Vital Signs Assessment Quiz

A patient has a blood pressure reading of 150/95 mmHg. What strategic plan should a nurse develop to address this condition?

• Advise the patient to increase salt intake.

• Recommend regular cardiovascular exercise and a low-sodium diet.

• Suggest the patient drink more caffeinated beverages.

• Encourage the patient to rest more and avoid physical activity.

Answer explanation

The correct choice is to recommend regular cardiovascular exercise and a low-sodium diet, as these strategies help lower blood pressure. Increasing salt intake and resting more are counterproductive for hypertension management.

When interpreting a heart rate of 120 beats per minute in an adult patient, what reasoning should a nurse use to determine the next steps?

• Consider it normal and take no action.

• Assess for potential causes such as fever, anxiety, or dehydration.

• Immediately administer beta-blockers.

• Schedule a follow-up appointment in a month.

Answer explanation

A heart rate of 120 bpm in an adult can indicate tachycardia. The nurse should assess for potential causes like fever, anxiety, or dehydration before taking further action, rather than assuming it's normal.

A patient presents with a respiratory rate of 8 breaths per minute. What strategic intervention should a nurse consider?

• Encourage the patient to hold their breath for longer periods.

• Administer oxygen and monitor for signs of respiratory distress.

• Suggest the patient engage in vigorous exercise.

• Increase the room temperature to make the patient more comfortable.

Answer explanation

A respiratory rate of 8 breaths per minute indicates bradypnea, which can lead to inadequate oxygenation. Administering oxygen and monitoring for respiratory distress is crucial to ensure patient safety.

How should a nurse evaluate a patient with an oxygen saturation level of 88%?

• Consider it within normal limits and document the finding.

• Initiate emergency protocols and prepare for intubation.

• Administer supplemental oxygen and reassess the patient.

• Advise the patient to take deep breaths and recheck in an hour.

Answer explanation

An oxygen saturation level of 88% is below normal. The appropriate action is to administer supplemental oxygen to improve saturation and then reassess the patient's condition.

A patient has a body temperature of 102°F. What reasoning should a nurse use to determine the appropriate intervention?

• Provide a warm blanket to increase comfort.

• Administer antipyretics and encourage fluid intake.

• Suggest the patient wear more layers of clothing.

• Ignore the temperature as it is not a concern.

Answer explanation

Administering antipyretics helps reduce fever, while encouraging fluid intake prevents dehydration. Providing warmth or ignoring the fever is inappropriate for a temperature of 102°F.

What strategic approach should a nurse take when recognizing abnormal vital signs in a patient?

• Document the findings and wait for the next scheduled assessment.

• Reassess the patient and notify the healthcare provider immediately.

• Assume the equipment is faulty and disregard the readings.

• Tell the patient not to worry and continue with their day.

Answer explanation

When abnormal vital signs are detected, the nurse should reassess the patient and notify the healthcare provider immediately to ensure timely intervention and patient safety.

A patient with a history of hypertension has a blood pressure reading of 180/110 mmHg. What plan should a nurse develop to address this situation?

• Advise the patient to stop taking their medication.

• Educate the patient on the importance of medication adherence and lifestyle changes.

• Suggest the patient increase their caffeine intake.

• Recommend the patient avoid all physical activity.

Answer explanation

Educating the patient on medication adherence and lifestyle changes is crucial to manage hypertension effectively, especially with a reading of 180/110 mmHg, rather than stopping medication or making inappropriate suggestions.

How should a nurse interpret a heart rate of 50 beats per minute in an adult patient?

• Consider it normal for all patients.

• Assess for symptoms of bradycardia and evaluate the patient's medication history.

• Immediately administer atropine.

• Schedule a follow-up appointment in a year.

Answer explanation

A heart rate of 50 bpm is considered bradycardia. The nurse should assess for symptoms and review the patient's medication history to determine if it's a concern or a normal finding for that individual.

A patient has a respiratory rate of 30 breaths per minute. What strategic intervention should a nurse consider?

• Encourage the patient to breathe faster.

• Assess for underlying causes such as anxiety or respiratory infection.

• Suggest the patient hold their breath for longer periods.

• Increase the room temperature to make the patient more comfortable.

Answer explanation

A respiratory rate of 30 breaths per minute is elevated. The nurse should assess for underlying causes like anxiety or respiratory infection, as these can indicate a need for further intervention.

What reasoning should a nurse use when evaluating a patient with an oxygen saturation level of 95%?

• Consider it within normal limits and document the finding.

• Initiate emergency protocols and prepare for intubation.

• Administer supplemental oxygen and reassess the patient.

• Advise the patient to take deep breaths and recheck in an hour.

Answer explanation

An oxygen saturation level of 95% is considered within normal limits for most patients. Therefore, the appropriate action is to document the finding rather than initiate emergency measures or provide supplemental oxygen.