NSG 522 Chapter 29 Vital Signs: Overview of Vital Sign Assessment

Question 1 of 15 – NSG 522 Chapter 29, Vital Signs Overview of Vital Sign Assessment

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Which response indicates a nurse has a correct understanding about the components of a vital sign assessment?

“Oxygen saturation is the measurable intake of oxygen and release of carbon dioxide.”
Respiration is the intake of oxygen and release of carbon dioxide (inhalation and exhalation); oxygen saturation is the measurable amount of oxygen available to tissue.

Correct

“Pulse is the detectable rhythmic expansion of an artery from the pumping action of the heart.”
This is a correct statement because pulse is the detectable rhythmic expansion of an artery from the pumping action of the heart and is measured as the number of beats per minute.

“Respiration is the measurable amount of oxygen available to the tissues.”
Oxygen saturation, not respiration, is the measurable amount of oxygen available to the tissues. Respiration is the intake of oxygen and release of carbon dioxide (inhalation and exhalation).

“Blood pressure is the measurable pressure of blood within the systemic veins.”
Blood pressure is the measurable pressure of blood within the systemic arteries, not veins.

Question 2 of 15

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Which actions are strictly a nurse’s responsibility?

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Assess patients to determine if medically stable.

Patients must be assessed by the nurse and determined to be medically stable, making this a responsibility of the nurse.

Correct

Interpret vital sign measurements.

Interpretation of vital sign data is strictly a nursing function because it requires clinical judgment.

Correct

Report significant vital sign findings to the health care provider.

To report unexpected values and other significant assessment findings to the appropriate health care provider is strictly a nursing responsibility because it requires clinical judgment.

Correct

Reassess any unexpected vital sign values.

To reassess any unexpected vital sign values is strictly a nurse’s responsibility because it requires clinical judgment.

Measure vital signs for stable patients.

The unlicensed assistive personnel may measure, record, and report vital signs for a stable patient; therefore it may be delegated by the nurse.

Question 3 of 15

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Which actions are required for proper documentation of vital signs?

Recording duplicate entries

Recording duplicate entries is not necessary when documenting vital signs as it can produce inconsistencies in the record.

Correct

Documenting in a standardized format

Documenting in a standardized format allows for easy communication to all members of the health care team.

Documenting at the end of the day

Results are documented promptly rather than waiting until the end of the day.

Correct

Recording on a specified form

Recording on the specified form where multiple sets of vital signs are easily visible at one time allows health care staff to identify trends for the patient. NSG 522 Chapter 29, Vital Signs Overview of Vital Sign Assessment

Recording just expected values

Expected and unexpected results are recorded, not just expected values.

Question 4 of 15

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How frequently would the nurse assess vital signs for a patient with a head injury who suddenly reports a severe headache and whose blood pressure rises from 118/62 to 170/94?

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Every 5 minutes
The nurse would monitor the patient’s vital signs every 5 minutes because this patient has experienced a sudden, severe change in condition as evidenced by the severe headache and blood pressure changes. These findings would be reported to the health care provider.

Every 30 minutes
Monitoring vital signs every 15 to 60 minutes is for a postprocedure or postoperative patient; this patient is not stable because of sudden, severe changes in condition, and there is no indication of a recent medical procedure.

Every 4 hours
Monitoring vital signs every 4 hours is for a stable patient, and this patient is not stable because of the severe change in blood pressure.

Every 8 hours
Monitoring vital signs every 8 hours is for a stable patient, and this patient is not stable because of the sudden changes in health status.

Question 5 of 15

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Which action would the nurse take for a stable patient who is scheduled for a transfer to the rehabilitation unit later in the afternoon?

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Take vital signs before the transfer.
Vital signs need to be taken before the transfer to confirm that the patient maintains a stable status and is suitable for transfer.

Require every 2-hour monitoring until the transfer.
The patient is stable and does not require 2-hour monitoring.

Monitor the pulse rate once a day after the transfer.
All vital signs, not just the pulse rate, would be monitored before the transfer and upon admission to the rehabilitation unit.

Delay vital signs monitoring since the patient is being transferred.
Although the patient is being transferred, the nurse would not delay vital signs monitoring. All stable hospitalized patients should have vital signs monitored every 4 to 8 hours to observe for early signs of any alteration in condition.

Question 6 of 15

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Which action would the nurse take when the unlicensed assistive personnel (UAP) reports the patient’s pulse increased from 74 beats/min to 100 beats/min and the temperature increased from 99° to 101.8°F (37.2° to 38.8°C)?

Advise the UAP to wait 1 hour and repeat vital signs.
This patient is no longer stable, and waiting to take vital signs in 1 hour is too long; the vital signs are taken more frequently.

Compare the findings to the expected values.
Comparing the findings to the expected values is not indicated because the nurse uses the patient’s baseline.

Correct

Reassess the patient.
The nurse verifies the vital signs since this is a significant change and notifies the health care provider.

Tell the UAP to give fluids to the patient.
The nurse would not tell the UAP to give fluids to the patient; the nurse needs to gather more data before telling the UAP what to do.

Question 7 of 15

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Which entries would the nurse include when documenting vital signs?

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Date of assessment

Date of assessment is documented to follow vital sign trends over several days.

Correct

Time of assessment

Time of assessment is documented to follow vital sign trends over time.

Names of visitors in the room

Names of visitors in the room are not necessary for vital sign assessment.

Correct

Numeric results of the assessment

Recording the specific numeric data is documented to accurately note changes.

NSG 522 Chapter 29, Vital Signs Overview of Vital Sign Assessment

Expected values for vital signs

Expected values for vital signs are not entries for documenting because the documentation focuses on the patient’s actual results.

Question 8 of 15

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Which patient trend does the vital sign graphic indicate?

The diastolic blood pressure is slowly increasing while the systolic pressure is remaining constant.
This statement is the opposite of what the image is depicting: the systolic blood pressure is slowly increasing while the diastolic blood pressure is relatively stable.

Correct

The systolic blood pressure is rising slightly while the diastolic pressure is steady.
The image depicts a systolic blood pressure that is rising slightly (from 142 mm Hg to 150 mm Hg) while the diastolic pressure is remaining constant and steady (around 86 mm Hg to 90 mm Hg).

The diastolic blood pressure is more varied than the systolic blood pressure.
This statement is the opposite of what the image is depicting: there is more variation in the systolic blood pressure than the diastolic blood pressure.

Both systolic and diastolic blood pressure readings require the nurse to immediately notify the health care provider.
While both systolic and diastolic blood pressures are high, all are within the patient’s baseline and do not require the nurse to immediately notify the health care provider. However, if the systolic blood pressure continues to rise, the nurse may have to notify the health care provider.

Question 9 of 15

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Which vital sign finding indicates the adult patient is improving?

Blood pressure changes from 120/78 to 80/60.
A drop in blood pressure indicates the patient is deteriorating, not improving.

Pulse rate increases from 85 to 110.
The pulse rate was in an expected range and increased to an unexpected range, indicating the patient is worsening, not improving.

Oxygen saturation changes from 90% to 85%.
This patient’s oxygen saturation level was lower than expected and decreased even further, indicating the patient is deteriorating, not improving.

Correct

Respiratory rate decreases from 36 to 20.
Respiratory rate was elevated and decreased to expected range, indicating the patient is improving.

Question 10 of 15

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Which actions are responsibilities of the nurse when assigning vital signs to the unlicensed assistive personnel (UAP)?

Correct

Ensure that the UAP uses the proper technique for measuring vital signs.

Since the task of vital sign measurement can be delegated, the nurse ensures accurate procedures are followed to obtain valid results.

Correct

Validate that the UAP knows what values need to be reported immediately for each patient.

The nurse validates that the UAP knows which values for each patient are immediately reported to the nurse to provide safe care.

Determine that the UAP knows to report unexpected values to the health care provider.

It is the nurse’s responsibility (not the UAP’s) to notify the health care provider of unexpected values.

Correct

Ensure that the UAP is competent to perform vital signassessments.

The nurse ensures that the UAP is competent to perform a vital sign assessment to obtain accurate, valid results.

Correct

Validate that the UAP uses appropriate equipment.

Since the task of vital sign measurement can be delegated, the nurse ensures appropriate equipment is used to obtain accurate readings.

Question 11 of 15

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Which factors influence the interpretation of a patient’s vital signs?

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Patient status

Interpretation of vital signs depends on patient status being stable,improving, or worsening.

Length of time the nurse is on duty

The length of time the nurse is on duty is irrelevant to the interpretation of vital signs.

Correct

Consideration of patient’s baseline vital signs

Consideration of the patient’s baseline vital signs assists in identifying trends.

Correct

Standard range for vital sign values

The standard range is a guide the nurse uses to interpret vital sign measurements.

Correct

Patient’s unique medical condition

The patient’s unique medical condition may explain vital signs being higher or lower (e.g., increased blood pressure in hypertension diagnosis).

Question 12 of 15

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Which finding is unexpected for a 15-year-old patient?

Pain level 0
This is an expected pain level. A pain level of 0 indicates the patient is having no pain; the higher the number, the worse the pain.

Pulse rate 88
This is an expected pulse rate; the pulse rate for a 15-year-old is 50 to 90.

Correct

Respirations 30
This is an unexpected (abnormal) finding; respirations within expected ranges are 14 to 20.

O 2 sat 97%
This is an expected finding; O 2 sat above 95% is within the expected range. NSG 522 Chapter 29, Vital Signs Overview of Vital Sign Assessment

Question 13 of 15

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Which information about a patient’s pain is accurate?

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It is a subjective experience.
Pain is a subjective experience of discomfort as described by a patient.

A high score on the rating scale indicates little pain.
A high score on the rating scale indicates a high level of pain; in fact, the higher the number, the worse the pain.

The nurse is the expert on the patient’s pain.
Pain is described by the patient, not the nurse; pain is a subjective experience.

A measurement of 0 to 10 mm Hg is expected.
A measurement of mm Hg is used for blood pressure, not pain. A pain scale of 0 to 10 measures the pain level.

Question 14 of 15

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Which vital sign measurements are unexpected?

99.5°F (37.5°C) temperature for a newborn

96° to 99.5°F (35.5° to 37.5°C) is an expected temperature for a newborn; thus this newborn’s temperature is expected, not unexpected.

Correct

60 pulse rate for a 1-year-old

80 to 150 (awake) or 70 to 120 (asleep) pulse rate is expected for a 1-year-old; thus this pulse rate is unexpected.

Correct

35 respirations for a 6-year-old

20 to 24 respirations are expected for a 6-year-old; thus this patient’s respirations are unexpected.

Correct

SpO 2 90% for a 15-year-old

Greater than 95% is expected for a 15-year-old; thus this patient’s SpO 2 is unexpected.

110/68 blood pressure for an older adult

90 to <120 systolic and 60 to <80 diastolic are expected for an older adult; thus this patient’s blood pressure is expected, not unexpected. Question 15 of 15 Report content error Which vital sign measurements of adult patients would require the nurse to immediately notify the health care provider? Correct 158 pulse rate This is an extremely elevated pulse rate and would require the nurse to immediately notify the health care provider; the expected rate is 60 to 100. Correct 8 respirations This is an extremely low respiratory rate and would require the nurse to immediately notify the health care provider; the expected rate is 12 to 20. 99.5°F (37.5°C) temperature Although this is a high value, it is expected and does not require the nurse to immediately notify the health care provider. 98% oxygen saturation Oxygen saturation above 95% is expected and does not require notification of the health care provider. Correct 50/30 blood pressure This is an extremely low blood pressure and would require the nurse to immediately notify the health care provider; expected is 90 to <120/60 to <80. NSG 522 Chapter 29, Vital Signs Overview of Vital Sign Assessment