TEST BANK FOR ESSENTIALS FOR NURSING PRACTICE 8TH EDITION BY POTTER Chapter 15: Vital Signs

Chapter 15: Vital Signs Potter: Essentials for Nursing Chapter 15: Vital Signs Potter: Essentials for Nursing Practice, 8th Edition MULTIPLE CHOICE 1. The nursing student is obtaining the patients vital signs. The patient has gone to the clinic seeking help because she is having chest pain. Which of the following vital signs are most important to obtain? a. Temperature, pulse, respirations b. Temperature, pulse, respirations, oxygen saturation c. Temperature, pulse, respirations, blood pressure, oxygen saturation d. Temperature, pulse, respirations, blood pressure, oxygen saturation, pain ANS: D The cardinal vital signs are temperature, pulse, respiration, blood pressure, and oxygen saturation. A sixth vital sign, assessment of pain, is a standard of care in health care settings. Frequently pain and discomfort are the signs that lead a patient to seek health care. Therefore assessing a patients pain helps a nurse understand the patients clinical status and progress. PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:270 OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Diagnosis MSC: NCLEX: Management of Care 2. Upon a patients admission to the nursing unit, the registered nurse delegated to the nursing assistive personnel to take her vital signs. What is the registered nurses responsibility regarding delegating this task? a. This is inappropriate delegation; the nurse should always take the vital signs b. Have the NAP repeat the measurement if vital signs appear abnormal. c. The nurse should review and interpret the vital sign measurements. d. This task has been delegated so the nurse is not responsible. ANS: C A nurse may delegate the measurement of selected vital signs (e.g., stable patients) to nursing assistive personnel. However, it is the nurses responsibility to review vital sign data, interpret their significance, and critically think through decisions about interventions. When vital signs appear abnormal, repeat the measurement. When caring for a patient, the nurse is responsible for vital sign monitoring. PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:271 OBJ: Correctly delegate vital sign measurement to nursing assistive personnel. TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 3. A 36-year-old African-American patient has been admitted to the hospital with diabetic ketoacidosis. The nurse who is admitting him notes that his blood pressure is 164/98. Which of the following should the nurse do next? a. Call the health care provider because the patients values differ from the stan b. Immediately call the health care provider and request antihypertensive medic c. Ask the patient what his blood pressure normally measures for comparison. d. Do nothing; this is within a normal range for a patient with diabetic ketoacido ANS: C Know the patients usual range of vital signs. A patients usual values sometimes differ from the standard range for that age or physical state. Use the patients usual values as a baseline for comparison with findings taken later. A single measurement does not adequately reflect a patients blood pressure. Blood pressure trends, not individual measurements, guide your nursing interventions. Hypertension is defined as systolic blood pressure (SBP) greater than 140 mm Hg, diastolic blood pressure (DBP) greater than 90 mm Hg PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) RE