NR 224- Week 2 Edapts- Vitals Signs
After obtaining a set of vital signs on a client, the nurse -The client just returned from a walk in the hallway.
determines that the results are abnormal for this client. Which -The client's room is very warm.
factors may have impacted the client's vital signs? -The blood pressure (BP) cuff used by the nurse might have been too small.
The nurse is measuring vital signs on a pediatric client. When -Higher pulse than adults
analyzing the data obtained, the nurse considers that, -Lower blood pressure than adults
compared with adults, children tend to have which of the -Higher respiratory rate than adults
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
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,NR 224- Week 2 Edapts- Vitals Signs
The nurse is delegating vital sign measurements to a nursing -Review the client's vital sign data obtained by the nursing assistant.
assistant. Which actions should be completed by the nurse? -Assess the client's stability prior to delegating vital signs.
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 of a problem or a -Does the client's diagnosis typically cause this type of change in vital signs?
change in condition, the nurse knows that there are several -Is this measurement typical for the client?
factors to consider before taking action. Which statements -Do the client's baseline vital signs usually run this high/low?
are true? Select all that apply. -Is the vital signs equipment working properly?
-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?
2 of 64
,NR 224- Week 2 Edapts- Vitals Signs
The nurse is preparing to document the client's vital sign -Document the route used to obtain vital signs.
measurements in the electronic health record (EHR). What -Document the follow-up actions taken after abnormal findings were obtained.
are the correct statements? Select all that apply. -Document the client's response to abnormal findings.
-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 obtaining a set of vital -After completing a nursing assessment and determining there are no other concerns,
signs along with a nursing assessment. The client (preferred the nurse administers the client's dose of antihypertensive medication.
pronouns: he/him/his) has a history of hypertension for which -The nurse completes the nursing assessment and analyzes any additional areas of
he is taking antihypertensive medication. The ordered concern.
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?
3 of 64
, NR 224- Week 2 Edapts- Vitals Signs
The nurse is assessing a client's vital signs and obtains the -Assess the client for additional cues of respiratory distress
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)
4 of 64
After obtaining a set of vital signs on a client, the nurse -The client just returned from a walk in the hallway.
determines that the results are abnormal for this client. Which -The client's room is very warm.
factors may have impacted the client's vital signs? -The blood pressure (BP) cuff used by the nurse might have been too small.
The nurse is measuring vital signs on a pediatric client. When -Higher pulse than adults
analyzing the data obtained, the nurse considers that, -Lower blood pressure than adults
compared with adults, children tend to have which of the -Higher respiratory rate than adults
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
1 of 64
,NR 224- Week 2 Edapts- Vitals Signs
The nurse is delegating vital sign measurements to a nursing -Review the client's vital sign data obtained by the nursing assistant.
assistant. Which actions should be completed by the nurse? -Assess the client's stability prior to delegating vital signs.
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 of a problem or a -Does the client's diagnosis typically cause this type of change in vital signs?
change in condition, the nurse knows that there are several -Is this measurement typical for the client?
factors to consider before taking action. Which statements -Do the client's baseline vital signs usually run this high/low?
are true? Select all that apply. -Is the vital signs equipment working properly?
-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?
2 of 64
,NR 224- Week 2 Edapts- Vitals Signs
The nurse is preparing to document the client's vital sign -Document the route used to obtain vital signs.
measurements in the electronic health record (EHR). What -Document the follow-up actions taken after abnormal findings were obtained.
are the correct statements? Select all that apply. -Document the client's response to abnormal findings.
-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 obtaining a set of vital -After completing a nursing assessment and determining there are no other concerns,
signs along with a nursing assessment. The client (preferred the nurse administers the client's dose of antihypertensive medication.
pronouns: he/him/his) has a history of hypertension for which -The nurse completes the nursing assessment and analyzes any additional areas of
he is taking antihypertensive medication. The ordered concern.
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?
3 of 64
, NR 224- Week 2 Edapts- Vitals Signs
The nurse is assessing a client's vital signs and obtains the -Assess the client for additional cues of respiratory distress
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)
4 of 64
