Vital Signs

You have delegated vital signs to assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse's most appropriate advice would be to:

• Take a rectal temperature.

• Take the oral temperature as planned.

• Advise the patient to drink a glass of cold water.

• Wait 30 minutes and take an oral temperature.

A patient had a sudden drop of 20mmHg in systolic pressure and 10mmHg in a diastolic pressure when the patient moves from a lying to sitting to a standing position. What is this called?

• Hypotension

• Orthostatic hypotension

• Hypertension

• None of the above

You notice that a teenager has an irregular pulse. the best action you should take as a nurse includes:

• Reading the history and physical

• assessing the apical pulse rate for 1 full minute

• Auscultating for strength and depth of pulse

• Asking whether the patient feels any palpitations of faintness of breath

A postoperative patient is breathing rapidly. You should immediately:

• Call the physician

• Count the respiration

• Assess the oxygen saturation

• Ask the patient if he feels uncomfortable

When assessing the blood pressure of a school-aged child, using an adult cuff of normal size will affect the reading and produce a value that is:

• Accurate

• Indistinct

• Falsely low

• Falsely high

It is okay to palpate both carotid arteries at the same time.

• True

• False

Respiratory status assessment includes:

• Breathing rate

• Breathing depth

• Breathing rhythm

• All of the above

Sudden alterations in vital signs or values outside the normal range are indicators of a priority situation for the nurse.

• True

• False

The (a)   pulse is a central pulse that can be auscultated over the apex of the heart at the point of maximal impulse (PMI).

Rate is the regularity of the heartbeat.

• True

• False