Vital Signs
While performing a 2-step blood pressure measurement, the nurse palpates the radial pulse and notes that it disappears at 150 mmHg during cuff inflation. What is the nurse’s next action?
A. Immediately begin auscultating while deflating the cuff.
B. Deflate the cuff completely, wait 30–60 seconds, then reinflate to 170–180 mmHg before auscultating.
C. Document 150 mmHg as the systolic pressure.
D. Reposition the stethoscope and continue inflating the cuff.
B. Deflate the cuff completely, wait 30–60 seconds, then reinflate to 170–180 mmHg before auscultating.
This low-pitched, snoring-like sound is caused by secretions in larger airways and may clear after coughing. Typically heard on exhalation.
What are rhonchi.
Clinicians are taught never to palpate these arteries at the same time because doing so can reduce blood flow to the brain and potentially cause fainting.
What are the carotid arteries.
When preparing to administer a scheduled medication, which action is the BEST way for the nurse to verify the patient’s identity?
A. Ask the patient to state their full name and date of birth while checking the information against the ID band.
B. Ask the patient if they are Mr. Smith and confirm the room number.
C. Check the name on the door and compare it with the medication administration record.
D. Ask a family member to confirm the patient’s identity.
A. Ask the patient to state their full name and date of birth while checking the information against the ID band.
A patient’s blood pressure reading is 168/92 mmHg. The patient asks the nurse, “What do those numbers mean?” What is the nurse’s BEST response?
A. “The top number is your heart rate, and the bottom number is your oxygen level.”
B. “The top number measures the pressure when your heart contracts, and the bottom number measures the pressure when your heart relaxes.”
C. “The numbers are slightly elevated, but nothing to worry about.”
D. “Your blood pressure is high, so you will need medication immediately.”
B. “The top number measures the pressure when your heart contracts, and the bottom number measures the pressure when your heart relaxes.”
Which of the following questions would best help the nurse determine the severity of a patient’s shortness of breath?
A. “When did the shortness of breath begin?”
B. “Do you have a history of asthma?”
C. “How many pillows do you use when sleeping at night?”
D. “Have you had a cough recently?”
C. “How many pillows do you use when sleeping at night?”
This auscultation site is located at the second intercostal space, right sternal border, and is where you listen for the aortic valve sounds.
What is the aortic auscultation site.
Which statement made by the nursing student indicates a need for further teaching?
A. "We perform percussion to assess underlying tissue texture."
B. "Before performing a rectal temperature, I should apply a water-based lubricant."
C. "For an accurate blood pressure, the patient's upper arm should be at the same level as the heart."
A. "We perform percussion to assess underlying tissue texture."
Which of the following tasks cannot be delegated to a UAP when assessing vital signs?
A. Measuring a patient’s oral temperature
B. Counting a patient’s respirations
C. Measuring a patient’s radial pulse
D. Auscultating a patient’s blood pressure and interpreting Korotkoff sounds
D. Auscultating a patient’s blood pressure and interpreting Korotkoff sounds
This sound is fine, high-pitched, heard mainly at the end of inspiration, and often indicates fluid in the alveoli as in pneumonia or pulmonary edema.
What are crackles.
This can be located by palpating over the precordium near the apex of the heart, typically at the fifth intercostal space along the left midclavicular line.
What is the point of maximal impulse (PMI)
The nursing student demonstrates an understanding of the Allen test when he/she:
A. Compresses both the radial and ulnar arteries, asks the patient to open the hand, and then releases only one artery to observe color return.
B. Palpates the radial artery and immediately draws blood before testing the ulnar artery.
C. Asks the patient to raise both arms above the head while observing for hand color changes.
D. Uses firm pressure on the radial artery to assess for hand swelling.
A. Compresses both the radial and ulnar arteries, asks the patient to open the hand, and then releases only one artery to observe color return.
This condition is defined as a drop in systolic blood pressure of at least 20 mmHg or diastolic blood pressure of at least 10 mmHg within three minutes of standing.
What is orthostatic hypotension.
This noninvasive monitoring method measures the concentration of carbon dioxide in exhaled air and is commonly used to assess a patient’s ventilatory status during anesthesia or in the ICU.
What is capnography.
The student nurse demonstrates an understanding of auscultating an S3 heart sound by which of the following actions?
A. Placing the diaphragm firmly at the right second intercostal space with the patient sitting upright.
B. Using the bell of the stethoscope lightly at the apex while the patient is in the left lateral position.
C. Auscultating over the left sternal border with the diaphragm while the patient leans forward.
D. Applying firm pressure with the bell at the base of the heart while the patient holds their breath.
B. Using the BELL of the stethoscope lightly at the apex while the patient is in the left lateral position.
A nursing student is assessing a 6-year-old child. Which of the following heart rates would be considered within the normal range for this age?
A. 45 beats per minute
B. 69 beats per minute
C. 110 beats per minute
D. 145 beats per minute
C. 110 beats per minute
This part of the brain acts as the body’s “thermostat,” regulating temperature by triggering mechanisms such as shivering and sweating.
What is the hypothalamus.
Which statement made by the student nurse indicates an understanding of breath sounds?
A. "Vesicular breath sounds are typically heard over the trachea/anterior chest near the sternum."
B. "I should auscultate lung sounds by comparing anterior to posterior."
C. "A dull percussion may be caused by increased lung density."
C. "A dull percussion may be caused by increased lung density."
A patient reports that his lower legs often feel heavy and achy at the end of the day. He notices swelling around his ankles that improves after he elevates his legs. The skin around his ankles appears brownish and slightly shiny. Based on this information, the nurse is concerned that the patient may be experiencing a problem involving the:
A. Arterial system
B. Venous system
C. Lymphatic system
D. Musculoskeletal system
B. Venous system
A nursing student demonstrates understanding of normal body temperature fluctuations by stating that:
A. Body temperature is usually highest in the morning and lowest in the evening.
B. Body temperature remains constant throughout the day in healthy adults.
C. Body temperature is usually lowest in the morning and highest in the late afternoon or evening.
D. Body temperature varies randomly and has no predictable pattern.
C. Body temperature is usually lowest in the morning and highest in the late afternoon or evening.