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 caring for a group of patients on a cardiac unit. Which finding will prompt the nurse to assess the apical-radial pulse?
Correct Answer: C
Rationale: The nurse assesses the apical-radial pulse when dysrhythmia exists or is suspected, manifested by tachycardia or irregular pulse. The difference between the apical and radial pulse rates, called the pulse deficit, captures heart beats not reaching the peripheral arteries.
Question 2 of 5
A nurse is assessing the blood pressure of a patient with traumatic injuries using a Doppler device. Which information does the nurse expect to obtain?
Correct Answer: C
Rationale: A Doppler provides an estimation of the systolic blood pressure when the pulse is inaudible. Diastolic pressure cannot be calculated because oscillations of the pulse will be audible during the entire BP assessment; recall the nurse can auscultate a pulse with the Doppler.
Question 3 of 5
A nurse enters a room and finds a patient who is unable to catch their breath, has a respiratory rate of 28, and is using accessory muscles to breathe. What intervention will the nurse use to relieve dyspnea?
Correct Answer: B
Rationale: Elevating the head of the bed facilitates lung expansion by allowing the abdominal contents to descend, which facilitates lung expansion and oxygenation. Elevated respiratory rate may occur due to distress or hypoxemia; assessing the respiratory rate does not resolve the problem of dyspnea.
Question 4 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 5 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.