ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 26 : Vital Signs Questions
Question 1 of 5
A nurse has assessed an older adult for orthostatic hypotension as shown in the electronic health record (EHR). What action will the nurse take?
Correct Answer: B
Rationale: Allowing the patient to 'dangle' on the edge of the bed prior to rising may prevent orthostatic hypotension, by allowing time to adjust to the upright position. A rising and moving about slowly, especially after a period of bed rest, might also prevent orthostatic hypotension.
Question 2 of 5
A nurse is caring for a postoperative patient who experienced hypovolemic shock necessitating transfer to the ICU. The nurse manager reviews the medical record and suspects which situation contributed to the emergency?
Correct Answer: B
Rationale: Pathologic hypotension, especially when associated with tachycardia, can result from vasodilation of the arterioles, failure of the heart to pump effectively, loss of blood (such as with a hemorrhage or shock), or poor oxygenation. The nurse reports such changes to the health care provider immediately and anticipates prescriptions to restore perfusion. Failing to report these changes likely contributed to the emergency.
Question 3 of 5
A patient has a blood pressure reading of 130/90 mm Hg during a clinic visit. What recommendation for follow-up will the nurse make?
Correct Answer: A
Rationale: A single blood pressure reading that is mildly elevated is not significant, but the measurement should be monitored over time to determine if hypertension exists. The nurse will recommend a follow-up visit with the health care provider for a recheck.
Question 4 of 5
A nurse participating in community blood pressure screening tells the patient their blood pressure is 120/80 mm Hg. When the patient asks what the numbers mean, what information does the nurse provide?
Correct Answer: B
Rationale: The systolic pressure, 120 mm Hg, occurs when ventricular contraction causes the highest pressure on arterial walls. The diastolic pressure, 80 mm Hg, correlates with the lowest pressure on arterial walls as the heart rests between beats.
Question 5 of 5
A nurse observes a nursing student is taking the blood pressure on a patient with a cuff that is too large for the patient's arm. What explanation does the nurse give to the student for why errors of measurement may result?
Correct Answer: D
Rationale: A blood pressure cuff that is too large will cause a falsely low reading; a cuff that is too small will cause a falsely high reading.