One of the main methods to obtain a good health assessment is to obtain vital signs. Of which of the listed descriptions below is not a use of obtaining vital signs?
Pain rating is often included as a vital sign that is subjective in nature.
In the less stable client, it is advised to check the vital signs once a day or as needed.
Vital signs help assess the effectiveness of the client’s circulatory, neurological, endocrine, and respiratory systems.
Vital signs include temperature, pulse, respirations, blood pressure, and pulse oximeter.
The Correct Answer is B
Choice A reason: Pain rating is considered a subjective vital sign, assessed via patient self-reporting, often on a 0-10 scale. It reflects neurological and emotional status, guiding pain management. Including it as a vital sign is a valid clinical practice, making this choice a correct use.
Choice B reason: In less stable clients, vital signs should be checked more frequently than once daily, often every few hours, to monitor deteriorating conditions like sepsis or shock. This statement inaccurately suggests infrequent monitoring, which is not a standard use of vital signs, making it the correct answer.
Choice C reason: Vital signs assess circulatory (blood pressure, pulse), respiratory (respirations, pulse oximetry), neurological (via pulse and responsiveness), and endocrine (temperature) systems. They provide critical data on physiological function, making this a valid use of vital signs in comprehensive health assessments.
Choice D reason: Vital signs include temperature, pulse, respirations, blood pressure, and pulse oximetry, which measure thermoregulation, cardiovascular, and respiratory status. This is a standard definition in clinical practice, accurately reflecting the components of vital sign assessment, making it a correct use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Clear bilateral lung sounds are a normal respiratory finding, indicating unobstructed airways and effective gas exchange. Abnormal sounds like wheezing or crackles would suggest pathology, but this choice reflects expected lung function, not an unexpected assessment outcome.
Choice B reason: Absence of cough is a normal finding, suggesting no airway irritation or obstruction. Coughing may indicate infection or fluid accumulation, but its absence aligns with healthy respiratory status, making this a typical and expected assessment result.
Choice C reason: Using an incentive spirometer post-surgery is an expected finding, as it promotes lung expansion and prevents atelectasis. It indicates patient compliance with respiratory therapy, a standard post-operative intervention, not an abnormal or unexpected respiratory assessment outcome.
Choice D reason: An oxygen saturation of 90% on 2 liters of oxygen via nasal cannula is unexpected, as normal saturation should be 95-100%. This suggests hypoxemia, potentially from lung pathology or inadequate oxygen delivery, warranting further investigation, making it the correct choice.
Correct Answer is A
Explanation
Choice A reason: Medication reconciliation involves compiling a complete, accurate list of current medications, including prescriptions, supplements, herbals, and OTC drugs, to ensure safe transitions across care settings. This prevents errors like omissions or duplications, critical for patient safety, guiding accurate prescribing and reducing adverse drug events in clinical practice.
Choice B reason: Listing medications prescribed at discharge is part of discharge planning, not full medication reconciliation, which includes all current medications across settings. This narrow definition risks missing ongoing therapies, leading to errors like discontinued drugs, compromising safety and continuity of care during transitions in healthcare settings.
Choice C reason: Listing medication allergies is part of allergy documentation, not medication reconciliation, which focuses on current medications. Confusing these risks overlooking active prescriptions, leading to potential drug errors or interactions. Reconciliation ensures a comprehensive medication profile, critical for safe prescribing and patient care across healthcare transitions.
Choice D reason: Obtaining medication interactions is a pharmacist’s analysis, not medication reconciliation, which compiles a current medication list. Assuming this misaligns with reconciliation’s purpose, risking incomplete profiles and errors like missed doses. Reconciliation ensures accurate medication records, essential for preventing adverse events and supporting safe care transitions.
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