Two hours after surgery, the NAP reports that a patient's vital signs are: BP R arm 112/72, L arm 124/96; HR 98, RR 22, temporal artery temp 36.4°C. Which of the following actions is appropriate by the nurse?

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Fundamentals of Nursing Vital Signs NCLEX Questions Questions

Question 1 of 5

Two hours after surgery, the NAP reports that a patient's vital signs are: BP R arm 112/72, L arm 124/96; HR 98, RR 22, temporal artery temp 36.4°C. Which of the following actions is appropriate by the nurse?

Correct Answer: C

Rationale: The vital signs show an elevated respiratory rate (RR 22, normal 12-20) and heart rate (HR 98, upper normal range), suggesting potential respiratory or cardiac distress post-surgery. A focused respiratory assessment and apical heart rate check are appropriate to investigate these abnormalities thoroughly, as they could indicate complications like atelectasis or tachycardia. The BP difference (12/24 mm Hg) is notable but not immediately alarming unless persistent, and the temperature is normal.

Question 2 of 5

Intermittent fever is common in

Correct Answer: D

Rationale: Intermittent fever, with spikes followed by normal temperatures, is characteristic of malaria (D) due to periodic parasite release. Influenza (A) and sepsis (C) cause more sustained fevers; typhoid (B) has a stepwise pattern.

Question 3 of 5

The main purpose of infection prevention in a healthcare setting is to:

Correct Answer: B

Rationale: Infection prevention protects all—patients, staff, visitors—not just workers (A), surgical cases (C), or communicable diseases (D).

Question 4 of 5

The vital signs commonly recorded by nurses include:

Correct Answer: B

Rationale: Vital signs—pulse, respiration, temp, BP—reflect core status. Others (A, C, D) are assessments, not routine vitals.

Question 5 of 5

A nurse assessing a patient's pulse is primarily checking for:

Correct Answer: B

Rationale: Pulse assessment checks heart rate and rhythm. BP (A), respiration (C), and temp (D) are separate vitals.

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