NCLEX : Taking and Interpreting Vitals
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Example Question #11 : Taking And Interpreting Vitals
What is the correct way to determine proper blood pressure cuff size?
The vinyl covering should be able to wrap at least twice around the forearm
The inflatable bladder should cover approximately 80% of the circumference of the forearm while its width should cover approximately 40%
The inflatable bladder should cover approximately 50% of the circumference of the forearm while its width should cover approximately 20%
The inflatable bladder should cover approximately 40% of the circumference of the forearm while its width should cover approximately 80%
The inflatable bladder should cover approximately 80% of the circumference of the forearm while its width should cover approximately 40%
Proper cuff size is very important for accurate blood pressure assessment. The correct way to determine proper blood pressure cuff size is to wrap the cuff around the arm, then note the area covered by the inflatable bladder. The inflatable bladder should cover approximately 80% of the circumference of the forearm while its width should cover approximately 40%.
Example Question #11 : Taking And Interpreting Vitals
A stethoscope has two components to the chest piece. These are called the __________ and the __________.
bell . . . diaphragm
cone . . . disc
cone . . . diaphragm
bell . . . disc
bell . . . diaphragm
The chest-piece of the stethoscope is made up of two components designed for auscultation: the bell and the diaphragm. The bell is dome-shaped and used for auscultation of low-pitched sounds, while the diaphragm is used to auscultate high-pitched sounds.
Example Question #12 : Taking And Interpreting Vitals
A nurse takes a patient's blood pressure and records it at 146/92 mmHg. This is the patient's first visit to the clinic and they have no past medical records available. Would this patient be diagnosed with hypertension?
No, there is not enough information
Yes, this is stage I hypertension
No, this is within the normal range
Yes, this is malignant hypertension
No, there is not enough information
A patient with a one-time high blood pressure reading can not be diagnosed as hypertensive. A diagnosis of hypertension requires at least three measurements of blood pressure over 140/90 mmHg on at least two separate visits to health care provider.
Example Question #11 : Procedures And Care
A patient with a blood pressure reading of 168/102 mmHg on three or more occasions would be diagnosed with what stage of hypertension?
Prehypertension
Stage I hypertension
Stage II hypertension
Stage III hypertension
Stage II hypertension
Stage II hypertension is defined as a blood pressure equal to or greater than 160 mmHg systolic over 100 mmHg diastolic, taken at three different times on at least two separate occasions. Stage I hypertension is systolic blood pressure of 140-160 mmHg or diastolic blood pressure of 90-100 mmHg, while prehypertension is defined as a systolic blood pressure of 120-140 mmHg or diastolic blood pressure of 80-90 mmHg.
Example Question #15 : Ethics, Processing, And Care
Which of the following is not a normal part of taking a patient's vitals?
Overall visual appearance
Pulse
All of these are part of taking a patient's vitals
Temperature
All of these are part of taking a patient's vitals
While most examiners remember to take the pulse, temperature, and blood pressure while assessing their patient's vitals, overall visual appearance is also an important part of an individuals vitals. Does the patient appear ill? Anxious? Are there any noticeable issues with hygiene or bizarre dress or movements? Are there any signs of pallor, jaundice, or cyanosis? All of these observations can be quickly noted in a patient's chart when taking vitals.
Example Question #12 : Procedures And Care
The pulse of your patient is 120 beats per minute. What is the appropriate term for this finding?
Bradycardia
Normal heart rate
Aortic stenosis
Tachycardia
Asystole
Tachycardia
Tachycardia is the term used to describe a faster than normal heart rate. A heart rate of more than 100 beats per minute is considered tachycardic. Bradycardia is used to describe a slower than normal heart rate. Less than 60 beats per minute is considered bradycardia.
Example Question #11 : Taking And Interpreting Vitals
The physician on call pages you to ask if the patient you are taking care of is afebrile. Which of the following vital signs would you find in an afebrile patient?
Temperature of 97.9 degrees Fahrenheit
Blood pressure of 105 over 89
Temperature of 103.2 degrees Fahrenheit
Respiratory rate greater than 25 breaths per minute
Heart rate of 105 beats per minute
Temperature of 97.9 degrees Fahrenheit
Afebrile is a term used to describe a patient who does not have a fever. Clinically, a fever is defined as a temperature greater than 100.4 Fahrenheit. Blood pressure, heart rate, and respiratory rate do not tell you if the patient has a fever.
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