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 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 2 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 3 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.
Question 4 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 5 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.