Nokea
Which of the following objective vital signs, all taken on adults, have one or more components that fall outside of typical normal ranges?
- A. BP - 118/66 mm Hg, T - 99.2°F, P - 74 regular and strong, R - 17, O2 sats - 99%
- B. BP - 98/62 mm Hg, T - 98.2°F, P - 98 regular and strong, R - 20, O2 sats - 97%
- C. BP - 142/92 mm Hg, T - 98.4°F, P - 62 regular and bounding, R - 14, O2 sats - 96%
- D. BP - 120/74 mm Hg, T - 100.6°F, P - 86 regular and strong, R - 24, O2 sats - 98%
Correct Answer: B,C,D
Rationale: Normal ranges: BP 100-130/60-80, T 97.8-99°F, P 60-100, R 12-20. Options B (low BP), C (high BP), and D (high T, R) are abnormal.
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The disadvantages of the oral and skin temperatures assessment routes for an adult patient include which of the following?
- A. Risk of body fluid exposure
- B. Affected by severe environmental temperatures
- C. Not affected by smoking
- D. Not for confused or unconscious patients
Correct Answer: A,B,D
Rationale: Oral and skin routes risk fluid exposure, are affected by environmental temperatures, and are unsuitable for confused or unconscious patients.
The nurse would refrain from taking a BP on which of the following areas?
- A. Amputation of the arm
- B. Mastectomy on the affected side
- C. IV infusion on the selected sites
- D. Presence of a shunt
Correct Answer: A,B,C,D
Rationale: BP measurement is contraindicated in areas with amputation, mastectomy, IV infusion, or shunts to avoid injury or inaccurate readings.
Uncontrolled hypertension can result in permanent damage of which organs?
- A. Heart and eyes
- B. Pancreas and spleen
- C. Large intestine and skeletal structures
- D. Brain and kidneys
- E. Urinary bladder
Correct Answer: A,D
Rationale: Hypertension damages the heart, eyes, brain, and kidneys due to increased vascular pressure.
A 68-year-old African American female is admitted for hypertension. She is at risk for hypertension based on which of the following?
- A. Smoking
- B. Obesity
- C. Lower cholesterol level in the blood
- D. Moderate to heavy alcohol consumption
- E. Low stress level
Correct Answer: A,B,D
Rationale: Smoking, obesity, and alcohol consumption are modifiable risk factors for hypertension.
You must assess the temperature of an 89-year-old female who is confused, hostile, and combative. Which route would be most appropriate to use?
- A. Rectal
- B. Oral
- C. Temporal
- D. Axillary
Correct Answer: C
Rationale: Temporal route is non-invasive, safe, and accurate for confused or combative patients.