler who has an apical pulse rate of 120/min
u u u u u u u u u u u
5. A nurse is caring for a client who has a heart rate of 120/min. Which of the following actio
u u u u u u u u u u u u u u u u u u
ns should the nurse take?
u u u u
a) Instruct the client to bear down like they are having a bowel movement
u u u u u u u u u u u u
b) Offer the client hot caffeinated tea to drink early in the morning
u u u u u u u u u u u
c) Hold the client’s thyroid medication u u u u
d) Encourage the client to take a warm shower u u u u u u u
6. A nurse is reviewing documentation of vital signs by a newly licensed nurse for an assign
u u u u u u u u u u u u u u u
ed client. Which of the following entries in the chart requires follow up by the nurse?
u u u u u u u u u u u u u u u
a) BP 130/82 mm Hg left arm, lying. Client reports experiencing postoperative pain
u u u u u u u u u u u u
as 7 on a scale of 0 to 10. Prescribed analgesic administered and will re-
u u u u u u u u u u u u u u
evaluate BP in 30 min
u u u u u
b) Pulse rate 116/min, left radial, standing, immediately following 10 min of am
u u u u u u u u u u u
bulating in hall u u
c) SaO2 93% left index finger, client sleeping, nasal O2 dislodged. Nasal O2 rea
u u u u u u u u u u u u
djusted and SaO2 increased to 95% u u u u u
Downloaded by Paul Wilson ()
Nursing Skill Development (Goodwin University)
Downloaded by Paul Wilson ()
, EXAM 2 – VITAL SIGNS
1. A nurse is planning care for a client who is experiencing tachycardia. Which of the
following interventions should the nurse plan to include?
a) Instruct the client to increase exercise
b) Instruct the client to consume no more than four caffeinated beverages per
day
c) Encourage the client to practice relaxation techniques each day
d) Encourage the client to engage in pattern paced breathing by panting
2. A nurse is providing teaching about thermoregulation to a group of newly licensed
nurses. Which of the following statements should the nurse include in the teaching?
a) “The body increases body temperature through the process known as
vasodilation”
b) “The body loses heat through shivering”
c) “The body lowers body temperature through sweating”
d) “The body generates heat through evaporation”
3. A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nur
u u u u u u u u u u u u u
ses. Which of the following statements should the charge nurse make?
u u u u u u u u u u
a) “The first step in checking for orthostatic hypotension is obtaining a client’s blo
u u u u u u u u u u u u
od pressure while they are standing”
u u u u u
b) “An increase of 5 milliliters of mercury in the diastolic pressure with a position cha
u u u u u u u u u u u u u u
nge indicates orthostatic hypotension”
u u u
c) “A decrease of 20 milliliters of mercury in the systolic pressure with a position cha
u u u u u u u u u u u u u u
nge indicates orthostatic hypotension”
u u u
d) “Wait 5 minutes to check the client’s blood pressure after each position cha
u u u u u u u u u u u u
nge”
4. A nurse on a pediatric unit is reviewing the medical records for a group of clients. Which
u u u u u u u u u u u u u u u u u
of the following clients has a vital sign outside the expected reference range and requir
u u u u u u u u u u u u u u
es intervention?
u
a) A 1-month old infant who has a respiratory rate of 58/min
u u u u u u u u u u
b) A 3-year old preschooler who has an apical pulse rate of 144/min
u u u u u u u u u u u
c) An 8-year old child who has a respiratory rate of 25/min
u u u u u u u u u u
d) An 18-month old toddler who has an apical pulse rate of 120/min
u u u u u u u u u u u
5. A nurse is caring for a client who has a heart rate of 120/min. Which of the following actio
u u u u u u u u u u u u u u u u u u
ns should the nurse take?
u u u u
a) Instruct the client to bear down like they are having a bowel movement
u u u u u u u u u u u u
b) Offer the client hot caffeinated tea to drink early in the morning
u u u u u u u u u u u
c) Hold the client’s thyroid medication u u u u
d) Encourage the client to take a warm shower u u u u u u u
6. A nurse is reviewing documentation of vital signs by a newly licensed nurse for an assign
u u u u u u u u u u u u u u u
ed client. Which of the following entries in the chart requires follow up by the nurse?
u u u u u u u u u u u u u u u
a) BP 130/82 mm Hg left arm, lying. Client reports experiencing postoperative pain
u u u u u u u u u u u u
as 7 on a scale of 0 to 10. Prescribed analgesic administered and will re-
u u u u u u u u u u u u u u
evaluate BP in 30 min
u u u u u
b) Pulse rate 116/min, left radial, standing, immediately following 10 min of am
u u u u u u u u u u u
bulating in hall u u
c) SaO2 93% left index finger, client sleeping, nasal O2 dislodged. Nasal O2 rea
u u u u u u u u u u u u
djusted and SaO2 increased to 95% u u u u u
Downloaded by Paul Wilson ()
