Vital Signs

The nurse has delegated vital signs to a nursing assistant. The assistant informs the nurse 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 nurse takes a teenager's radial pulse and notices the pulse is irregular. What should the nurse do next?

• read the history and physical

• assess the apical pulse rate for one full minute

• auscultate the strength and depth of pulse

• as, if the patient feels any palpations or faintness of breath

A post-operative patient is breathing rapidly. The nurse should immediately

• call the physician

• count the respirations

• assess the oxygen saturation

• ask the patient if they feel uncomfortable

When assessing the blood pressure of a school-age child, using a normal-size adult cuff will produce a blood pressure reading that is

• accurate

• indistinct

• falsely low

• falsely high

The nurse has just taken the vital signs of a young adult. Based on the results, the nurse will report which of the following findings is out of the expected range for a patient of his age

• Temp = 98.8F

• Pulse = 90 beats/min

• Resp = 10 breaths/min

• BP = 120/76 mmHg

The postoperative vital signs of an average size adult patient are: BP=110/68 mmHg, P=54 beat/min, Resp =8 breaths/min. The patient is pale, disoriented, and has a minimal urinary output. The nurse should

• retake the vital signs in 30 minutes

• continue with care as planned

• administer a stimulant

• notify the physician

After measuring the patient's vital signs, the nurse obtains the following results: BP 180/100mmHg, Pulse 82, Resp 16, and rectal temp 99.6

• retake the blood pressure

• retake the patient's temperature

• report all of the findings immediately

• record the finding as within normal limits

A patient is being monitored with pulse oximetry. Which factor will influence the pulse oximetry reading the most

• the placement of the sensor on the extremity

• a diagnosis of peripheral vascular disease

• a reduced amount of artificial light in the room

• the patient's room temperature is 80 degrees F