Quiz - Vitals Signs
1. You are removing an intravenous line from a patient's arm. As you pull out the angiocatheter, you notice that a 1 cm piece of it is missing. What do you do?
a. Apply a tourniquet high on the arm, get a stat order for an x-ray.
b. Palpate the arm to locate the missing angiocatheter. Try to slowly push it back toward the intravenous site and out of the arm.
c. Do nothing. Angiocatheter material left in the body will be absorbed by the body after 5 days.
d. Grab a scalpel and do an immediate cut-down at the bedside.
2. You are assigned to triage in the emergency room. Two buses collide in front of the hospital – you have been presented with 53 patients to triage immediately. Which of the following patients should take priority?
a. The screaming 7 year old boy with an obvious deformity to his right shoulder.
b. The unconscious man in his thirties who still is not breathing after you adjust his airway. He also has a compound fracture to the left lower leg.
c. The 22 year old woman who was fine three minutes ago but now states her asthma is bothering her. You observe a moderate respiratory effort as she leans forward to put her hands on the ground in front of her.
d. The 50 year old woman bleeding from a 9 cm avulsion to her left upper arm. The bleeding can only be controlled if you ask the patient next to her (the one with the broken leg) to continue applying direct pressure to the wound.
3. After reviewing the blood pressure of a 60 year old male patient, you note that his pulse pressure is widening. Of what is a widening pulse pressure indicative?
a. Aortic dissection.
b. Diabetes type II.
c. Diabetes type I.
d. Systemic sepsis.
4. Your 70 year old patient presents with chronic obstructive pulmonary disease and moderate dyspnea. How much oxygen would it be appropriate to give your patient?
a. Low flow oxygen via nasal cannula.
b. High flow oxygen via nasal cannula or partial rebreather mask.
c. None - her dyspnea is not sever, room air is appropriate.
d. High flow oxygen via non-rebreather mask.
5. A 30 year old pregnant woman is at full gestation. She has been laboring for several hours. The fetal monitor shows persistent FHR (fetal heart rate) of 60 bpm. What is your first course of action?
a. Change the monitoring equipment to a new unit. Call maintenance immediately to collect the broken unit for repair.
b. Apply 100% oxygen via non-rebreather mask to the patient and turn her onto her left side.
c. Call the doctor to report that the patient will be delivering soon.
d. Notify the OR that you are on your way with an emergency C-section. There is no time to move the patient to a stretcher. Bring her down the hallway on the bed she is on now.
6. A 29 year old male presents with full thickness burns to his entire chest and to the anterior portion of his left arm. The patient's treatment depends heavily on the type of burn as well as the percentage of BSA (Body Surface Area) that is burned. How do you estimate the percentage of BSA that is burned?
a. By checking evaluation done by the surgeon who will be doing eventual debridement of the burnt tissue.
b. By referring to Lippincott's Estimation of BSA charts.
c. By using the Rule of Nines.
d. By looking up the appropriate numbers in Gray's Anatomy diagrams.
7. Your 29 year old male burn patient has an order for fluid replacement. Which of the following will you expect to provide to your patient?
a. Lactated Ringer's
b. Normal Saline
c. Gatorade
d. Half-Normal Saline
8. You are preparing a transfusion of packed red blood cells for a 42 year old female with a low hemoglobin. After starting the infusion, she complains of flank pain. What do you suspect and what is your priority action?
a. You suspect an acute anaphylactic reaction. You immediately go to the nurses' station to telephone the physician for stat orders.
b. You suspect an allergic reaction. Since she is not complaining of dyspnea, you administer the prn order of diphenhydramine.
c. You suspect an acute hemolytic reaction. You turn off the infusion.
d. You suspect nothing out of the ordinary. Flank pain has nothing to do with a blood transfusion.
9. Your 19 year old male car accident patient has just been pronounced clinically deceased. According to the family, he had previously expressed his desire to donate his organs. The family intends to carry through with his wishes. What characteristic would be cause for rejection as an organ donor?
a. The donor's status as a homosexual male.
b. Sustained blood pressure under 100 mm Hg systolic.
c. Treatment thirty days ago for strep throat infection.
d. Fever over 100ºF (37.8ºC).
10. What is the most important thing you can do for your patients?
a. Follow physician orders.
b. Advocate for them.
c. Take detailed nursing notes.
d. Help them to be discharged as quickly as possible.
ANSWERS:
1. You are removing an intravenous line from a patient's arm. As you pull out the angiocatheter, you notice that a 1 cm piece of it is missing. What do you do?
The correct answer was Apply a tourniquet high on the arm, get a stat order for an x-ray..
Angiocatheters are radio-opaque and will show on xray. They are not, of course, able to be absorbed. It is beyond the scope of nursing practice to manipulate the catheter or do a cut-down procedure.
2. You are assigned to triage in the emergency room. Two buses collide in front of the hospital – you have been presented with 53 patients to triage immediately. Which of the following patients should take priority?
The correct answer was The 22 year old woman who was fine three minutes ago but now states her asthma is bothering her. You observe a moderate respiratory effort as she leans forward to put her hands on the ground in front of her..
Disaster triage is different from typical emergency room triage. The priority patient is the one with dyspnea whose status is worsening. The unconscious man in this instance is considered unsalvageable if he continues not breathing after adjustment of his airway. The bleeding from the avulsion is controlled with direct pressure (it is acceptable to use another able and willing patient to assist with first aid care). The screaming boy can scream all he wants: his injuries do not appear life-threatening.
3. After reviewing the blood pressure of a 60 year old male patient, you note that his pulse pressure is widening. Of what is a widening pulse pressure indicative?
The correct answer was Aortic dissection..
A widening pulse pressure may be indicative of an aortic dissection. Immediate surgical intervention may be required.
4. Your 70 year old patient presents with chronic obstructive pulmonary disease and moderate dyspnea. How much oxygen would it be appropriate to give your patient?
The correct answer was Low flow oxygen via nasal cannula..
For most people, increased blood CO2 levels stimulate their respiratory drive. The stimulus for the respiratory drive of a patient with COPD, however, will gradually change to decreased blood O2. Administering more than low flow oxygen will increase O2 levels in the blood and turn off the patient's internal breathing drive, which can lead to bradypnea. Room air is not therapeutic given your patient's history and current complaint.
5. A 30 year old pregnant woman is at full gestation. She has been laboring for several hours. The fetal monitor shows persistent FHR (fetal heart rate) of 60 bpm. What is your first course of action?
The correct answer was Apply 100% oxygen via non-rebreather mask to the patient and turn her onto her left side..
A persistent FHR under 60 bpm is a life-threatening situation for the fetus and must be handled with immediate therapeutic intervention. The administration of oxygen to the mother will increase oxygen available to the fetus. Positioning your patient on her left side will decrease pressure on vital arteries that supply oxygenated blood to the uterus and placenta. While the other options may be valid, none will be your initial action.
6. A 29 year old male presents with full thickness burns to his entire chest and to the anterior portion of his left arm. The patient's treatment depends heavily on the type of burn as well as the percentage of BSA (Body Surface Area) that is burned. How do you estimate the percentage of BSA that is burned?
The correct answer was By using the Rule of Nines..
The "Rule of Nines" assigns burn percentages to body parts of adults and infants. For adults, the chest is 9% and an arm (anterior and posterior) is 9%.
7. Your 29 year old male burn patient has an order for fluid replacement. Which of the following will you expect to provide to your patient?
The correct answer was Lactated Ringer's.
Lactated Ringer's is the solution of choice for the fluid resuscitation of a burn patient.
8. You are preparing a transfusion of packed red blood cells for a 42 year old female with a low hemoglobin. After starting the infusion, she complains of flank pain. What do you suspect and what is your priority action?
The correct answer was You suspect an acute hemolytic reaction. You turn off the infusion..
Flank pain during a blood transfusion is a sign of an acute hemolytic reaction. The kidney pain is due to the processing of the hemolyzed red blood cells by the kidneys. This reaction is life-threatening. The transfusion must be stopped immediately before any other action is taken.
9. Your 19 year old male car accident patient has just been pronounced clinically deceased. According to the family, he had previously expressed his desire to donate his organs. The family intends to carry through with his wishes. What characteristic would be cause for rejection as an organ donor?
The correct answer was Sustained blood pressure under 100 mm Hg systolic..
A sustained blood pressure under 100 mg Hg systolic is not sufficient for adequate organ perfusion. The patient's sexuality, history of strep throat or fever do not cause rejection as a donor.
10. What is the most important thing you can do for your patients?
The correct answer is advocate for them.
A nurse's duty and focus is to advocate for his or her patients. All other objectives fall into place if advocacy is maintained.
a. Apply a tourniquet high on the arm, get a stat order for an x-ray.
b. Palpate the arm to locate the missing angiocatheter. Try to slowly push it back toward the intravenous site and out of the arm.
c. Do nothing. Angiocatheter material left in the body will be absorbed by the body after 5 days.
d. Grab a scalpel and do an immediate cut-down at the bedside.
2. You are assigned to triage in the emergency room. Two buses collide in front of the hospital – you have been presented with 53 patients to triage immediately. Which of the following patients should take priority?
a. The screaming 7 year old boy with an obvious deformity to his right shoulder.
b. The unconscious man in his thirties who still is not breathing after you adjust his airway. He also has a compound fracture to the left lower leg.
c. The 22 year old woman who was fine three minutes ago but now states her asthma is bothering her. You observe a moderate respiratory effort as she leans forward to put her hands on the ground in front of her.
d. The 50 year old woman bleeding from a 9 cm avulsion to her left upper arm. The bleeding can only be controlled if you ask the patient next to her (the one with the broken leg) to continue applying direct pressure to the wound.
3. After reviewing the blood pressure of a 60 year old male patient, you note that his pulse pressure is widening. Of what is a widening pulse pressure indicative?
a. Aortic dissection.
b. Diabetes type II.
c. Diabetes type I.
d. Systemic sepsis.
4. Your 70 year old patient presents with chronic obstructive pulmonary disease and moderate dyspnea. How much oxygen would it be appropriate to give your patient?
a. Low flow oxygen via nasal cannula.
b. High flow oxygen via nasal cannula or partial rebreather mask.
c. None - her dyspnea is not sever, room air is appropriate.
d. High flow oxygen via non-rebreather mask.
5. A 30 year old pregnant woman is at full gestation. She has been laboring for several hours. The fetal monitor shows persistent FHR (fetal heart rate) of 60 bpm. What is your first course of action?
a. Change the monitoring equipment to a new unit. Call maintenance immediately to collect the broken unit for repair.
b. Apply 100% oxygen via non-rebreather mask to the patient and turn her onto her left side.
c. Call the doctor to report that the patient will be delivering soon.
d. Notify the OR that you are on your way with an emergency C-section. There is no time to move the patient to a stretcher. Bring her down the hallway on the bed she is on now.
6. A 29 year old male presents with full thickness burns to his entire chest and to the anterior portion of his left arm. The patient's treatment depends heavily on the type of burn as well as the percentage of BSA (Body Surface Area) that is burned. How do you estimate the percentage of BSA that is burned?
a. By checking evaluation done by the surgeon who will be doing eventual debridement of the burnt tissue.
b. By referring to Lippincott's Estimation of BSA charts.
c. By using the Rule of Nines.
d. By looking up the appropriate numbers in Gray's Anatomy diagrams.
7. Your 29 year old male burn patient has an order for fluid replacement. Which of the following will you expect to provide to your patient?
a. Lactated Ringer's
b. Normal Saline
c. Gatorade
d. Half-Normal Saline
8. You are preparing a transfusion of packed red blood cells for a 42 year old female with a low hemoglobin. After starting the infusion, she complains of flank pain. What do you suspect and what is your priority action?
a. You suspect an acute anaphylactic reaction. You immediately go to the nurses' station to telephone the physician for stat orders.
b. You suspect an allergic reaction. Since she is not complaining of dyspnea, you administer the prn order of diphenhydramine.
c. You suspect an acute hemolytic reaction. You turn off the infusion.
d. You suspect nothing out of the ordinary. Flank pain has nothing to do with a blood transfusion.
9. Your 19 year old male car accident patient has just been pronounced clinically deceased. According to the family, he had previously expressed his desire to donate his organs. The family intends to carry through with his wishes. What characteristic would be cause for rejection as an organ donor?
a. The donor's status as a homosexual male.
b. Sustained blood pressure under 100 mm Hg systolic.
c. Treatment thirty days ago for strep throat infection.
d. Fever over 100ºF (37.8ºC).
10. What is the most important thing you can do for your patients?
a. Follow physician orders.
b. Advocate for them.
c. Take detailed nursing notes.
d. Help them to be discharged as quickly as possible.
ANSWERS:
1. You are removing an intravenous line from a patient's arm. As you pull out the angiocatheter, you notice that a 1 cm piece of it is missing. What do you do?
The correct answer was Apply a tourniquet high on the arm, get a stat order for an x-ray..
Angiocatheters are radio-opaque and will show on xray. They are not, of course, able to be absorbed. It is beyond the scope of nursing practice to manipulate the catheter or do a cut-down procedure.
2. You are assigned to triage in the emergency room. Two buses collide in front of the hospital – you have been presented with 53 patients to triage immediately. Which of the following patients should take priority?
The correct answer was The 22 year old woman who was fine three minutes ago but now states her asthma is bothering her. You observe a moderate respiratory effort as she leans forward to put her hands on the ground in front of her..
Disaster triage is different from typical emergency room triage. The priority patient is the one with dyspnea whose status is worsening. The unconscious man in this instance is considered unsalvageable if he continues not breathing after adjustment of his airway. The bleeding from the avulsion is controlled with direct pressure (it is acceptable to use another able and willing patient to assist with first aid care). The screaming boy can scream all he wants: his injuries do not appear life-threatening.
3. After reviewing the blood pressure of a 60 year old male patient, you note that his pulse pressure is widening. Of what is a widening pulse pressure indicative?
The correct answer was Aortic dissection..
A widening pulse pressure may be indicative of an aortic dissection. Immediate surgical intervention may be required.
4. Your 70 year old patient presents with chronic obstructive pulmonary disease and moderate dyspnea. How much oxygen would it be appropriate to give your patient?
The correct answer was Low flow oxygen via nasal cannula..
For most people, increased blood CO2 levels stimulate their respiratory drive. The stimulus for the respiratory drive of a patient with COPD, however, will gradually change to decreased blood O2. Administering more than low flow oxygen will increase O2 levels in the blood and turn off the patient's internal breathing drive, which can lead to bradypnea. Room air is not therapeutic given your patient's history and current complaint.
5. A 30 year old pregnant woman is at full gestation. She has been laboring for several hours. The fetal monitor shows persistent FHR (fetal heart rate) of 60 bpm. What is your first course of action?
The correct answer was Apply 100% oxygen via non-rebreather mask to the patient and turn her onto her left side..
A persistent FHR under 60 bpm is a life-threatening situation for the fetus and must be handled with immediate therapeutic intervention. The administration of oxygen to the mother will increase oxygen available to the fetus. Positioning your patient on her left side will decrease pressure on vital arteries that supply oxygenated blood to the uterus and placenta. While the other options may be valid, none will be your initial action.
6. A 29 year old male presents with full thickness burns to his entire chest and to the anterior portion of his left arm. The patient's treatment depends heavily on the type of burn as well as the percentage of BSA (Body Surface Area) that is burned. How do you estimate the percentage of BSA that is burned?
The correct answer was By using the Rule of Nines..
The "Rule of Nines" assigns burn percentages to body parts of adults and infants. For adults, the chest is 9% and an arm (anterior and posterior) is 9%.
7. Your 29 year old male burn patient has an order for fluid replacement. Which of the following will you expect to provide to your patient?
The correct answer was Lactated Ringer's.
Lactated Ringer's is the solution of choice for the fluid resuscitation of a burn patient.
8. You are preparing a transfusion of packed red blood cells for a 42 year old female with a low hemoglobin. After starting the infusion, she complains of flank pain. What do you suspect and what is your priority action?
The correct answer was You suspect an acute hemolytic reaction. You turn off the infusion..
Flank pain during a blood transfusion is a sign of an acute hemolytic reaction. The kidney pain is due to the processing of the hemolyzed red blood cells by the kidneys. This reaction is life-threatening. The transfusion must be stopped immediately before any other action is taken.
9. Your 19 year old male car accident patient has just been pronounced clinically deceased. According to the family, he had previously expressed his desire to donate his organs. The family intends to carry through with his wishes. What characteristic would be cause for rejection as an organ donor?
The correct answer was Sustained blood pressure under 100 mm Hg systolic..
A sustained blood pressure under 100 mg Hg systolic is not sufficient for adequate organ perfusion. The patient's sexuality, history of strep throat or fever do not cause rejection as a donor.
10. What is the most important thing you can do for your patients?
The correct answer is advocate for them.
A nurse's duty and focus is to advocate for his or her patients. All other objectives fall into place if advocacy is maintained.
nice post. thanks.
You're welcome..
great! i answered 8/10 though :(
it's not that bad, 2 mistakes is not bad at all. keep practicing! =)