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HESI RN · HESI Fundamentals of Nursing · Vital Signs in Nursing Assessment

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Showing all 5 practice questions with expert explanatory rationales.

Question 1 of 5

Which of the following accurately reflects a recommended guideline when assessing blood pressure?

A. If this is the initial nursing assessment of a patient, take the blood pressure on both arms and use the arm with the lower reading for subsequent pressures.

B. Use electronic monitoring devices on patients with irregular heartbeats, tremors, or the inability to hold the arm still.

C. Raise the patient's arm over the head to help relieve congestion of blood in the limb and make the sounds louder and more distinct.

D. In newborns, take the blood pressure in one arm and one leg and document the difference to check for heart defects.

Expert Explanatory Rationale

Correct Answer: Raise the patient's arm over the head to help relieve congestion of blood in the limb and make the sounds louder and more distinct.

Question 2 of 5

Older adults have an increase in systolic pressure related to what?

A. Increased vessel flexibility

B. Decreased vessel elasticity

C. Enlarged vessel dexterity

D. Diminished vessel porosity

Expert Explanatory Rationale

Correct Answer: Decreased vessel elasticity

Question 3 of 5

A nurse assesses orthostatic hypotension in an older adult. What would be an appropriate intervention for this patient?

A. Encourage the patient to rise from a sitting position quickly to improve blood flow.

B. Allow the patient to dangle for a few minutes prior to rising to a standing position.

C. If the patient feels faint or dizzy, return the patient to bed and place in Fowlers position.

D. Administer a beta-adrenergic blocker to increase blood pressure.

Expert Explanatory Rationale

Correct Answer: Allow the patient to dangle for a few minutes prior to rising to a standing position.

Question 4 of 5

The patient is admitted with shortness of breath and chest discomfort. Which of the following laboratory values could account for the patient's symptoms?

A. Hemoglobin level of 8.0

B. Hematocrit level of 45%

C. Red blood cell count of 5.0 million/mm3

D. Pulse oximetry of 95%

Expert Explanatory Rationale

Correct Answer: Hemoglobin level of 8.0

Question 5 of 5

A nurse is assessing a client's body temperature using a tympanic thermometer. How should the nurse position the thermometer for accurate measurement?

A. Place the thermometer in the client's mouth.

B. Insert the thermometer into the client's rectum.

C. Aim the thermometer at the client's forehead.

D. Position the thermometer in the client's ear canal.

Expert Explanatory Rationale

Correct Answer: Position the thermometer in the client's ear canal.

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