Vital Signs nclex questions

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ajax726
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233254
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Vital Signs nclex questions
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2013-10-07 17:00:46
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100 exam three
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nclex vital sign questions
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  1. a nurse assesses an oral temperature for a patient as 38.5°C (101.3°F).  What term would the nurse use to report this temperature?
    A. fever
    B. hyptertension
    C. afebrile
    D. hypothermia
    A. fever
    (this multiple choice question has been scrambled)
  2. a nurse is assessing vital signs on several hospitalized children.  the nurse would plan to use the oral route to assess temperature for which patient?
    A. 6 month old infant
    B. patient receiving oxygen therapy by mask
    C. 15 year old healthy adolescent
    D. unconscious patient
    C. 15 year old healthy adolescent.
    (this multiple choice question has been scrambled)
  3. when assessing a temperature rectally, the nurse would use extreme care when inserting the thermometer to prevent which of the following?
    A. increase in respirations
    B. decrease in BP
    C. increase in heart rate
    D. decrease in heart rate
    D. decrease in heart rate.  insertion of a rectal thermometer may stimulate the vagus nerve, which in turn, would decrease heart rate.  This may potentially be harmful for patients with cardiac problems
    (this multiple choice question has been scrambled)
  4. while taking an adult patient's pulse, a nurse finds the rate to be 140 bpm.  what should the nurse do next?
    A. check pulse again in two hours
    B. check the BP
    C. record the information
    D. report the rate
    D. report the rate.  a heart rate of 140 bpm in an adult is abnormal and should be reported to the instructor or the nurse in charge of the patient.
    (this multiple choice question has been scrambled)
  5. a patient complains of severe abdominal pain.  when assessing the vital signs, the nurse would not be surprised to find what assessment?
    A. a decrease in BP
    B. an increase in pulse rate
    C. a decrease in body temp
    D. an increase in respiratory depth
    B. an increase in pulse rate.  pulse often increases when someone experiencing pain.  pain doesn't affect body temp, and may increase (not decrease) BP.  acute pain may increase respiratory rate, but decrease depth.
    (this multiple choice question has been scrambled)
  6. two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 bpm.  the nurse would document this difference as which of the following?
    A. pulse amplitued
    B. heart arrhythmia
    C. pulse deficiet
    D. ventricular rythm
    C. pulse deficit
    (this multiple choice question has been scrambled)
  7. before assessing respirations, the nurse reviews normal rates for adults.  which rate would the nurse identify as normal?
    a. 1-6 br/m
    b. 12-20 br/m
    c. 60-80 br/m
    d. 100-120 br/m
    12-20 br/m
  8. a patient is having dyspnea.  what would the nurse do first?
    A. take BP
    B. elevate the foot of the bed
    C. remove pillows from under the head
    D. elevate the head of the bed
    D. elevate the head of the bed.  elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm greater room for expansion and facilitating lung expansion.
    (this multiple choice question has been scrambled)
  9. a student nurse is learning to assess BP.  what does the BP measure?
    A. force of blood against atrial walls
    B. flow of blood through the circulation
    C. flow of blood through the heart
    D. force of blood against venous walls
    A. force of blood against atrial walls.
    (this multiple choice question has been scrambled)
  10. a nurse knows BP is often higher in older adults based on the understanding that which of the following occurs with aging?
    A. loss of muscle mass
    B. decreased peripheral resistance
    C. changes in exercise levels
    D. decreased elasticity in arterial walls
    D. decreased elasticity in arterial walls
    (this multiple choice question has been scrambled)
  11. a patient has a BP reading of 130/90 mmHg when visiting a clinic.  what would a nurse recommend to the patient?
    A. a change in dietary intake
    B. immediate treatment by a physician
    C. follow-up measurements of BP
    D. nothing because the nurse thinks this reading is due to anxiety
    C. follow-up BP measurements.  a single reading of a mildly elevated BP is not significant, but measurement should be taken again over time to determine if hypertension is a problem.  the nurse would recommend a return visit to the clinic for a recheck.
    (this multiple choice question has been scrambled)
  12. it is important to have the appropriate cuff size when taking the BP.  what error may occur when the cuff size is wrong?
    A. injury to the patient
    B. an incorrect reading
    C. prolonged pressure on the arm
    D. loss of Korotkoff sounds
    B. an incorrect reading
    (this multiple choice question has been scrambled)
  13. a patient has intravenous fluids infusing in the right arm.  when taking a BP on this patient, what would the nurse do in this situation?
    A. take it in the right arm
    B. use the smallest possible cuff
    C. take it in the left arm
    D. report inability to take BP
    C. take it in the left arm.
    (this multiple choice question has been scrambled)

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