Chapter 032

Potter & Perry: Fundamentals of Nursing, 7th Edition
Test Bank
Chapter 32: Vital Signs
MULTIPLE CHOICE
1. A client has developed pneumonia, and his temperature has increased to 37.7 C. The
client is shivering and feels uncomfortable. The nurse should:
1. Apply hot packs to the axilla and groin
2. Wrap the clients four extremities
3. Restrict oral fluid consumption
4. Apply a hypothermia mattress
ANS: 3
Wrapping the clients extremities has been recommended to reduce the incidence and
intensity of shivering. Hot packs should not be applied to the clients axilla and groin.
Fluids should not be restricted, but increased to replace fluids lost as a result of the fever.
Hypothermia blankets may be used to reduce fever, but if the client is already shivering, a
hypothermia blanket is not used, as further stimulation of shivering should be avoided.
DIF: A
REF: 506
OBJ: Comprehension
TOP: Nursing Process: Application
MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs
2. The client comes to the emergency department after having been in the sun for an
extended period of time. The nurse also determines that the client is taking a diuretic.
Heatstroke is suspected and the nurse observes for:
1. Diaphoresis
2. Confusion
3. Temperature of 36 C
4. Decreased heart rate
ANS: 2
Confusion is a symptom of heatstroke, along with delirium, nausea, muscle cramps,
visual disturbances, and even incontinence. The most important sign of heatstroke is hot,
dry skin, not diaphoresis. Victims of heatstroke do not sweat because of severe electrolyte
loss and hypothalamic malfunction. A normal temperature is 36 to 38 C. With
heatstroke the clients body temperature may reach as high as 45C. The heart rate is
increased with heatstroke, not decreased.
DIF: A
REF: 507
OBJ: Comprehension
TOP: Nursing Process: Assessment
3. A construction worker is seen in the emergency department with low blood pressure,
normal pulse rate, diaphoresis, and weakness. These are clinical signs of:
Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
1.
2.
3.
4.
32-2
Heatstroke
Heat cramp
Hypothermia
Heat exhaustion
ANS: 4
The client is exhibiting signs of heat exhaustion (e.g., symptoms of fluid volume deficit).
If the client were experiencing heatstroke, the client would have an increased pulse rate
and would not be sweating. Muscle cramps are related to heatstroke. The client is not
exhibiting signs consistent with heatstroke. The client is not exhibiting signs of
hypothermia such as shivering, loss of memory, or cyanosis.
DIF: A
REF: 508
OBJ: Comprehension
TOP: Nursing Process: Diagnosis
4. A 6-year-old boy has just eaten a grape popsicle and the nurse is ready to take vital signs.
An appropriate action would be to:
1. Take the rectal temperature
2. Take the oral temperature as planned
3. Have the child rinse out the mouth with warm water
4. Wait 20 minutes before assessing the oral temperature
ANS: 4
The nurse should wait 20 to 30 minutes before measuring the oral temperature. The nurse
should wait, rather than measuring the childs temperature rectally, as this is not an
emergency situation. Taking the oral temperature at this time would result in an
inaccurate reading. Rinsing the mouth with warm water may also provide an inaccurate
reading of the childs actual body temperature. The nurse should wait 20 minutes and
measure the childs oral temperature.
DIF: A
REF: 510
OBJ: Comprehension
TOP: Nursing Process: Planning
5. The client is seen in the emergency center for heat exhaustion as a result of exposure. The
nurse anticipates that treatment will include:
1. Replacement of fluid and electrolytes
2. Initiation of oral antibiotic therapy
3. Application of hypothermia wraps
4. Alcohol sponge baths
ANS: 1
The treatment of heat exhaustion includes transporting the client to a cooler environment
and restoring fluid and electrolyte balance. Antibiotic therapy is not warranted.
Hypothermia wraps are not used to treat heat exhaustion. Alcohol baths are not
recommended.
Test Bank
32-3
DIF: A
REF: 508
OBJ: Comprehension
6. The appropriate site for taking the pulse of a 2-year-old is:
1. Radial
2. Apical
3. Femoral
4. Pedal
ANS: 2
The brachial or apical pulse is the best site for assessing an infants or young childs pulse
because other peripheral pulses are deep and difficult to palpate accurately. The radial
pulse is not the best site for assessing a 2-year-olds pulse. The femoral pulse is not the
best site for assessing a 2-year-olds pulse. The pedal pulse is not the best site for
assessing a 2-year-olds pulse.
DIF: A
REF: 521
OBJ: Comprehension
7. The client appears to be breathing faster than before. The nurse should:
1. Ask the client if he has felt stressful
2. Have the client lay down on the bed
3. Count the clients rate of respirations
4. Palpate the clients own radial pulse
ANS: 3
The first action the nurse should take is to assess the clients respiratory rate. The nurse
can then determine if it is within normal limits and will be able to compare it to the
previous measurement to determine if the client is breathing faster than before. Stress
may increase an individuals respiratory rate. The nurse should first make the objective
measurement of the clients rate. Having the client lay down may decrease a clients
respiratory rate, but the nurse should first assess the client before implementing any
nursing measures. The nurse should count the respiratory rate. Based on these findings
the nurse may or may not need to take the clients pulse. Assessing the pulse will not
verify if the client is breathing faster.
DIF: A
REF: 529
OBJ: Comprehension
8. A nurse administers pain medication for a client complaining of pain. The nurse first
assesses vital signs and finds them to be as follows: blood pressure, 134/92 mm Hg;
pulse, 90 beats per minute; respirations, 26 breaths per minute. The nurses most
appropriate action is to:
1. Give the medication
Test Bank
32-4
2. Ask if the client is anxious

3. Check the clients dressing for bleeding
4. Recheck the clients vital signs in 30 minutes
ANS: 1
The clients vital signs are consistent with the client being in pain. It would be safe and
appropriate for the nurse to give the pain medication. Asking if the client is anxious is not
the most appropriate action. The client is not demonstrating signs of shock (e.g.,
decreased blood pressure, increased pulse). The most appropriate action is for the nurse to
administer pain medication. Rechecking would not be the most appropriate action. The
nurse should medicate the client for pain.
DIF: C
REF: 529
OBJ: Analysis
9. The client has bilateral casts on the upper extremities, so the nurse will be measuring the
blood pressure in the leg. The nurse expects the diastolic pressure to be:
1. 10 to 40 mm Hg higher than in the brachial artery
2. 20 to 30 mm Hg lower than in the brachial artery
3. 40 to 50 mm Hg higher than in the brachial artery
4. Essentially the same as that in the brachial artery
ANS: 4
When measuring the blood pressure in the legs, systolic pressure is usually higher by 10
to 40 mm Hg than that in the brachial artery, but the diastolic pressure is the same. The
systolic pressure, not the diastolic pressure, is 10 to 40 mm Hg higher than that in the
brachial artery.
Measurements of 20 to 30 mm Hg lower and 40 to 50 mm Hg higher are not true
statements.
DIF: A
REF: 546
OBJ: Comprehension
TOP: Nursing Process: Evaluation
10. An 84-year-old client with diabetes is admitted for insulin regulation. Which of the
following blood pressure, pulse, and respiration measurements, respectively, is
considered to be within the expected limits for a client of this age?
1. BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/min
ANS: 1
Test Bank
32-5
These measurements are within the expected limits for an older client. An adults average
blood pressure is 120/80 mm Hg. The systolic pressure may increase with age, but the
blood pressure should not exceed 140/90 mm Hg. The range for an adults pulse is 60100 beats/min. The expected respiratory rate is 16-25 breaths/min. BP = 104/52 mm Hg,
P = 68 beats/min, R = 30 breaths/min; BP = 108/80 mm Hg, P = 112 beats/min, R = 15
breaths/min; and BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min are not
within the expected limits for a client of this age.
DIF: A
REF: 527
OBJ: Comprehension
11. The student nurse is assessing the vital signs of a 10-year-old client. The expected values
for a client of this age are:
1. P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg
ANS: 3
These are expected findings of a 10-year-old client. The normal pulse range for a 10year-old is 75-100 beats/min; the normal respiratory rate is 20-30 breaths/min. The
expected blood pressure range for a 7-year-old is 87-117/48-64 mm Hg; children who are
larger (e.g., heavier and/or taller) have higher blood pressures. The average blood
pressure for a 10-year-old is 110/65 mm Hg mm Hg. P = 140 beats/min, R = 50
breaths/min, BP = 80/50 mm Hg; P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm
Hg; and P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hg are not expected
values of a 10-year-old client.
DIF: A
REF: 537
OBJ: Comprehension
12. The nurse has just taken vital signs for a 30-year-old client. Based on the results, the
nurse will report the following finding that is out of the expected range for a client of this
age:
1. T = 37.4 C
2. P = 110 beats/min
3. R = 20 breaths/min
4. BP = 120/76 mm Hg
ANS: 2
The expected pulse range for an adult is 60-100 beats/min. This clients pulse is elevated
at 110 beats/min. This clients temperature is within the normal range of 36 to 38 C for
an adult. This clients respiratory rate is within the normal range of 12-20 breaths/min for
an adult. This clients blood pressure reading is within the normal range of 120/80 mm
Hg for an adult.
Test Bank
32-6
DIF: A
REF: 527
OBJ: Comprehension
13. When using a glass thermometer at home to accurately assess axillary temperature, the
nurse should tell the parent of a 1 1/2-year-old child to:
1. Hold the thermometer at the bulb end
2. Cleanse the thermometer in hot water
3. Assess the thermometer for 5 minutes
4. Allow the child to hold the thermometer
ANS: 3
When assessing a clients axillary temperature with a glass thermometer, the thermometer
should be left in place for 3 to 5 minutes. The thermometer should be held at the opposite
end of the bulb. The thermometer should be covered with a plastic sheath when in use
and after used the plastic sheath is discarded. If the thermometer requires cleaning, the
nurse should not use hot water, as it could cause the thermometer to break. The parent
should hold the thermometer, not the child. A 1 1/2-year-old client may drop the
thermometer, creating a mercury spill.
DIF: A
REF: 630
OBJ: Comprehension
14. The postoperative vital signs of an average size adult client are: BP = 110/68 mm Hg, P =
54 beats/min, R = 8 breaths/min. The client appears pale, is disoriented, and has minimal
urinary output. The nurse should:
1. Retake the vital signs in 30 minutes
2. Continue with care as planned
3. Administer a stimulant
4. Notify the physician
ANS: 4
The nurse should notify the physician, as these are abnormal findings. The clients
respirations are becoming dangerously low at 8 breaths/min (normal 12-20 breaths/min).
The clients pulse rate is low at 54 beats/min (expected 60-100 beats/min), and the blood
pressure should be =120/80 mm Hg, which it is at 110/68 mm Hg. The additional
assessment findings are also not normal, and should be reported to the physician. The
nurse should not wait another 30 minutes to retake vital signs. The present readings
warrant notifying the physician. These are abnormal findings. The nurse should not
continue with care as planned. The nurse should first notify the physician. Administering
a stimulant would require a physicians order and may not be what the client requires. For
example, the client may need a narcotic antagonist rather than a stimulant.
DIF: B
REF: 504
OBJ: Application
Test Bank
32-7

15. A client has just gotten out of bed to go to the bathroom. As the nurse enters the room, the
client says, I feel dizzy. The nurse should:
1. Go for help
2. Take the clients blood pressure
3. Assist the client into a sitting position
4. Tell the client to take several deep breaths
ANS: 3
The nurses primary concern should be the patients safety and preventing an accidental
fall. If the client just got up from bed and is complaining of dizziness, the client may be
experiencing orthostatic hypotension. The nurse should first assist the client to sit down
before performing any other assessment. The nurse should not leave the client and go for
help. The nurse should assist the client to a sitting position. If help is required, the nurse
can then put on the clients call light.
The nurse may take the clients blood pressure after assisting the client to a sitting
position to prevent the client from falling. The nurse should first assist the client to sit
down to prevent the client from falling accidentally. The nurse may then assess the client.
If the nurse finds during the assessment that the clients pulse oximetry is low, the nurse
may instruct the client to take deep breaths.
DIF: B
REF: 538
OBJ: Application
16. A false high blood pressure reading may be assessed, as the nurse explains to the nurse
assistant, if the assistant:
1. Wraps the cuff too loosely around the arm
2. Deflates the blood pressure cuff too quickly
3. Repeats the blood pressure assessment too soon
4. Presses the stethoscope too firmly in the antecubital fossa
ANS: 1
If the cuff is wrapped too loosely or unevenly around the arm, the effect on the blood
pressure measurement may be a false high reading. A false low systolic and false high
diastolic blood pressure reading may occur if the cuff is deflated too quickly. A false high
systolic reading may be obtained if the blood pressure assessment is repeated too soon. A
false low diastolic reading may be obtained if the stethoscope is applied too firmly
against the antecubital fossa.
DIF: A
REF: 541
OBJ: Comprehension
17. The client is febrile, and the temperature needs to be reduced. The nurse anticipates that
treatment will include:
Test Bank
1.
2.
3.
4.
32-8
An alcohol and water bath

Ice packs to the axillae and groin
Tepid, plain water sponge down
Application of a cooling blanket
ANS: 4
Blankets cooled by circulating water delivered by motorized units increase conductive
heat loss. Cooling blankets are used to reduce a fever. Bathing with an alcohol/water
solution is not recommended because it may lead to shivering. Shivering is
counterproductive and can increase energy expenditure up to 400%. Application of ice
packs to the axillae and groin is no longer recommended because they may induce
shivering (which is counterproductive and increases the clients energy expenditure), and
because they have no advantage over antipyretic medications.
Tepid sponge baths are no longer recommended because it may lead to shivering and is
no more advantageous than administering antipyretics.
DIF: A
REF: 520
OBJ: Comprehension
18. The nurse is alert to which of the following factors that lowers the blood pressure?
1. Stress-producing anxiety
2. Heavy alcohol consumption
3. Cigarette, cigar, or pipe smoking
4. Prescribed diuretic administration
ANS: 4
Diuretics lower blood pressure by reducing reabsorption of sodium and water by the
kidneys, thus lowering circulating fluid volume.
The effects of sympathetic nerve stimulation, such as with anxiety, increase blood
pressure.
Heavy alcohol consumption has been linked to hypertension.
Cigarette smoking has been linked to hypertension.
DIF: A
REF: 537
OBJ: Comprehension
19. While the nurse is taking the clients blood pressure, the client asks if the reading is high.
In accordance with the newest guidelines, the nurse informs the client that a blood
pressure measurement that is consistent with hypertension is:
1. 120/70 mm Hg
2. 130/84 mm Hg
3. 120/78 mm Hg
4. 118/80 mm Hg
ANS: 2
Test Bank
32-9
The diagnosis of prehypertension in adults is made when an average of two or more

diastolic readings on at least two subsequent visits is between 80 and 89 mm Hg or when
the average of multiple systolic blood pressures on two or more subsequent visits is
between 120 and 139 mm Hg. Hypertension is noted with diastolic readings greater than
90 mm Hg and systolic readings greater than 140 mm Hg. According to the newest
guidelines, this clients blood pressure reading (130/84 mm Hg) would fall into the prehypertension category.
Normal is 120/80 mm Hg; this is a normal blood pressure reading.
DIF: A
REF: 537
OBJ: Comprehension
20. After measuring the clients vital signs, the nurse obtains the following results: blood
pressure = 180/100 mm Hg, pulse = 82 beats/min, R = 16 breaths/min, and rectal temp =
37.5 C. The nurse should:
1. Retake the blood pressure
2. Retake the clients temperature
3. Report all of the findings immediately
4. Record the findings as within normal limits
ANS: 1
The normal blood pressure reading is 120/80 mm Hg. This clients blood pressure is
significantly higher at 180/100 mm Hg, and may be an indication of hypertension. (One
elevated blood pressure measurement does not qualify as a diagnosis of hypertension; it
would have to be elevated on at least two separate occasions). The nurse should retake
the blood pressure. The clients temperature is within normal limits for a rectal
temperature. The average rectal temperature is 37.5 C. The nurse should repeat the blood
pressure measurement to confirm the reading before reporting the findings. The blood
pressure reading is not within normal limits. The pulse rate, respiratory rate, and
temperature are within normal limits.
DIF: B
REF: 537
OBJ: Application
21. The client is identified by the nurse as having a remittent fever. The student asks what
that means and the nurse explains that a remittent fever is:
1. A constant body temperature above 100.4 F with little fluctuation
2. Spikes that are interspersed with normal temperatures within 24 hours
3. Spikes and falls in temperature, but temperature does not return to the normal limits
4. Periods of febrile episodes interspersed with normal body temperatures
ANS: 3
A remittent fever spikes and falls without a return to normal temperature levels.
Test Bank
32-10
A sustained fever is a constant body temperature continuously above 38 C (100.4 F)

that demonstrates little fluctuation. An intermittent fever has fever spikes interspersed
with usual temperature levels. Temperature returns to acceptable levels at least once in 24
hours.
A relapsing fever has periods of febrile episodes interspersed with acceptable temperature
values.
DIF: A
REF: 508
OBJ: Comprehension
22. The nurse is working in the newborn nursery. In planning for temperature measurement,
the nurse will obtain the reading on the infants by using the:
1. Oral site
2. Rectal site
3. Axillary site
4. Tympanic site
ANS: 3
The axillary site can be used with newborns and uncooperative clients. The oral site
should not be used with infants. The rectal site should not be used for routine vital signs
in newborns. The tympanic site is questioned as being accurate in newborns.
DIF: A
REF: 515
OBJ: Comprehension
23. A client is being monitored with pulse oximetry. On review of the following factors, the
nurse suspects that the values will be influenced by:
1. The placement of the sensor on the extremity
2. A diagnosis of peripheral vascular disease
3. A reduced amount of artificial light in the room
4. The increased ambient temperature of the clients room
ANS: 2
Peripheral vascular disease can reduce pulse volume, which may affect the pulse
oximetry reading. The sensor should be placed on an extremity site (such as an earlobe or
digit) with adequate local circulation and the site should be free of moisture. Reduced
light in the room will not affect the oximetry reading. Outside light sources can interfere
with the oximeters ability to process reflected light. An increased temperature of the
room will not affect the oximetry reading. If the room was very cold, the clients
peripheral blood flow may decrease, affecting the oximetry reading.
DIF: A
REF: 533
OBJ: Comprehension
Test Bank
32-11
24. An individual contacts the emergency department of the local hospital to ask what to do
for a skiing partner who appears to be suffering from hypothermia. The victim is alert and
able to respond to questions. The nurse instructs the individual who has called to have the
victim:
1. Take sips of brandy
2. Drink a bowl of warm soup
3. Drink a cup of very hot coffee
4. Run the affected extremities under hot water
ANS: 2
A conscious client benefits from drinking hot liquids such as soup. Alcohol should be
avoided.
Caffeinated fluids should be avoided. Extremities should be warmed gradually. Tissue
damage could occur if placed under hot water. The entire body should be warmed, such
as by putting heating pads next to the head and neck that lose heat the quickest.
DIF: B
REF: 508
OBJ: Application
25. A spouse assists the nurse evaluating the measurement of the clients blood pressure. The
nurse feels additional teaching is required if the spouse is observed:
1. Deflating the cuff at 2 mm Hg/second
2. Having the client sit down for the measurement
3. Using the same time each day for the measurement
4. Taking the blood pressure after the client comes back from a walk
ANS: 4
The clients blood pressure should not be measured after the client has exercised,
smoked, or ingested caffeine. The client should wait 30 minutes before assessment of the
blood pressure.
The cuff should be deflated at a rate of 2 mm Hg per second. When possible, the client
should be sitting in a chair. The blood pressure should be assessed at the same time each
day.
DIF: A
REF: 537
OBJ: Comprehension
26. The nurse measures the blood pressure in the leg due to the fact that the client has
bilateral casts on the upper extremities. The nurse palpates the pulse before the
measurement at the:
1. Popliteal fossa behind the knee
2. Inner side of the ankle below the medial malleolus
3. Top of the foot between the extension tendons of the great toe
4. Inguinal ligament midway between the symphysis pubis and the anterior superior
iliac spine
Test Bank
32-12
ANS: 1
The popliteal artery, palpable behind the knee in the popliteal space, is the site for
auscultation when taking the blood pressure in the leg. The inner side of the ankle, top of
the foot, and inguinal ligament are not the correct sites for assessment.
DIF: A
REF: 546
OBJ: Comprehension
27. The clients apical pulse will be taken by a student. According to the nurse the
stethoscope should be placed along the left clavicular line at the:
1. Second to third intercostal space
2. Third to fourth intercostal space
3. Fourth to fifth intercostal space
4. Fifth to sixth intercostal space
ANS: 3
An apical pulse should be assessed at the clients PMI. The PMI is located at the fourth to
fifth intercostal space at the left midclavicular line. Second to third intercostals space is
not the correct placement for auscultating a clients apical pulse. The PMI is higher and
more medial in children under 8 years old, thus the third to fourth is incorrect. The client
is not identified as being a child.
Fifth to sixth is not the correct placement for auscultating a clients apical pulse.
DIF: A
REF: 525
OBJ: Comprehension
28. The nurse enters the room to measure the clients pulse rate. The nurse recognizes that the
clients rate may be increased as a result of:
1. A febrile condition
2. Administration of digoxin
3. The clients athletic conditioning
4. Unrelieved severe postoperative pain
ANS: 1
Fever and heat may increase a clients pulse rate. Digoxin is a negative chronotropic
drug; it will decrease the clients pulse rate. A conditioned athlete who participates in
long-term exercise will have a lower heart rate at rest. Unrelieved severe pain increases
parasympathetic stimulation; decreasing the heart rate.
DIF: A
REF: 526
OBJ: Comprehension
Test Bank
32-13
29. Upon entering the room, the nurse notes that the client has an irregular respiratory rate,
with periods of apnea and increases in respiration, followed by a reversal of the pattern.
The nurse reports this respiratory assessment as:
1. Biots respirations
2. Kussmauls respirations
3. Hyperpneic respirations
4. Cheyne-Stokes respirations
ANS: 4
Cheyne-Stokes respirations are characterized by an irregular respiratory rate with
alternating periods of apnea and hyperventilation. The respiratory cycle begins with slow,
shallow breaths that gradually increase to an abnormal rate and depth. The pattern then
reverses, breathing slows and becomes shallow, and the pattern climaxes in apnea before
respiration resumes. Biots respirations are abnormally shallow for two to three breaths
followed by an irregular period of apnea. Kussmauls respirations are abnormally deep,
regular, and increased in rate. Hyperpneic respirations are labored, increased in depth,
and increased in rate (>20 breaths/min); they normally occur during exercise.
DIF: A
REF: 532
OBJ: Comprehension
30. The nurse has assigned the vital signs of the elderly clients residing in the facilitys
assisted living unit to the nursing assistant. Which of the following statements made by
the ancillary personnel requires immediate correction by the RN?
1. As you age your blood pressure may go up, but it doesnt have to if your vessels
are healthy.
2. If anyones oral temperature is over 100 F, Ill let you know right away since that
means they have a fever.
3. I always wait a good 30 minutes after returning the older client back to bed before
I count their pulse.
4. I watch the elderly clients stomach and count the number of times it rises when I
am counting respirations.
ANS: 2
RAT: The temperature of older adults is at the lower end of the normal temperature range,
36 to 36.8 C (96.9 to 98.3 F) orally and 36.6 to 37.2 C (98 to 99 F) rectally.
Therefore temperatures considered within normal range sometimes reflect a fever in an
older adult. The normal range for blood pressure is the same for older adults and younger
people, while older adults depend more on accessory abdominal muscles during
respiration than on weaker thoracic muscles, so observing the rise and fall of the
abdomen would not be inappropriate. Once elevated, the pulse rate of an older adult takes
longer to return to normal resting rate, so waiting 30 minutes would not be inappropriate.
DIF: C
REF: 506
OBJ: Analysis
Test Bank
32-14
31. The nurse appropriately instructs trained ancillary personnel to avoid using an electronic
blood pressure cuff to take the blood pressure of which of the following clients?
1. A 25-year-old who was admitted for depression and anxiety
2. A 69-year-old diagnosed with Parkinsons disease 5 years ago
3. A 57-year-old prescribed antihypertensive medication 6 weeks ago
4. An 80-year-old client whose systolic BP is routinely assessed in the low 90s
ANS: 2
Blood pressure less than 90 mm Hg systolic, irregular heart rate, peripheral vascular
obstruction (e.g., clots, narrowed vessels), shivering, seizures, excessive tremors, and the
inability to cooperate are reasons to avoid using an electronic BP monitor. The clients
Parkinsons disease causes tremors, so a manual cuff should be used when assessing this
clients BP.
DIF: C
REF: 546
OBJ: Comprehension
32. The nurse appropriately instructs trained ancillary personnel to use an electronic blood
pressure cuff to take the blood pressure of which of the following clients?
1. A 25-year-old who was admitted for alcohol detoxification
2. A 69-year-old diagnosed with Parkinsons disease 5 years ago
3. A 57-year-old placed on antihypertensive medication therapy 2 months ago
4. An 80-year-old client whose systolic BP is routinely assessed in the high 80s
ANS: 1
Blood pressure less than 90 mm Hg systolic, irregular heart rate, peripheral vascular
obstruction (e.g., clots, narrowed vessels), shivering, seizures, excessive tremors, and
inability to cooperate are reasons to avoid using an electronic BP monitor. The answer
reflects the client whose BP is most stable and best assessable via electronic BP monitor.
DIF: A
REF: 546
OBJ: Analysis
33. The nurse has assigned nursing assistive personnel to obtain the blood pressures on the
units clients. Which of the following statements made by the assistive personnel shows
the best understanding regarding appropriate communication of the BP readings?
1. Ill ask the clients what their blood pressure usually runs.
2. Ill give you a list of all the readings I get before I chart them.
3. Ill chart the results and let you know whose pressure is high.
4. Ill recheck any pressure that seems higher than their normal.
ANS: 2
Test Bank
32-15
The nurse is responsible for assessing the impact of changes in blood pressure and so
must be aware of each clients reading, not merely the values that the assistive personnel
believes to be high. Asking the client to share what their BP is routinely and/or retaking a
questionable reading is appropriate but not directly related to effective communication of
the findings.
DIF: C
REF: 539
OBJ: Analysis
34. The nurse has assigned nursing assistive personnel to obtain the blood pressures on the
the greatest need for additional instruction regarding appropriate communication of the
BP readings?
1. Ill give you a list of all the readings after I chart them.
2. May I ask the clients what their blood pressure usually runs?
3. Ill chart the results and let you know whose pressure is running high.
4. Do you want me to take the readings before they get their medications?
ANS: 3
The nurse is responsible for assessing the impact of changes in blood pressure and so
must be promptly made aware of each clients reading, not merely the values that the
assistive personnel believes to be high. The questions asked may reflect a need for further
instruction, but the issues are not as critical as the need to report all readings for the nurse
to evaluate.
DIF: C
REF: 539
OBJ: Analysis
35. The nurse has assessed a clients blood pressure (BP) using the left thigh because of
bilateral upper arm casts. The clients precasting left arm BP was 108/70 mm Hg. The
nurse expects the present BP reading to be:
1. 10-40 mm Hg higher systolic pressure than before the casting
2. 5-10 mm Hg higher reading in both systolic and diastolic pressures
3. Representative of the original baseline established before the casting
4. A slight decrease in the diastolic pressure when compared to precasting pressure
ANS: 1
Systolic pressure in the legs is usually higher by 10 to 40 mm Hg than in the brachial
artery, but the diastolic pressure is the same.
DIF: A
REF: 546
OBJ: Comprehension
Test Bank
32-16
36. The nurse is using a manual cuff to assess the blood pressure of a client experiencing
hypertension. To best ensure accommodation for a possible auscultatory gap, the nurse
should use which of the following as a guide for inflating the cuff appropriately?
1. Review the clients chart for his last blood pressure reading.
2. Ask the client what his typical blood pressure reading is when taken manually.
3. Inflate 30 mm Hg higher than where the radial pulse can no longer be palpated.
4. Take the clients blood pressure both sitting and standing and use the higher
reading.
ANS: 3
The examiner needs to be certain to inflate the cuff high enough to hear the true systolic
pressure before the auscultatory gap. Palpation of the radial artery helps to determine how
high to inflate the cuff. The examiner inflates the cuff 30 mm Hg above the pressure at
which the radial pulse was palpated. Taking the blood pressure in various positions will
not help eliminate the possible loss of auditory sound between the systolic and diastolic
sounds. While asking the client and/or reviewing the chart may provide information
concerning the clients pressure, these options are not the recommended method for
minimizing the effect of the auditory gap on the assessment process.
DIF: C
REF: 541
OBJ: Analysis
37. The nurse is assessing an elderly clients blood pressure during a routine visit. When
asked, the client volunteers that when he took his pressure at home yesterday it was
126/72 mm Hg. The nurse determines that the clients pressure today is 134/70 mm Hg.
The nurse recognizes that the most likely cause of the elevation is:
1. The difference between the monitoring equipment being used
2. The client may be experiencing mild anxiety regarding the check-up
3. The effects of aging on the clients ability to hear the first Korotkoff sound
4. The client is not inflating the cuff sufficiently to detect the systolic pressure
ANS: 2
Blood pressure measurements taken at the clients place of employment or in a health
care providers office are higher than those taken at the clients home. The remaining
options may be a factor but they are not the most likely.
DIF: C
REF: 537
OBJ: Analysis
38. The nurse is assessing a clients blood pressure to establish a baseline. The pressure in the
right arm is 12 mm Hg lower than that in the left arm. The nurse most appropriately
realizes that these data:
1. Reflect a normal variation
2. Should be reported to the clients health care provider
3. Dictate that pressure should be monitored in the left arm
Test Bank
32-17
4. Indicate that the client may be experiencing vascular problems

ANS: 2
During the initial assessment, obtain and record the blood pressure in both arms.
Normally there is a difference of 5 to 10 mm Hg between the arms (Lane and others,
2002). In subsequent assessments, measure the blood pressure in the arm with the higher
pressure. Pressure differences greater than 10 mm Hg indicate vascular problems and are
reported to the health care provider or nurse in charge. Reporting the assessment findings
is the most appropriate outcome.
DIF: C
REF: 536
OBJ: Analysis
39. The nurse recognizes that which of the following clients present at the annual July 4th
marathon is at greatest risk for hyperthermia and the resulting heatstroke?
1. A 34-year-old running for the first time in the July 4th marathon who is sweating
profusely
2. A 16-year-old volunteer, with type 1, insulin-dependent diabetes, who is checking
runners in for the marathon at the starting gate
3. A 75-year-old who is prescribed medication for Crohns disease and who is sitting
outdoors watching her granddaughter run the marathon
4. A 55-year-old diagnosed with bipolar disease and prescribed a phenothiazine
(Serentil), who will be walking the marathon course
ANS: 2
Clients at risk include those who are very young or very old and those who have
cardiovascular disease, hypothyroidism, diabetes, or alcoholism. Also at risk are those
who take medications that decrease the bodys ability to lose heat (e.g., phenothiazines,
anticholinergics, diuretics, amphetamines, and beta-adrenergic receptor antagonists) and
those who exercise or work strenuously (e.g., athletes, construction workers, and
farmers). While all the options represent risk factors, the degree of exercise, medical
history, and age are greatest for the 16-year-old client with diabetes.
DIF: C
REF: 506
OBJ: Analysis
40. The nurse recognizes that which of the following clients present at the annual July 4th
marathon is showing the most compelling signs of hyperthermia and the resulting
heatstroke?
1. The 75-year-old who has forgot where the car is parked
2. The 16-year-old volunteer whose skin appears sunburned but dry
3. The 34-year-old who finished the race and is reporting leg cramps
4. The 55-year-old observer who complains of nausea and being thirsty
ANS: 2
Test Bank
32-18
Signs and symptoms of heatstroke include giddiness, confusion, delirium, excess thirst,
nausea, muscle cramps, visual disturbances, and even incontinence. Vital signs reveal a
body temperature sometimes as high as 45 C (113 F) with an increase in heart rate and
lowering of blood pressure. The most important sign of heatstroke is hot, dry skin.
Victims of heatstroke do not sweat because of severe electrolyte loss and hypothalamic
malfunction. If the condition progresses, the client with heatstroke becomes unconscious
with fixed, unreactive pupils. Permanent neurological damage occurs unless cooling
measures are rapidly started.
DIF: C
REF: 508
OBJ: Analysis
41. The nurse has assigned nursing assistive personnel to obtain the temperatures on the
the greatest need for additional instruction regarding appropriate temperature monitoring
orally?
1. Are all the clients cooperative enough to take the temperatures orally?
2. Do you want me to take the temperature tympanically on everyone?
3. Ill wait until breakfast is over so I wont distract them from eating.
4. Ill chart the results and let you know whose temperature is running high.
ANS: 3
When taking oral temperature, wait 20 to 30 min before measuring temperature if the
client has smoked or ingested hot or cold liquids or foods. The nurse needs to reinforce
this information so that the assessment will occur before breakfast or to allow enough
time to pass after breakfast so as not to affect the readings. The options containing a
question reflect a need for knowledge but do not have priority over an obvious indication
of possible poor assessment technique. The nurse needs to evaluate the readings and so
should be sure to give the assistive personnel guidance as to what readings are running
high.
DIF: C
REF: 510
OBJ: Analysis
42. Which of the following sites is best suited for measuring oxygen saturation (pulse
oximetry)?
1. A polished ring finger of a client with pneumonia whose nail capillary refill time is
2.5 seconds
2. A pierced earlobe of a client with a closed head injury whose nail capillary refill
time is 3.5 seconds
3. The ring finger of a client with Parkinsons disease that has a capillary refill time of
less than 3 seconds
4. An earlobe of a client who is experiencing moderate diaphoresis with a nail
capillary refill time of 3.5 seconds
Test Bank
32-19
ANS: 2
Determine most appropriate client-specific site (e.g., finger, earlobe) for sensor probe
placement by measuring capillary refill. If capillary refill is greater than 3 seconds, select
an alternate site. Sites should be free of moisture and tremors, and the nail should be free
of polish (no artificial nails).
DIF: C
REF: 534
OBJ: Analysis
43. The nurse has asked the assistive personnel to take the blood pressure of a client who
experienced a left mastectomy 3 days ago. Which of the following statements by the
assistive personnel shows the best understanding regarding the appropriate assessment
technique for this particular client?
1. Is there anything affecting her right arm?
2. Has she been experiencing any edema in that left arm?
3. How long has it been since she had her breast removed?
4. Ill wait until shes been medicated for pain before I take it.
ANS: 1
Avoid applying the cuff to the extremity when intravenous fluids are infusing; an
arteriovenous shunt or fistula is present; breast or axillary surgery has been performed on
that side; or the extremity has been traumatized, diseased, or requires a cast or bulky
bandage. The answer reflects an understanding that the right arm is the extremity of
choice for monitoring this clients blood pressure.
DIF: C
REF: 539
OBJ: Analysis
MULTIPLE RESPONSE
1. The nurse is assisting the wife of a client who has been diagnosed with hypertension to
monitor his blood pressure. The nurse states that the blood pressure should be taken:
(Select all that apply.)
1. At the same time each day
2. On the same arm each time
3. In the same position each time
4. After the client has had a brief rest
5. After his blood pressure medication
6. Right before getting up in the morning
ANS: 1, 2, 3, 4
Instruct the client or primary caregiver to take BP at same time each day and after the
client has had a brief rest. Take BP sitting or lying down; use the same position and arm
each time pressure is taken. The other options are not necessary because they do not
affect blood pressure readings.
Test Bank
32-20
DIF: C
REF: 537
OBJ: Analysis
2. Which of the following factors make using a pulse oximeter on an elderly client
challenging? (Select all that apply.)
1. Possibility of decreased cardiac output
2. Potential for peripheral vascular disease
3. Existence of decreased red blood cell count
4. Uncooperative behavior related to senility
5. Inability to comprehend rationale for monitoring
6. Vasoconstriction related to impaired heat regulation
ANS: 1, 2, 3, 6
Identifying an acceptable pulse oximeter probe site is difficult with older adults because
of the likelihood of peripheral vascular disease, decreased cardiac output, cold-induced
vasoconstriction, and anemia. It would be inappropriate to assume that the process is
made more difficult because of the remaining options because they are not seen in the
majority of the elderly population.
DIF: C
REF: 533
OBJ: Analysis
3. The nurse is providing a health promotion session regarding the factors that contribute to
heatstroke for members of a college cross-country running team. Which of the following
statements should the nurse include in the discussion? (Select all that apply.)
1. Take frequent breaks to rest out of the sun.
2. The greater the humidity, the greater the hazard.
3. Wear clothing that will absorb the perspiration.
4. The higher the temperature, the higher the risk.
5. The more fluids you drink, the fewer chances you take.
6. Pay attention to pacing yourself when its hot and muggy.
ANS: 2, 4, 5, 6
Teach clients risk factors for heatstroke: strenuous exercise in hot, humid weather; tightfitting clothing in hot environments; exercising in poorly ventilated areas; sudden
exposures to hot climates; poor fluid intake before, during, and after exercise. When
paying close attention to avoiding risk factors for heatstroke, the remaining options are
not required.
DIF: C
REF: 507-508
OBJ: Analysis
Test Bank
32-21
4. The nurse is discussing risk factors for hypertension with family members attending a
self-help group meeting for clients in cardiac rehabilitation. Which of the following
statements made by the nurse are relevant to this discussion on prevention of this
disorder? (Select all that apply.)
1. Low fat foods are your blood pressures best friend.
2. Have your triglycerides checked on a regular basis.
3. Ideal weight is ideal for keeping blood pressure under control.
4. Nicotine is a no-no when attempting to control blood pressure.
5. If they are prescribed, take your blood pressure medicine as suggested.
6. Keep alcohol consumption down and your blood pressure will be down.
ANS: 1, 2, 3, 4, 6
Persons with a family history of hypertension are at significant risk. Obesity, cigarette
smoking, heavy alcohol consumption, high blood cholesterol and triglyceride levels, and
continued exposure to stress are risk factors linked to hypertension. Medication
compliance, while important, is related to the management of hypertension, not
prevention.
DIF: C
REF: 537-538
OBJ: Analysis
5. The nurse is discussing the correct technique for taking a blood pressure with clients and
their caregivers. Which of the following nursing statements would appropriately identify
the most likely causes for experiencing difficulty actually hearing the blood pressure?
(Select all that apply.)
1. The cuff cannot be too small or too big.
2. Dont release the air out of the cuff to quickly.
3. Keep the arm you are using at the level of the heart.
4. If you are having difficulty, try taking it in the other arm.
5. The stethoscope needs to be placed directly over a pulse point.
6. Remember to pump up the cuff until you can no longer feel the pulse.
ANS: 1, 2, 5, 6
Instruct the client or primary caregiver that if it is difficult to hear the pressure, the cuff is
probably too loose, not big enough, or too narrow; the stethoscope is not over an arterial
pulse; the cuff was deflated too quickly or too slowly; or the cuff was not inflated enough
for systolic readings. The remaining options do not directly affect the actual hearing of
the blood pressure.
DIF: C
REF: 539
OBJ: Analysis
Test Bank
32-22
6. The nurse is discussing the proper technique for obtaining an accurate blood pressure
reading with assistive nursing personnel. Which of the following statements reflect
techniques that will minimize the risk of a false high systolic reading? (Select all that
apply.)
1. Slowly deflate the pressure from the cuff.
2. Wrap the cuff snuggly around the clients arm.
3. Always support the clients arm at the level of the heart.
4. Be sure that the cuff is wide enough for the clients arm.
5. Allow the arm to rest before repeating the blood pressure.
6. Make sure your stethoscope is fitted in your ears appropriately.
ANS: 2, 3, 4, 5
Using a bladder or cuff that is too narrow or too short, wrapping the cuff too loosely or
unevenly, resting the arm below heart level, and repeating assessments too quickly all
contribute to a falsely high systolic reading. The rapid deflation of the cuff and an illfitted stethoscope will likely result in a falsely low systolic reading.
DIF: C
REF: 539
OBJ: Analysis

Chapter 032

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Chapter 032

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Potter & Perry: Fundamentals of Nursing, 7th Edition

2. Ask if the client is anxious

MSC: NCLEX test plan designation: Reduction of Risk Potential/Vital Signs

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4. Indicate that the client may be experiencing vascular problems

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