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Nur 101 - Test 3 - Chapter 4 - Vital Signs Test, Part II, 50 Questions

50 Questions
Study Guide Quizzes & Trivia

Foundations of Nursing By Christensen Kockrow, 6th Edition, pages 71 - 91

Questions and Answers
  • 1. 
    Match the Pulse site on the left with its description on the right. 
    • A. Radial Pulse
    • A.
    • B. Brachial Pulse
    • B.
    • C. Femoral Pulse
    • C.
    • D. Popliteal Pulse
    • D.
    • E. Dorsalis Pedis Pulse
    • E.
    • F. Posterior Tibial Pulse
    • F.
  • 2. 
    When a patient's condition suddenly deteriorates which is the best site to locate a pulse quickly? 
    • A. 

      Ulnar

    • B. 

      Carotid

    • C. 

      Apical

    • D. 

      Brachial

  • 3. 
    Actual beating of the heart and is normally used when taking the pulse rate of an infant
    • A. 

      Carotid pulse

    • B. 

      Apical pulse

    • C. 

      Brachial pulse

    • D. 

      Radial pulse

  • 4. 
    Represents one cardiac cycle or heartbeat
    • A. 

      Lubb-dupp

    • B. 

      Sytole-dystole

    • C. 

      Cardiac perfusion

    • D. 

      Cardiac tamponade

  • 5. 
    Difference between radial and apical rates
    • A. 

      Radial deficit

    • B. 

      Apical deficit

    • C. 

      Pulse deficit

    • D. 

      Heart rate difference

  • 6. 
    When a patient has a pulse rate above normal, which of the following related data would require further assessment?  
    • A. 

      Digoxin intoxication

    • B. 

      Pain, fear anxiety, low blood pressure

    • C. 

      Pallor or loss of consciousness

    • D. 

      Tissue perfusion

  • 7. 
    Antidysrhythmic medication could cause pulse rates to:
    • A. 

      Go down below normal

    • B. 

      Increase

    • C. 

      Remain the same

    • D. 

      Go up and down

  • 8. 
    Point of Maximal Impulse
    • A. 

      Angle of Louis

    • B. 

      Apical area

    • C. 

      Thoracic region

    • D. 

      Chest cavity

  • 9. 
    Fifth intercostal space, left of the midclavicular line
    • A. 

      Site for apical pulse

    • B. 

      Site for femoral pulse

    • C. 

      Site for popliteal pulse

    • D. 

      Site for radial pulse

  • 10. 
    • A. 

      Apex of the heart

    • B. 

      Base of the heart

    • C. 

      Periphery of the heart

    • D. 

      Surface of the heart

  • 11. 
    ‚ÄčExchange of gas at tissue level caused by the process of cellular oxidation (any process wherein the oxygen compound is increased)
    • A. 

      Internal respiration

    • B. 

      External respiration

    • C. 

      Metabolism

    • D. 

      Oxygenation

  • 12. 
    Breathing movements of a patient that a nurse observes
    • A. 

      Inspiration

    • B. 

      Expiration

    • C. 

      Internal respiration

    • D. 

      External respiration

  • 13. 
    The rate of respiration is controlled by:
    • A. 

      Medulla oblongata

    • B. 

      Hypothalamus

    • C. 

      Pituitary gland

    • D. 

      Cerebellum

  • 14. 
    Factors that influence respiration. Select all that apply:
    • A. 

      Nicotine

    • B. 

      Gender

    • C. 

      Acute pain

    • D. 

      Hyperpyrexia

    • E. 

      Sublimation

  • 15. 
    Normal respiratory range for an adult per minute:
    • A. 

      16-30

    • B. 

      10-16

    • C. 

      12-20

    • D. 

      20-40

  • 16. 
    A slow respiratory rate, below 10 per minute
    • A. 

      Tachypnea

    • B. 

      Bradypnea

    • C. 

      Orthopnea

    • D. 

      Dyspnea

  • 17. 
    After responding to the call light of a new mother, she complains that her baby sometimes stops breathing for around 10 to 15 seconds. What would be your most appropriate response?  
    • A. 

      "Short apneic spells of less than 20 seconds are normal in a newborn"

    • B. 

      "You need to talk to the pediatrician immediately"

    • C. 

      "Let me call the supervisor and tell her about it"

    • D. 

      "How is your baby doing?"

  • 18. 
    Amount of air inspired with each breath is ______ ml.
  • 19. 
    Match the pattern of respiration on the left with is description on the right
    • A. apnea
    • A.
    • B. cheyne-stokes
    • B.
    • C. hyperventilation
    • C.
    • D. hypoventilation
    • D.
  • 20. 
    The best time to assess a patient's respiration is when:  
    • A. 

      Counting a radial or an apical pulse

    • B. 

      The patient is asleep

    • C. 

      A head to toe assessment is being done

    • D. 

      After a bed bath

  • 21. 
    Pressure exerted by the circulating volume of blood on the arterial walls, the veins, and the chambers of the heart
    • A. 

      Metabolic Pressure

    • B. 

      Air Pressure

    • C. 

      Cardiac Pressure

    • D. 

      Blood Pressure

  • 22. 
    Represents the ventricles contracting, forcing blood into the aorta and the pulmonary arteries It is indicated by the first sound heard on auscultation
    • A. 

      Cardiac Output

    • B. 

      Pulse Pressure

    • C. 

      Diastolic Pressure

    • D. 

      Systolic Pressure

  • 23. 
    Pressure within the artery between beats; between contractions of the atria or the ventricles, when blood enters the relaxed chambers from the systemic circulation and the lungs
    • A. 

      Diastolic pressure

    • B. 

      Systolic pressure

    • C. 

      Cardiac pressure

    • D. 

      Pulse pressure

  • 24. 
    Pulse Pressure
    • A. 

      Pressure in the radial pulse

    • B. 

      Difference between systolic and diastolic pressures

    • C. 

      Difference between apical and radial pulse

    • D. 

      Pressure in the apical pulse

  • 25. 
    The diagnosis of hypertension among adults is not made with only one random elevated reading. Which of the following is true? Select all that apply. 
    • A. 

      An average of 90 mm HG or higher on two or more diastolic readings on at least two subsequent visits is necessary

    • B. 

      An average higher than 140 mm Hg of two or more systolic readings on at least two visits.

    • C. 

      Patient should have a high elevated reading for the past 6 months

    • D. 

      Patient has a chronic elevated reading during a week or more

  • 26. 
    Which of the following are true about orthostatic hypotension? Select all that apply.
    • A. 

      A drop of 25 mm Hg in systolic pressure when person moves from lying to a sitting or from a sitting to a standing position

    • B. 

      A drop of 10 mm Hg in diastolic pressure when a person moves from lying to a sitting or a sitting to a standing position.

    • C. 

      The patient frequently feels light headed and unstable

    • D. 

      Orthostatic hypotension can be caused by excessive excitement

  • 27. 
    When obtaining blood pressure, korotkoff sounds needed to determine the systolic and diastolic pressures are normally listened to at which site?
    • A. 

      Brachial artery

    • B. 

      Radial artery

    • C. 

      Femoral artery

    • D. 

      Carotid artery

  • 28. 
    Which of the following conditions raises blood pressure? Select all that apply
    • A. 

      Hemorrhage

    • B. 

      Increased ICP (intracranial pressure)

    • C. 

      Acute pain

    • D. 

      End-stage renal disease

    • E. 

      Primary essential hypertension

    • F. 

      General anesthesia

    • G. 

      Excercise

    • H. 

      Postural change

    • I. 

      Smoking

  • 29. 
    Which of the following conditions lowers blood pressure?
    • A. 

      Hemorrhage

    • B. 

      Increased ICP (intracranial pressure)

    • C. 

      Acute pain

    • D. 

      End-stage renal disease

    • E. 

      Primary essential hypertension

    • F. 

      General anesthesia

    • G. 

      Exercise

    • H. 

      Postural change

    • I. 

      Smoking

  • 30. 
    In patients with hypertension, the sounds usually heard over the brachial artery disappear as pressure is reduced and then reappear at a lower level. It occurs between the first and the second Korotkoff sounds. What is it called?
    • A. 

      Auscultatory gap

    • B. 

      Cardiac silence

    • C. 

      Brachial space

    • D. 

      Korotkoff space

  • 31. 
    You were about the obtain the blood pressure of a patient when he told you that he just finished smoking while taking coffee less than 5 minutes ago. In order to obtain an accurate reading, what should you do next?  
    • A. 

      Be sure that you have the right equipment that fits him

    • B. 

      Be sure that he is properly sitting down and that he does not cross his legs

    • C. 

      Come back to him after 30 minutes because caffeine and nicotine could cause false elevations

    • D. 

      Proceed in obtaining blood pressure since caffeine and nicotine do not affect it.

  • 32. 
    A higher, inaccurate reading will be obtained if too small a cuff is used. A lower inaccurate reading will be obtained if too large a cuff is used. In order to prevent this, which of the following needs to be implemented? 
    • A. 

      Cuff should be approximately 40% of the circumference of the extremity on which the cuff is to be used

    • B. 

      The arm on which the cuff is to be used should be within 40% of the cuff around it.

    • C. 

      The cuff should be more than 40% of the circumference of the extremity where it will be used

    • D. 

      The cuff should have the same size as the arm

  • 33. 
    With the following pre-exiting conditions, applying the cuff to obtain a blood pressure may complicate that condition. Which of these conditions should a cuff BE NOT APPLIED? Select all possible choices. 
    • A. 

      Catheter is in antecubital fossa and fluids are infusing

    • B. 

      Breast or axillary surgery has been performed on that side

    • C. 

      Arteriovenous shunt is in place

    • D. 

      A lower arm cast or bulky bandage is in place

    • E. 

      An arm or hand has been traumatized or is diseased

    • F. 

      An elevated birthmark is on the forearm

  • 34. 
    When obtaining blood pressure, what would be the best way to avoid auscultatory gap?  
    • A. 

      Slowly deflate cuff at a rate of 2 mm Hg

    • B. 

      When the Kortokoff sounds are no longer audible, continue to listen for another 10 to 20 mm Hg

    • C. 

      Reinflate cuff to 30 mm Hg above point at which radial artery was obliterated

    • D. 

      Palpate radial artery

  • 35. 
    When obtaining blood pressure, applying the cuff to bare arms with patient's palm facing upward will normally have the same accurate reading as placing the cuff above the clothes. 
    • A. 

      True

    • B. 

      False

  • 36. 
    A student nurse needs more teaching on how to obtain an accurate blood pressure when one of these is done. 
    • A. 

      The cuff is applied 1 to 2 inches above the antecubital space.

    • B. 

      The cuff is centered over the brachial artery

    • C. 

      The patient's upper arm is held at the level of the heart.

    • D. 

      The patient's lower arm is dangling and not rested.

  • 37. 
    In order to confirm blood pressure reading, when the Korotkoff sounds are no longer audible, what should you do next?
    • A. 

      Continue to listen for another 10 to 20 mm Hg

    • B. 

      Take away the cuff and document the result

    • C. 

      Ask the patient if the pressure of the cuff is still felt

    • D. 

      Look at the gauge and document the reading

  • 38. 
    Which of the following statements regarding the assessment of blood pressure is true? Select all that apply.   
    • A. 

      Systolic pressure in the lower extremities is usually higher by 10 to 40 mm Hg than in the brachial artery, but the diastolic pressure is essentially the same

    • B. 

      Normally, a difference of 5 to 10 mm Hg exists between the arms

    • C. 

      Pressure differences higher than 10 mm Hg indicate conditions such as aortic stenosis or an arterial occlusion in the arm with the lower pressure.

    • D. 

      Interchanging the cuffs of electronic blood pressure machines will produce the same result.

  • 39. 
    A patient weighting 176 lbs says she lost around 2.2 pounds recently. She expressed that all she lost was water. How many liters of water did she lose?
    • A. 

      1 Liter

    • B. 

      2 Liters

    • C. 

      0.5 Liters

    • D. 

      1 ml

  • 40. 
    For some patients, in order to determine right dosage calculation, what do we need to measure? 
    • A. 

      Blood pressure

    • B. 

      Height and weight

    • C. 

      Respiration

    • D. 

      Heart rate

  • 41. 
    A patient who is about to be admitted claims that her weight has always been 110 lbs and that there is no need to weigh her again. What would be the nurse's most appropriate response?
    • A. 

      "I am sure you are right, but we need to weigh you once more."

    • B. 

      "Not all scales are the same. Let us see what our scales say".

    • C. 

      "There might have been some changes".

    • D. 

      "That is good to know. It save me a lot of work"

  • 42. 
    Talking to a patient when the blood pressure is being assessed increases readings 10 to 40 percent
    • A. 

      True

    • B. 

      False

  • 43. 
    The most ideal time to weight a patient
    • A. 

      Any time after taking a shower before dressing up

    • B. 

      After voiding, before breakfast at around 6:00 am

    • C. 

      At night, before going to sleep

    • D. 

      Before dinner at around 6:00 pm

  • 44. 
    A 42 year old patient has a rectal temperature of 102.4 F. What would the oral temperature possible be?
    • A. 

      101.4 F

    • B. 

      103.4 F

    • C. 

      100.3 F

    • D. 

      104.3 F

  • 45. 
    A 12 year old child seems to be febrile early in the morning but goes to bed with a normal temperature. This has been happening for the past three days. How is the fever classified?
    • A. 

      Constant

    • B. 

      Intermittent

    • C. 

      Remittent

    • D. 

      Chronic

  • 46. 
    A 42 year old patient is suffering from a history of rheumatic heart disease. For an accurate assessment, what should the nurse obtain?
    • A. 

      Ulnar pulse

    • B. 

      Radial pulse

    • C. 

      Apical pulse

    • D. 

      Femoral pulse

  • 47. 
    A 20-year old patient was admitted after a motor vehicle accident. The nurse assessing his pulse pressure also had a blood pressure reading as 130/90. What then would be the correct pulse pressure? 
    • A. 

      70

    • B. 

      80

    • C. 

      40

    • D. 

      220

  • 48. 
    Which of the following is the correct orthostatic method of assessing blood pressure?
    • A. 

      Supine, then sitting, then standing

    • B. 

      Sitting and then lying down

    • C. 

      Wait for 5 minutes before assessing blood pressure in sitting position

    • D. 

      Patient should lie down for 10 minutes before assessing blood pressure

  • 49. 
    Electronic Blood pressure measurement is inappropriate for these patients. Select all that apply
    • A. 

      Patients who have irregular heart rate

    • B. 

      Patients with seizures

    • C. 

      Patients whose BMI is above 30

    • D. 

      A 92-year old patient

    • E. 

      A person suffering from DVT

  • 50. 
    A patient's MAR indicates that he is taking cardiotonics and antihypertensives. As a nurse, what do you need to assess before the administration of these medication? Select all that aooky
    • A. 

      Pulse and Temperature

    • B. 

      Blood Pressure and Heart rate

    • C. 

      Pressure Sores and Inflammation

    • D. 

      Height and Weight