ATI LPN
Foundations and Adult Health Nursing Test Bank
Chapter 12 : Vital Signs Questions
Question 1 of 5
The nurse is alarmed when a patient with a severe head injury of the occipital lobe has a respiratory rate of 10 breaths/min. Where might this finding indicate that there is an injury?
Correct Answer: B
Rationale: Rate of respiration is controlled by the medulla oblongata.
Question 2 of 5
The nurse assesses respirations of a patient demonstrating pursed-lip breathing flared nostrils and retractions. How will the nurse describe these respirations?
Correct Answer: C
Rationale: The patient who is using ancillary muscles to breathe is exhibiting dyspnea.
Question 3 of 5
A nurse assesses a neonate's temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonate's temperature is 96°F (35.5°C)?
Correct Answer: A
Rationale: The neonate's temperature normally ranges from 96° to 99.5°F (35.5° to 37.5°
C). Temperature regulation is labile (unstable) during infancy because of immature physiologic mechanisms. Axillary measurement is considered the least accurate method and is used less frequently since the advent of the tympanic membrane thermometer. Tympanic thermometer readings are suitable for patients of all ages, except infants.
Question 4 of 5
A nurse assesses a neonate's temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonate's temperature is 99.5°F (37.5°C)?
Correct Answer: A
Rationale: The neonate's temperature normally ranges from 96° to 99.5°F (35.5° to 37.5°
C). Temperature regulation is labile (unstable) during infancy because of immature physiologic mechanisms. Axillary measurement is considered the least accurate method and is used less frequently since the advent of the tympanic membrane thermometer. Tympanic thermometer readings are suitable for patients of all ages, except infants.
Question 5 of 5
A nurse assesses a patient's dorsalis pedis pulse. The pulse is difficult to feel and not palpable when only slight pressure is applied. How should the nurse document this finding?
Correct Answer: C
Rationale: 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. A bounding pulse feels full and springlike even under moderate pressure.