NCLEX-PN › Taking and Interpreting Vitals
A stethoscope has two components to the chest piece. These are called the __________ and the __________.
bell . . . diaphragm
cone . . . disc
bell . . . disc
cone . . . 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.
Which of the following would be considered a normal adult blood pressure?
110/72 mmHg
124/84 mmHg
88/56 mmHg
132/88 mmHg
Normal adult blood pressure is anywhere from 90-120 mmHg systolic over 60-80 mmHg diastolic. 120-140 mmHg over 80-90 mmHg would be considered pre-hypertension, while anything over that would be considered either stage I or stage II hypertension.
What is a normal heart rate for a school aged child (6-12 years of age) in beats per minute (bpm)?
70-120 bpm
50-70 bpm
120-160 bpm
100-140 bpm
Normal heart rate for a child aged 6-12 is 70-120 bpm. This is moderately higher than normal heart rate for an adult, which is 60-100 bpm.
Which of the following locations is most appropriate for assessing the pulse of an infant?
Brachial artery
Carotid artery
Popliteal artery
Radial artery
The most appropriate location for assessing the pulse of an infant is the brachial artery, which travels from the axilla down the ventral surface of the upper arm to the cubital fossa. The popliteal and radial pulses are difficult to palpate on an infant due to their size, and the carotid artery can be difficult to palpate due to an infant's shorter, thicker neck.
Which of the following is a normal adult respiratory rate?
Normal adult respiratory rate is 12-20 breaths per minute. A respiratory rate below 12 is defined as bradypnea, while a respiratory rate above 20 is considered tachypnea.
What is a normal respiratory rate for a child aged 1-6 years old?
24-34 breaths per minute
12-24 breaths per minute
34-44 breaths per minute
36-54 breaths per minute
A normal respiratory rate in a child aged 1-6 years is 24-34 breaths per minute. This is significantly higher than an adult normal respiratory rate, which is 12-20 breaths per minute.
A patient with a blood pressure reading of 168/102 mmHg on three or more occasions would be diagnosed with what stage of hypertension?
Stage II hypertension
Stage I hypertension
Prehypertension
Stage III 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.
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
Temperature of 103.2 degrees Fahrenheit
Respiratory rate greater than 25 breaths per minute
Heart rate of 105 beats per minute
Blood pressure of 105 over 89
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.
A 2+ radial pulse is considered to be __________.
A normal pulse
A bounding pulse
A weak pulse
An absent pulse
The following scale applies to the amplitude of a pulse when palpated at the radial artery:
3+ is an increased or bounding pulse
2+ is a normal pulse
1+ is a weak pulse
0 is an absent pulse
How might an overlarge cuff affect a blood pressure reading?
The reading would be artificially low
The reading would be artificially high
The reading may be unstable
There would be no significant effect
An overlarge blood pressure cuff will often result in a blood pressure reading that is artificially low. It is important that the nurse chooses the appropriate blood pressure cuff size for each individual patient.