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 nursing student is caring for a patient who has intravenous fluids infusing in the right arm. What action will the student take to correctly obtain the blood pressure?
Correct Answer: B
Rationale: The blood pressure should be taken in the arm opposite of the arm with intravenous access or infusion.
Question 2 of 5
The nurse must assess a patient's blood pressure using a thigh cuff, due to presence of a right antecubital IV and a left arm dialysis access. Which of these arteries will the nurse use for auscultation?
Correct Answer: C
Rationale: When the patient's brachial artery is inaccessible and/or the use of the upper arm is contraindicated, blood pressure can be assessed using the popliteal artery of the leg.
Question 3 of 5
A nurse receives information during shift report that a patient is afebrile. What action will the nurse take in response?
Correct Answer: D
Rationale: Afebrile means without fever, or a temperature is within the normal range. No additional actions are needed.
Question 4 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 5 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.