ATI LPN
Foundations and Adult Health Nursing Test Bank
Chapter 12 : Vital Signs Questions
Question 1 of 5
A nurse assesses a patient's dorsalis pedis pulse. The pulse is easily felt but not palpable when moderate pressure is applied. How should the nurse document this finding?
Correct Answer: B
Rationale: A normal pulse is easily felt but not palpable when moderate pressure is applied. A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A bounding pulse feels full and springlike even under moderate pressure.
Question 2 of 5
A nurse assesses a patient's dorsalis pedis pulse. The pulse feels full and springlike even under moderate pressure. How should the nurse document this finding?
Correct Answer: D
Rationale: A bounding pulse feels full and springlike even under moderate pressure. A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied.
Question 3 of 5
When instructing a primary caregiver about keeping a daily log of blood pressure readings what instructions should the nurse include?
Correct Answer: B,E
Rationale: Readings for a blood pressure log should be taken at the same time every day on the same arm. The cuff should be applied 2 in above the antecubital fossa and snugly secured. The pulse should be assessed with the diaphragm of the stethoscope. If unable to get a reading the first time, the cuff should be deflated completely and reinflated after several minutes.
Question 4 of 5
When assessing factors that may influence the patient's pulse rate what should the nurse take into consideration?
Correct Answer: A,B,C,D
Rationale: All the options listed can affect the pulse rate, except religion.
Question 5 of 5
A patient is admitted to a medical surgical unit. What factors will determine how frequently vital signs will be assessed?
Correct Answer: B,D,E
Rationale: Whether and how frequently vital signs are measured depends on the nurse's judgment of need, orders of the health care provider, and patient's condition. Desire of the patient and family members cannot override these factors, but can be taken into consideration within reason of these factors.