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Vital Signs Assessment: Exercises and Questions for Nursing Students, Exams of Nursing

A comprehensive set of exercises and questions related to vital signs assessment in nursing. It covers various aspects of temperature, pulse, respiration, and blood pressure measurement, including normal ranges, techniques, and potential variations. Designed to help nursing students develop their understanding and skills in this essential area of patient care.

Typology: Exams

2024/2025

Available from 04/15/2025

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BSN 206 - Hallmark Study Stack
Which of following patients would reguire following up?
An adult with a respiratory rate of 10 breaths per minute.
The normal respiratory rate for a newborn is 30 to 60 breaths per minute. The normal respiratory rate of
a child is 20 breaths per minute. The normal respiratory rate for a teenager is 16-20 breaths per minute .
Respirations for adult is 12-20
therefore a 10 breaths per minute for a follow up
Which of the following vital signs recorded for an older adult would be considered acceptable (within
normal Limits)?
Temp 97.0 F (36.1C), P-60, R-16, BP 116/78, O2 sat 95%
Normal Older Adult Body temp- 36c(96.8F)
Normal HR 60-100 BPM
Normal Resp. rate 16-25
Average BP 120/80 (BP over 140/90 is HTN)
Pulse Ox - 95-100%
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BSN 206 - Hallmark Study Stack

Which of following patients would reguire following up?

An adult with a respiratory rate of 10 breaths per minute.

The normal respiratory rate for a newborn is 30 to 60 breaths per minute. The normal respiratory rate of a child is 20 breaths per minute. The normal respiratory rate for a teenager is 16-20 breaths per minute.

Respirations for adult is 12- 20

therefore a 10 breaths per minute for a follow up

Which of the following vital signs recorded for an older adult would be considered acceptable (within normal Limits)?

Temp 97.0 F (36.1C), P-60, R-16, BP 116/78, O2 sat 95%

Normal Older Adult Body temp- 36c(96.8F)

Normal HR 60-100 BPM

Normal Resp. rate 16- 25

Average BP 120/80 (BP over 140/90 is HTN)

Pulse Ox - 95 - 100%

The nurse has delegated the task of temperature assessment to the NAP. Which information should be provided to the NAP? Select all the apply

The frequency for taking or monitoring the temperature

What changes to report immediately to the nurse

The type of temperature required

Which of the following situations may affect a patient's vital signs?

(Select all that apply)

Time of day

Moving from lying to standing position

Pain rated as a 7 to 0-10 pain scale

for which patient would a tympanic thermometer be the preferred thermometer to use?

A tachypneic patient who is receiving oxygen by nasal cannula.

Adult Normal body temp

36c - 38c (96.8-100.4)

Temperature Measurement sites

rectum

tympanic membrane

oral

temporal artery

types of thermometers

electronic

tympanic/ear theremometer

temporal artery theremometer

chemical dot disposable

axillary

electronic thermometer

oral - blue

rectal - red

Axillary - blue

tympanic theremometer

does not accurately measure core temp. changes during and after exercise

Do not use with those who have had ear surgery

signs of hyperthermia

decreased skin turgor

dry mucous membranes

tachycardia

hypotension (low bp)

decreased venous filling

concentrated urine

signs of heatstroke

body temp - 40 c (104 f) or more

hot dry skin

tachycardia

temps fluctuate 0.9-1.8 throughout day

how to take rectal temp

red prob

sims position

lubricate water soluble 1 - 1.5 in

insert prob 1.5 in anus (adult)

insert probe .5-1 inch for child

insert toward umbilcus

how to take axillary temp

use blue tip

cover probe

raise arm

place probe

rest arm across chest

How to take temp with tympanic thermometer adult

hold thermometer with your dominant hand

use ear on your dominant side

Ie youre left handed take temp in pts left ear

pull pinna back, up and out fit tip in the ear canal and aim toward pts nose.

How to take temp with tympanic thermometer child under 3

pull pinna down and back and aim speculum toward midpoint between eyebrow and sideburns

How to take temp with tympanic thermometer older than 3

pull pinna up and back

Pulse sites

temporal

carotid

Brachial

Apical

radial

femoral

popliteal

posterial tibial

dorsal pedis

ulnar

where to locate apical pulse

between 4th and 5th intercostal space at left midclavicular line

Assessing pulse rythym

should be regular and steady

irregular may have pause

assessing amplitude

3+ full - bounding

2+ normal

1+ weak

0 absent

how long should a weak pulse be counted for?

one minute

when should a pulse be measured for 1 minute

abnormality of rate, rhythm or amplitude

anatomy of stethoscope

earpiece

binaural

tubing

bell - low pitched sounds

diaphragm - used for high pitched sounds

Heart ascultation

see chart for where each area is located

apical aka

PMI

normal adult respirations

12 - 20/minute

cheyne-stokes

abnormal breathing pattern; periods of dyspnea and apnea

kussmaul

rapid breathing - deep labored

systolic pressure

hypertension classifications

prehypertension 120-139 / 80- 89

stage 1 - 140 - 159/90- 99

stage 2 160+/100+

repirations 12 + kids

12 - 20

respirations kids 5- 12

20 - 25

respirations kids 2- 5

25 - 30

respirations 1- 2

25 - 35

respirations less than 1 yer

normal bp kids chart

infant 72-104/27/

toddler 85-106/42- 58

preschool 90-110/48- 70

school age 93-120/60- 78

which of the following vitale signs are expected for the adult patient who has problems with oxygenation?

temp 98.6f, p-102, R-28, BP 98/50, O2 sat 85%

3 multiple choice options

a healthy 30 year old male arrives at the clinic for a physical. the nurse is responsible for collecting his vital signes.

which of these can be delegated to the NAP?

bp, temp, pulse ox, resp, pulse - because the patient has not indicated any physical complaints that would affect.

the nurse decides to collect the patient's temp orally using an electronic thermometer. choose equipment to be used from the list:

lubricant, tympanic thermometer, chemical oral thermometer, tissue, chemical external thermometer red probed thermometer, blue probe electronic thermometer, watch with second hand, patient data recording sheet and pen, thermometer cover

use the bell side

keep the stethoscope tubing still to avoid extraneous sound

ensure the bladder of the cuff is centered 1 in above the brachial artery

ensure the chest piece is rotated to the diaphragm side

reduce environment noise by turning off the TV or closing the door

make sure the stethoscope does not touch the patient's clothing or BP cuff

keep the stethoscope tubing still to avoid extraneous sound

ensure the bladder of the cuff is centered 1 in above the brachial artery

the NAP reports to the nurse that the patient's pulse oximetry is 88% what actions should the nurse take (select all that apply)

be prepared to admin. o

verify the reading by taking the patient's spo

perform a cardiopulmonary assessment

assist the patient to a high-fowlers position

notify the health care provider

a 15 year old male patient is hypothermic. which temperature reflects hypothermia?

95 f

3 multiple choice options

Identify why a child's respirations might be shallow.

the child is in acute pain

3 multiple choice options

you are taking a patient's bp by using the one-step method. which of the following is the incorrect step in the sequence?

pup the cuff to 20 mm hg above the patient's normal diastolic pressure. release the valve quickly observe the needle fall. identify the onset of the first korokoff sound in mmh.

the cuff should be pumped 30 over normal systolic and valve release slowly

a patient has been given an opioid (e.g Morphine) for pain relief. why does the nurse assess the patients respiratory rate before administering the next dose.

opioid analgesics may depress rate and depth of respirations

3 multiple choice options

65 year old with bp of 140/

88 year old with temp of 96.

75 year old with pulse ox of 88 %

8 year old with resp. rate of 24 bpm

65 year old with bp of 140/

75 year old with pulse ox of 88 %

The nurse reads the following nurse's note in the patient's health record. What is the priority nursing intervention based on this information?

9/21/17 1800 patient complains of headaches almost daily occurring more frequently in the evening. bp 164/98 p johnson NAP

obtain a complete set of vitals and gather further assessment data

3 multiple choice options

a nursing student is assigned to take the vital sings on a patient and finds the radial pulse to be irregular what action should the nursing student take

auscultate the patient's apical pulse.

name 5 safety considerations

call bell within reach

non-exit side rails up for support

bed alarm

bedside commode placed alongside bed if needed

nonskid footwear available

S.P.L.A.T.T

symptoms at time of fall

previous fall

location of fall

activity at time of fall

time of fall

trauma after fall

timed get up and go (TUG)

longer than 12 seconds to complete - high risk