Ch20 | Exam Questions – Measuring And Recording Vital Signs

Test Generator Questions, Chapter 20, Measuring and Recording Vital Signs, Height, and Weight

Format:  Multiple Response

Chapter Number:  20

Client Needs:  Physiological Integrity: Basic Care and Comfort

Cognitive Level:  Apply

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  4

Page and Header:  422, Introduction to Vital Signs

1. The nursing assistant collects a resident’s vital signs (VS). The blood pressure, pulse, and respirations are elevated from the resident’s baseline. What action(s) should the nursing assistant take? Select all that apply.

A) Ask another nursing assistant to double-check the blood pressure.

B) Determine what activity the resident recently engaged in.

C) Retake the VS after the resident rests for several minutes.

D) Chart the VS because it is normal to have changes.

E) Report the VS and findings to the nurse.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  422, Introduction to Vital Signs

2. A nursing assistant takes a client’s blood pressure and finds it to be very different from when it was last recorded. What will the nursing assistant do?

A) Take the blood pressure again and tell the nurse about the difference.

B) Record the last blood pressure measurement as well as the new one.

C) Take the blood pressure again and record the second measurement.

D) Record the blood pressure measurement immediately.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  423, Body Temperature

3. The nursing assistant prepares to use a glass thermometer to take the client’s temperature. Which action should the nursing assistant take?

A) Shake the thermometer near the overbed table.

B) Use a glass thermometer labeled for the rectal route under the client’s tongue.

C) Ask the client to hold the thermometer in place with their teeth.

D) Use the axillary route because the client has hemorrhoids.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  4

Page and Header:  423, Body Temperature

4. The nursing assistant (NA) is obtaining the rectal temperature of an adult client. Which action indicates that the NA requires further instruction?

A) Placing a disposable sheath over the probe

B) Preparing to insert the sheath 1 ½ inches

C) Applying lubricant jelly to the sheath

D) Choosing the red probe and inserting it into the machine

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  4

Page and Header:  423, Body Temperature

5. The nursing assistant (NA) prepares to take the adult client’s rectal temperature using a glass thermometer. Which action indicates the nursing assistant requires further instruction?

A) Shaking the thermometer below 94°F

B) Placing the client in the prone position

C) Using lubricant jelly on the thermometer at 1 inch

D) Observing for hemorrhoids or bleeding from the rectum

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  423, Body Temperature

6. A newer model of glass thermometer is likely to be safer than an older model because it:

A) does not contain mercury.

B) is stronger.

C) is built differently.

D) is disposable.

Difficulty:  Difficult

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  423, Body Temperature

7. The nursing assistant prepares to collect the temperature of an unconscious client who frequently has seizures. What action should the nursing assistant take?

A) Use the oral probe covered with a sheath under the tongue.

B) Place the glass thermometer under the tongue.

C) Employ the Sims position and use a rectal probe.

D) Apply the blue probe covered with sheath under the armpit.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  423, Body Temperature

8. The nursing assistant is caring for a client diagnosed with a bilateral ear infection and recent dental surgery. What method should the nursing assistant employ? Use:

A) a lubricated glass rectal thermometer in the Sims position.

B) the tympanic thermometer with a soft probe cover.

C) the electronic thermometer under the tongue on the unaffected side.

D) the temporal artery thermometer swept across the forehead.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  423, Body Temperature

9. The nursing assistant uses an oral electronic thermometer on an adult client and observes that the temperature is 99.6°F. What action should the nursing assistant take first?

A) Report the finding to the nurse immediately.

B) Determine whether the client recently drank something hot.

C) Chart the finding according to the facility policy.

D) Establish if there is a slight change in temperature from past measurements.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  4

Page and Header:  423, Body Temperature

10. How is the spread of infection prevented when using an electronic thermometer?

A) The probe is discarded after it is used.

B) The probe is stored in a disinfectant-filled case.

C) A new probe sheath is used with each measurement.

D) Sheath colors are different for rectal and oral probes.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1 & 5

Page and Header:  428, Pulse

11. What is meant by the term pulse rhythm?

A) The force of the pulse

B) A wave of blood through the arteries

C) The pattern of the beats and the pauses

D) The number of beats that can be felt in 1 minute

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  430, Respiration

12. The nursing assistant measures respirations that are irregular by:

A) counting the number of respirations in 30 seconds and multiplying by 2.

B) counting the number of respirations for 1 full minute.

C) using a stethoscope to listen to the respirations for 1 minute.

D) having another nursing assistant measure as well.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  4

Page and Header:  430, Respiration

13. The nursing assistant is caring for a client lying in bed who suddenly develops dyspnea with respirations 28 breaths per minute. What action should the nursing assistant take first?

A) Raise the head of the bed.

B) Chart the findings.

C) Collect the other vital signs.

D) Provide comfort measures.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  431, Blood Pressure

14. The nursing assistant is caring for a client after a right mastectomy and prepares to take their blood pressure (BP). What action should the nursing assistant take?

A) Place the cuff above the right upper arm resting at heart level.

B) Determine the BP on the left side using a wrist cuff.

C) Notify the nurse because there is an IV in the left forearm.

D) Apply the cuff above the left upper arm loosely and take the BP.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  431, Blood Pressure

15. When a blood pressure measurement needs to be repeated to assure an accurate measurement, the nursing assistant will:

A) fully deflate the cuff and wait 1 full minute before reinflating it.

B) partially deflate and then reinflate the cuff quickly.

C) ask the nurse to take the person’s blood pressure.

D) quickly use an automated sphygmomanometer.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  431, Blood Pressure

16. When taking a person’s blood pressure, how should the person’s arm be positioned?

A) Higher than the heart with the palm facing down

B) Lower than the heart with the palm facing down

C) Higher than the heart with the palm facing up

D) Level with the heart with the palm facing up

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  431, Blood Pressure

17. When taking a person’s blood pressure, the nursing assistant inflates the cuff:

A) 30 mm Hg beyond where the radial pulse could no longer be felt.

B) 50 mm Hg beyond the last recorded systolic blood pressure.

C) until the radial pulse can no longer be felt.

D) until the gauge reads 200 mm Hg.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  431, Blood Pressure

18. A client returns to the room after a physical therapy session. The client has a cast on the right arm. The nursing assistant takes the blood pressure (BP) and notes the reading is 160/90 mm Hg, which is higher than the client’s previous reading. What is the appropriate action for the nursing assistant to take?

A) Repeat the BP using the opposite arm.

B) Retake the BP with a smaller sized cuff.

C) Report the findings to the nurse immediately.

D) Wait 5 minutes before rechecking the BP.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  431, Blood Pressure

19. The nursing assistant (NA) prepares to take the blood pressure (BP) of a client returning from dialysis. Which action by the NA requires further intervention?

A) Waiting 5 minutes for the client to rest after returning to their chair

B) Asking the client to keep legs uncrossed and feet flat on the floor

C) Placing the cuff below the dialysis access point in the right arm

D) Determining the correct size BP cuff to use on the client

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  436, Height and Weight

20. Which scale will be used to measure the weight of a client who cannot stand independently but can get out of bed?

A) Upright

B) Digital

C) Sling

D) Chair

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  436, Height and Weight

21. The primary reason(s) a nursing assistant regularly weighs a resident is that: (Select all that apply)

A) changes in weight help evaluate the person’s nutritional status.

B) a change in weight can be an early sign of several diseases.

C) medication dosage is often determined by a person’s weight.

D) residents are usually very concerned about their weight.

E) obesity is a widespread health problem.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  2

Page and Header:  436, Height and Weight

22. The nursing assistant prepares to weigh the resident in a rehab center. What is the best action for the nursing assistant to take?

A) Examine the Kardex to determine which scale on the unit is used.

B) Determine how steady the resident is before deciding what scale to use.

C) Explain that the resident must empty their bladder before being weighed.

D) Employ the unit’s policy when weighing the resident as to details.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  431, Blood Pressure

23. The nursing assistant is caring for an ambulatory older adult client who has a history of hypertension and who has begun taking several medications to control blood pressure. What action should the nursing assistant take?

A) Dangle the client for several minutes before helping the client out of bed.

B) Assess blood pressure and pulse when the client is lying, then sitting, then standing.

C) Determine whether the client ever gets dizzy when rising from the bed or chair.

D) Advise the client to wait a minute before standing up from the bed or chair.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  431, Blood Pressure

24. What effect does hypertension have on the human body?

A) Blood flow is decreased due to the collapse of arteries.

B) The heart is forced to work much harder than is healthy.

C) Body tissue does not get enough oxygen to stay healthy.

D) The brain itself is deprived of the energy it needs to function.

Difficulty:  Moderate

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  4

Page and Header:  428, Pulse

25. The nursing assistant collects a client’s vital signs and the client has a “thready pulse” with a rate of 45. What is the first action for the nursing assistant to take?

A) Complete the set of vital signs with respiration and blood pressure.

B) Notify the nurse immediately about the situation.

C) Determine the responsiveness of the client.

D) Prepare to administer cardiopulmonary resuscitation (CPR) if needed.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  3

Page and Header:  428, Pulse

26. When asked by the nurse to check a resident for a pulse deficit, the nursing assistant will:

A) first measure the resident’s apical pulse and then immediately measure the radial pulse.

B) ask another nursing assistant to measure the resident’s radial pulse in both arms.

C) measure the resident’s radial pulse while the nurse measures the apical pulse.

D) subtract the current radial pulse from the last recorded radial pulse.

Difficulty:  Easy

Integrated Process:  Clinical Problem-solving Process (Nursing Process)

Objective:  1

Page and Header:  431, Blood Pressure

27. Which statement about the relationship between the accurate measurement of blood pressure and the size of the cuff used is true?

A) Cuff size is not as important as cuff placement.

B) A cuff that is too big will result in a high blood pressure reading.

C) A cuff that is too small will result in a low blood pressure reading.

D) The cuff must fit the arm appropriately or the measurement will be incorrect.