Foundations of Nursing Chapter 30 Vital Signs Exam

The registered nurse teaches the student nurse about the correct times to measure vital signs. Which statement by the student nurse shows ineffective learning? 1 "I will assess the vital signs during home care visits." 2 "I will assess the vital signs before, during, and after a surgical procedure." 3 "I will assess the vital signs of a patient who reports nonspecific symptoms of physical distress." 4 "I will assess the vital signs every hour when the physical condition of the patient worsens." - 4 Vital signs are the rapid and efficient way of monitoring a patient's condition. These signs help to identify problems and to evaluate the patient's response to interventions. The nurse is responsible for judging the frequency of assessment of these signs. The nurse should measure vital signs every five to 10 minutes when the physical condition of the patient worsens.The nurse should measure vital signs during home care visits. The vital signs should also be monitored before, during, and after a surgical procedure. When a patient reports nonspecific symptoms of physical distress, the nurse should assess the vital signs. Which statement is true regarding the pulse rate of an older adult? 1 Pedal pulse can easily be palpated in older adults. 2 Older adults have increased heart rate at rest. 3 It takes longer for the heart rate to rise in older adults during illness. 4 Heart sounds are sometimes muffled due to decreased air space in the lungs. - 3 It takes longer for the heart rate to rise in the older adults during illness to meet increased demands during conditions such stress, illness, and excitement. Pedal pulses are often difficult to palpate in older adults. Older adults have decreased heart rate at rest. Heart sounds are sometimes muffled or difficult to hear in older adults because of an increase in air space in the lungs. The nurse is measuring the vital signs of a patient. What is the normal range of pulse pressure? 1 10 to 15 mm Hg 2 20 to 25 mm Hg 3 30 to 50 mm Hg 4 60 to 70 mm Hg - 3 Pulse pressure is defined as the difference between the systolic and diastolic blood pressure normally ranging from 30 to 50 mm Hg. Any value below 30 mm of Hg and above 50 mm of Hg is considered to be outside the normal range. What consequence may occur due to kyphosis in an older patient? 1 Anorexia 2 Hyperthermia 3 Postural hypotension 4 Restricted chest expansion - 4 Kyphosis in older patients may restrict chest expansion. The subtle changes in temperature may cause anorexia. In older patients, decreased sweat gland reactivity may cause hyperthermia. Older patients are instructed to change position slowly to prevent postural hypotension. The nurse is teaching the nursing student about when to measure the vital signs in a patient. Which statement by the nursing student indicates the need for further learning? Select all that apply. 1 "Vital signs should be measured before ambulating a patient previously on bed rest." 2 "Vital signs should be measured before and after a transfusion of blood products." 3 "Vital signs should be measured after a patient reports increased intensity of pain." 4 "Vital signs should be measured before a patient performs range-of-motion exercises." 5 "Vital signs should be measured after the administration of medication that affects temperature control functions." - 2, 5 Vital signs should be measured before, during, and after a transfusion of blood products, not only before and after. During the blood transfusion, it is important to measure vital signs to check the occurrence of any complication due to transfusion rate or amount of blood product transfusion. Vital signs should be measured before, during, and after the administration of medication that affects temperature control functions, not only after. Before the administration of medication that affects temperature control, it is important to measure vital signs to determine whether the patient is really in need of that medication. During the administration of medication that affects temperature control, it is important to measure the vital signs to check for overdosing. Vital signs should be measured before a patient previously on the bed ambulates. Vital signs should be measured after a patient reports increased intensity of pain. Vital signs should be measured before a patient performs range-of-motion exercises.