Vital Signs Post Test

1. 1. Which of the following patients would require follow-up? A. B. C. A child with a respiratory rate of 20 breaths per minute. An adolescent with a respiratory rate of 16 breaths per minute. An adult with a respiratory rate of 10 breaths per minute. Correct The normal respiratory rate for a newborn is 30 to 60 breaths per minute. The normal respiratory rate of a child is 20 breaths per minute. The normal respiratory rate for a teenager is 16 to 20 breaths per minute. The normal respiratory rate for an adult is 12 to 20 breaths per minute. A rate of 10 would require follow-up. D. A newborn with a respiratory rate of 40 breaths per minute. Awarded 1.0 points out of 1.0 possible points. 2. 2. Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? A. B. C. Temp 96.8° F (36 °C), P-60, R-18, BP 160/90, O2 sat 93%. Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%. Correct Normal values for an older adult are: average body temperature approximately 36° C (96.8° F), heart rate 60 to 100 beats per minute, respiratory rate 16 to 25 breaths per minute, average BP less than 120 over 80, and pulse oximetry 95% to 100%. A BP greater than 140 over 90 may be an indication of hypertension. Temp 98.6 °F (37 °C), P-56, R-20, BP 120/80, O2 sat 91%. D. Temp 98.0 °F (36.7 °C), P-76, R-22, BP 110/70, O2 sat 88%. Awarded 1.0 points out of 1.0 possible points. 3. 3. The nurse has delegated the task of temperature assessment to the NAP. Which information should be provided to the NAP? (Select all that apply.) A. The patient's age. B. The type of temperature required. Correct C. The patient's diagnosis. D. The frequency for taking or monitoring the temperature. Correct E. What changes to report immediately to the nurse. Correct It is more important that the temperature be done on time by the correct route, with the correct equipment, and that identified changes be reported as requested. Awarded 3.0 points out of 3.0 possible points. 4. 4. Which of the following situations may affect a patient's vital signs? (Select all that apply.) A. Time of day. Correct B. Occupation. C. Moving from lying to standing position. Correct D. Pain rated as a 7 on 0-10 pain scale. Correct E. Isolation precautions. Factors that may alter vital signs include time of day, stress (emotional and physical), temperature alterations/weather conditions, exercise/activity, emotions, medication, postural changes, acute pain, smoking, disease/injury status, noise, food/liquid consumption, and odors. The person's occupation and isolation precautions do not alter vital signs. If a person's job requires an activity that increases exertion or stress, the activity affects vital signs, not the occupation. Awarded 3.0 points out of 3.0 possible points. 5. 5. The nurse will take the patient's vital signs preoperatively and record them as part of the patient's preparation for surgery. Why is it necessary to take vital signs preoperatively? (Select all that apply.) A. To determine whether the patient is "feeling funny" or "different". B. To provide a set of vital signs to use for comparison during and after surgery. Correct C. To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention. Correct D. To provide the patient with reassurance that he or she is being cared for by a competent staff. E. To ensure the equipment is appropriately calibrated and functional. The patient who is going to surgery is going to experience a change in condition and an invasive procedure. Vital signs are necessary so that the operative team has a baseline for comparison as well as to rule out any complications before the beginning of the surgical event. Providing reassurance to the patient can be done verbally. If a patient reports feeling different, assessing vital signs is appropriate. There is no indication the patient is feeling different. Equipment should be maintained in a functional state at all times. Awarded 2.0 points out of 2.0 possible points. 6. 6.ID: 18668360376 The NAP reports to the nurse a 65-year-old patient s blood pressure is 160/98. What is the appropriate initial response of the nurse? A. B. Ask the NAP if the patient is nauseous. Assess the patient s blood pressure. Correct This is out of normal range. If there is a question regarding a patient's vital signs or a suspected change in the patient's condition that may require further assessment, the nurse should take the patient's vital signs rather than delegating the task. C. Instruct the NAP to obtain a full set of vital signs. D. Document this as a normal finding in an elderly adult. Awarded 1.0 points out of 1.0 possible points. 7. 7. Which patient would it be appropriate for the nurse to delegate vital signs? A. B. C. New admission to the hospital. Patient transferred from ICU. Elderly nursing home resident. Correct The nurse may delegate routine vital signs of stable patients. Obtaining a baseline upon admission or transfer patient should be completed by the nurse. If a patient has a change in condition, such as a headache which could be reflective of hypertension, the nurse should assess the patient’s vital signs. D. Patient with recent complaint of headache. Awarded 1.0 points out of 1.0 possible points.