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
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 2 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.
Question 3 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 4 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 5 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.