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 is assessing the vital signs of a group of patients in the emergency department. Which patients require followup by the nurse? Select all that apply.
Correct Answer: A,C,F
Rationale: The normal temperature range for infants is 98.7?° to 100.5?°F (37.1?° to 38.1?°
C), so 100.5?°F is at the upper limit and warrants monitoring. The normal blood pressure for a toddler is approximately 89/46, so 118/80 is elevated and requires follow-up. The normal temperature for a school-age child is 98.2?° to 100?°F (36.8?° to 37.8?°
C), so 102.2?°F is elevated and needs attention. The adolescentâ??s pulse rate of 70 is within the normal range (55 to 105). The adultâ??s respiratory rate of 20 is within the normal range (12 to 20). The older adultâ??s pulse rate of 42 is below the normal range (40 to 100) and requires follow-up.
Question 2 of 5
A nurse is caring for a newborn with hypothermia. What action does the nurse take to prevent heat loss from convection?
Correct Answer: A
Rationale: Convection refers to heat disseminated by motion between areas of unequal density, for example, a fan blowing cool air over the body or an uncovered body. Wrapping the newborn in a blanket prevents heat loss by convection. Placing the baby on a warmed surface would prevent heat loss via conduction. Reducing or increasing the temperature in the room may affect heat loss via evaporation.
Question 3 of 5
A charge nurse working on a medical-surgical unit stops the AP from taking rectal temperatures on patients with which problems? Select all that apply.
Correct Answer: C,D,E
Rationale: The rectal site should not be used in newborns, children with diarrhea, and in patients who have undergone rectal or vaginal surgery. Inserting a rectal thermometer can stimulate the vagus nerve causing or worsening bradycardia; this route may be contraindicated in certain cardiac patients. The rectal route is also contraindicated in patients who have neutropenia (low white blood cell counts, such as in leukemia or those receiving chemotherapy) and thrombocytopenia (low platelet counts).
Question 4 of 5
While taking an adult patient's pulse, a nurse obtains a heart rate of 140 beats/min. What should the nurse do next?
Correct Answer: D
Rationale: A pulse rate of 140 beats/min in an adult, tachycardia, is abnormally fast, and should be reported to the primary nurse or health care provider immediately. Tachycardia at rest often reflects an underlying issue and can lead to decreased tissue perfusion; additional assessments are needed.
Question 5 of 5
During assessment of vital signs, a patient reports severe abdominal pain. Which pain-related changes in vital signs may be present? Select all that apply.
Correct Answer: A,C,E
Rationale: The pulse, blood pressure, and respiratory rate often increase when a person is experiencing pain; respiratory depth decreases. Pain does not affect body temperature. Thus, a pulse rate of 102, blood pressure of 154/86, and respiratory rate of 24 are consistent with pain-related changes.