Test Bank Docx Ch.20 Measuring Vital Signs

Chapter 20

Measuring Vital Signs

Multiple Choice Questions

1. Pulse rates should be reported to your immediate supervisor if they

A) are less than 97 or greater than 100.

B) are less than 60 or more than 100.

C) are between 72 and 80.

D) are greater than 28 or less than 14.

LO#3-Describe how to measure a client’s pulse at different pulse points on the body.

2. Which statement about thermometers is correct?

A) Glass thermometers are common today.

B) Glass thermometers are easy to use accurately.

C) There are six different types of thermometers.

D) The tympanic thermometer is used in a client’s axillary.

LO#2-Describe different ways of measuring and recording a client’s temperature.

3. Systolic blood pressure is determined by

A) listening for the sound to change to a soft muffled thump.

B) waiting for the needle to stop bouncing.

C) listening for the first clear sound.

D) listening for the sound to become louder.

LO#6-Describe how to measure a client’s blood pressure.

4. Respiration is

A) the process of inhaling and exhaling.

B) covering over the trachea to prevent aspiration.

C) difficulty breathing.

D) small amounts of fluid taken into the air.

LO#5-Describe how to measure a client’s respiratory rate and oxygen saturation.

5. Vital signs are influenced by which of the following?

A) caffeine

B) emotions

C) medications

D) all of the above

LO#1-Describe what measurements are included when monitoring a client’s vital signs.

6. The average normal pulse rate for adults is

A) 60 to 100 beats per minute.

B) 62 to 110 beats per minute.

C) 60 to 80 beats per minute.

D) 80 to 100 beats per minute.

LO#3-Describe how to measure a client’s pulse at different pulse points on the body.

7. Diastolic blood pressure is determined by

A) listening for the last sound.

B) listening for the sounds to become irregular.

C) listening for the first clear sound.

D) listening for the fifth beat before it stops.

LO#6-Describe how to measure a client’s blood pressure.

8. Apical pulse is taken to directly measure the heartbeats at the

A) temple.

B) apex of the heart.

C) groin.

D) wrist.

LO#3-Describe how to measure a client’s pulse at different pulse points on the body.

9. When counting respirations, you should

A) do this without the client being aware that you are counting respirations.

B) tell the client what you are going to do.

C) count five respirations and then check your watch.

D) have the client count respirations while you take his/her pulse.

LO#5-Describe how to measure a client’s respiratory rate and oxygen saturation.

10. Which of the following pain types should be reported to the nurse?

A) Client says "I have pain"

B) stabbing pain, client moaning

C) dull pain, client crying

D) all of the above

LO#7-Explain how pain scales can be used to monitor a client’s pain level.

11. When taking oral temperatures it is best to

A) let the client know when to expect you.

B) schedule and take the temperature before meal service

C) immediately write down the key numbers and information

D) all of the above

LO#2-Describe different ways of measuring and recording a client’s temperature.

12. In which situation would you NOT take a rectal temperature?

A) the client is alert and oriented.

B) the client is unconscious.

C) the client is an infant.

D) all of the above

LO#2-Describe different ways of measuring and recording a client’s temperature.

13. When taking a pulse, what should you report to your supervisor?

A) force

B) rhythm

C) rate

D) all of the above

LO#4-Describe the rate, force, and rhythm of a client’s pulse.

14. Why should you refrain from using your thumb to check the pulse?

A) Your thumb might hurt the client.

B) Your thumb is not as sensitive as your fingers.

C) Your thumb has its own pulse.

D) all of the above

LO#3-Describe how to measure a client’s pulse at different pulse points on the body.

15. Stertorous respirations

A) are shallow respirations.

B) are abnormal sounds.

C) are irregular respirations (fast then slow) made with breathing.

D) none of the above

LO#5-Describe how to measure a client’s respiratory rate and oxygen saturation.

16. Vital-sign measurement includes:

A) temperature and pulse only
B) temperature, pulse, weight and height
C) heart rate, calorie intake
D) heart rate, respiration rate, and blood pressure

LO#1-Describe what measurements are included when monitoring a client’s vital signs.

17. When recording a client’s pulse, three characteristics should be observed and recorded:

A) rate, force, and ability
B) rate, rhythm, and style
C) rate, force, and amount
D): rate, rhythm, and force.

LO#4-Describe the rate, force, and rhythm of a client’s pulse.

18. A common method of assessing a client’s pain is to use the O.P.Q.R.S.T. mnemonic:

A) onset, provocation, quality, region, severity, time
B) onset, pain, quality, region, severity, time
C) onwards, provocation, quality, region, severity, time
D) onset, provocation, quality, relation, severity, time

LO#7-Explain how pain scales can be used to monitor a client’s pain level.

True/False Questions

1. The area under the arms or armpits is called the axilla.

LO#3-Describe how to measure a client’s pulse at different pulse points on the body.

2. Celsius is also known as centigrade.

LO#2-Describe different ways of measuring and recording a client’s temperature.

3. Fahrenheit is a system for measuring the blood pressure.

LO#6-Describe how to measure a client’s blood pressure.

4. Oral temperatures are recommended on unconscious clients.

LO#2-Describe different ways of measuring and recording a client’s temperature.

5. Axillary temperatures are recommended for clients who cannot hold a thermometer

in their mouths.

LO#2-Describe different ways of measuring and recording a client’s temperature.

6. An instrument used for measuring temperature is called a sphygmomanometer.

LO#2-Describe different ways of measuring and recording a client’s temperature.

7. Average normal temperature is 98.6 degrees F or 37 degrees C.

LO#2-Describe different ways of measuring and recording a client’s temperature.

8. The average normal pulse rate for a young adult is 80 to 160 beats per minute.

LO#4-Describe the rate, force, and rhythm of a client’s pulse.

9. Average normal adult respiration is 10 to 14 breaths per minute.

LO#5-Describe how to measure a client’s respiratory rate and oxygen saturation.

10. The pulse rate indicates the number of times the heart beats in one minute.

LO#4-Describe the rate, force, and rhythm of a client’s pulse.

11. When using a non-invasive blood pressure monitoring machine, place the cuff on the same arm with an intravenous infusion line, or the same arm with any impaired circulation.

LO#6- Describe how to measure a client’s blood pressure.

12. Apical pulses are taken with children age 12 to 14.

LO#4-Describe the rate, force, and rhythm of a client’s pulse.

13. Always wash your hands between clients when using a battery thermometer.

LO#2-Describe different ways of measuring and recording a client’s temperature.

14. An aneroid sphygmomanometer has a dial-type gauge.

LO#6- Describe how to measure a client’s blood pressure.

15. The force of the blood on the inner walls of the arteries, veins, and chamber of the heart is called blood pressure.

LO#6- Describe how to measure a client’s blood pressure.

16. To determine a client’s pulse deficit, count the apical pulse with a stethoscope over the apex of the heart and count the pulse rate at the radial pulse at the same time.

LO#4-Describe the rate, force, and rhythm of a client’s pulse.

17. Accurate blood pressures depend on using the correct size cuff for each client.

LO#6- Describe how to measure a client’s blood pressure.

18. When the heart muscle is contracting, the diastolic blood pressure is measured.

LO#6- Describe how to measure a client’s blood pressure.

19. The diastolic blood pressure is measured in the relaxing phase of the heartbeat.

LO#6- Describe how to measure a client’s blood pressure.

20. It is best to take the BP on an extremity that has a surgical site on it.

LO#6- Describe how to measure a client’s blood pressure.

21. Vital-sign measurement may also include other measurements such as oxygen saturation (SpO2) and pain intensity.

LO#1-Describe what measurements are included when monitoring a client’s vital signs.

22. Vital signs need to be measured rarely

LO#1-Describe what measurements are included when monitoring a client’s vital signs.

23. The radial pulse is often the easiest and most common place to take a routine measurement of a client’s pulse.

LO#3-Describe how to measure a client’s pulse at different pulse points on the body.

24. One respiration cycle includes one inhalation only.

LO#5-Describe how to measure a client’s respiratory rate and oxygen saturation.

25. As a personal care provider, you may not use a pain measurement scale to evaluate changes in a client’s experience of pain.

LO#7-Explain how pain scales can be used to monitor a client’s pain level.

26. Within the O.P.Q.R.S.T., the “T” refers to total pain

LO#7-Explain how pain scales can be used to monitor a client’s pain level.