NCLEX PRACTICE QUESTIONS BASED ON VITAL SIGNS AND LABORATORY REFERENCE PART 3

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Key Points to remember regarding vital signs and laboratory reference:

  • The nurse ensures that vital sign measurements are documented correctly and always reports abnormal findings to the PHCP.
  • The temperature is not taken rectally in cardiac clients; the client who has undergone rectal surgery; or the client with diarrhea, fecal impaction, or rectal bleeding or who is at risk for bleeding.
  • The apical pulse is counted for 1 full minute and is assessed in clients with an irregular radial pulse or a heart condition, before the administration of cardiac medications such as digoxin and beta blockers, and in children younger than 2 years.
  • The respiratory rate may be counted for 30 seconds and multiplies by 2, except in a client who is known to be very ill or is exhibiting irregular respirations, in which case respirations are counted for 1 minute.
  • When taking a BP, select the appropriate cuff size; a cuff that is too small will yield a falsely high reading, and a cuff that is too large will yield a falsely low one.
  • A usual pulse oximetry reading is between 95% and 100%. A pulse oximetry reading lower than 90% necessitates PHCP notification, values below 90% are acceptable only in certain conditions. Agency procedures and PHCP prescriptions are followed regarding actions to take for specific readings.
  • Consider the client’s culture and spiritual and religious beliefs in assessing pain, some cultures frown on the outward expression of pain.
  • Ice and heat should be applied with a towel or other barrier between the pack and the skin but should not be left in place for more than 15 – 30 minutes.
  • The major concern with acetaminophen is hepatotoxicity
  • An electronic infusion device is always used for continuous or dose demand IV infusion of opioid analgesics.
  • Drawing blood specimens from an extremity in which an IV solution is infusing can produce an inaccurate result, depending on the test being performed and the type of solution infusing. Prolonged use of a tourniquet before venous sampling can increase the blood level of potassium, producing an inaccurate result.
  • If the aPTT value is prolonged (longer than 100 seconds or per agency policy) in a client receiving IV heparin therapy or in any client at risk for thrombocytopenia, initiate bleeding precautions.
  • If the PT value is longer than 25 seconds and the INR is greater than 3.0 in a client receiving standard warfarin therapy, initiate bleeding precautions.
  • Monitor the platelet count closely in clients receiving chemotherapy because of the risk for thrombocytopenia. In addition, any client who will be having an invasive procedure such as liver biopsy or thoracentesis should have coagulation studies and platelets counts done before the procedure.
  • Monitor the WBC count and differential closely in clients receiving chemotherapy because of the risk for neutropenia; neutropenia places the client at risk for infection.
GRADING SCALE FOR PULSES
4+ STRONG AND BOUNDING
3+ FULL PULSE, Increased
2+ Normal, easily palpable
1+ Weak, barely palpable
0 Absent, not palpable
HEMOGLOBIN AND HEMATOCRIT: REFERENCE INTERVALS
Blood component Reference interval
HEMOGLOBIN
Male Adult 14-18g/dL
Female Adult 12-16g/dL
HEMATOCRIT
Male Adult 42%-52%
Female Adult 37%-47%
LIPIDS: REFERENCE INTERVALS
BLOOD COMPONENTREFERENCE INTERVAL
Cholesterol<200 mg/dL
High density lipoproteins
HDLs		>60mg/dL
Low-density lipoproteins
LDLs		<100mg/dL
TriglyceridesMale 40-60mg/dL
Female 35-135mg/dL
HgbA1C%
Glycosylated hemoglobin		eAG mg/dL
Estimated Average Glucose		eAG mmol/L
4653.62
51005.57
61357.52
71709.47
820511.42

PRACTICE NCLEX QUESTIONS:

  1. A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time PT of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription?
    1. Adding a dose of heparin sodium
    2. Holding the next dose of warfarin
    3. Increasing the next dose of warfarin
    4. Administering the next dose of warfarin.
  2. A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management?
    1. I will be sure to ask my client what his pain level is on a scale of 0 to 10.
    2. I know that I should follow up after giving medication to make sure it is effective
    3. I will be sure to cue into any indicators that the client may be exaggerating their pain
    4. I know that pain in the older client might manifest as sleep disturbances or depression
  3. A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to which value?
    1. 3mg/dL or 1.08mmol/L
    2. 15mg/dL or 5.4mmol/L
    3. 29mg/dL or 10.44mmol/L
    4. 35 mg/dL or 12.6mmol/L
  4. The nurse is explaining the appropriate methods for measuring an accurate temperature to assistive personnel. Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?
    1. Taking a rectal temperature for a client who has undergone nasal surgery
    2. Taking an oral temperature for a client with a cough and nasal congestion
    3. Taking an axillary temperature for a client who has just consumed hot coffee
    4. Taking a temperature on the neck behind the ear using an electronic device for a client who is diaphoretic
  5. A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client’s activated partial thromboplastin time (aPTT) is 65seconds. The nurse anticipates that which action is needed?
    1. Discontinuing the heparin infusion
    2. Increasing the rate of the heparin infusion
    3. Decreasing the rate of the heparin infusion
    4. Leaving the rate of the heparin infusion as is
  6. A client with a history of heart failure is due for a morning dose of furosemide. Which serum potassium level, if noted in the client’s laboratory report, should be reported before administering the dose of furosemide?
    1. 3.2mEq/L
    2. 3.8mEq/L
    3. 2mEq/L
    4. 8mEq/L
  7. Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply.
    1. Platelets35,000mm3
    2. Sodium150mEq/L
    3. Potassium5.0mEq/L
    4. Segmented neutrophils 40%
    5. Serum creatinine, 1 mg/dL
    6. White blood cells, 3000mm3
  8. The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client’s medication history and determines it is necessary to contact the primary health care provider (PHCP) if the client is also taking which medications? Select all that apply..
    1. Warfarin
    2. Glimepiride
    3. Amlodipine
    4. Simvastatin
    5. Atorvastatin
  9. A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On the basis of this test result, the nurse plans to teach the clients about the need for which measures?
    1. Avoiding infection
    2. Taking in adequate fluids
    3. Preventing and recognizing hypoglycemia
    4. Preventing and recognizing hyperglycemia
  10. The nurse is caring for the patient with a diagnosis of breast cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client’s white blood cell count was which value?
    1. 2000mm3
    2. 5800mm3
    3. 8400mm3
    4. 11500mm3
  11. A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?
    1. Prepare to administer an antidote
    2. Draw a sample for type and crossmatch and transfuse the client
    3. Draw a sample for an activated partial thromboplastin time(aPTT) level
    4. Draw a sample for prothrombin time (PT) and international normalized ratio (INR)
  12. The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient- controlled analgesia (PCA) pump for pain control. The nurse enters the client’s room and finds the client drowsy and records the following vital signs: temperature 97.2-degree F orally, Pulse52 beats per minute, blood pressure101/58mm Hg, respiratory rate 11 breaths per minutes, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next?
    1. Document the findings
    2. Attempt to arouse the client
    3. Contact the primary health care provider PHCP immediately
    4. Check the medication administration history on the PCA pump
  13. An adult female client has a hemoglobin level of 10.8g/dL. The nurse interprets that this result is most likely caused by which condition noted in the client’s history?
    1. Dehydration
    2. Heart failure
    3. Iron deficiency anemia
    4. Chronic obstructive pulmonary disease
  14. A client with a history of upper gastrointestinal bleeding has a platelet count of 300000 mm3. The nurse should take which action after seeing the laboratory results?
    1. Report the abnormally low count
    2. Report the abnormally high count
    3. Place the client on bleeding precautions
    4. Place the normal report in the client’s medical record

ANSWERS

  1. 2
  2. 3
  3. 2
  4. 2
  5. 4
  6. 1
  7. 1,2,4,6
  8. 1,2,3
  9. 4
  10. 1
  11. 4
  12. 2
  13. 3
  14. 4

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