The nursing student is obtaining the patient's vital signs (VS). The patient has gone to the clinic seeking help because she is having chest pain. Which of the following vital signs are most important to obtain?

Temperature, pulse, respirations, BP

Temperature, pulse, respirations, BP, pain

BP. respirations, temperature, pulse

Temperature, pulse, respirations, blood pressure, O2 sat, pain

Answer and Explanation

The Correct Answer is D

A. Temperature, pulse, respirations, BP. While these are standard vital signs, they do not include oxygen saturation or pain level, both of which are critical in a patient with chest pain.
B. Temperature, pulse, respirations, BP, pain. Pain is an essential assessment, especially for chest pain, but oxygen saturation should also be measured to assess for hypoxia, which can contribute to cardiac symptoms.
C. BP, respirations, temperature, pulse. This option omits both oxygen saturation and pain level, which are essential in evaluating cardiac and respiratory function in a patient presenting with chest pain.
D. Temperature, pulse, respirations, blood pressure, O2 sat, pain. This option includes all critical assessments for a patient with chest pain. Oxygen saturation helps assess respiratory and circulatory efficiency, and pain assessment is vital in determining the severity and possible cause of the chest pain.

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Correct Answer is C

Explanation

Client A has normal vital signs except for a mild fever, no urgent intervention needed.

Client B shows mild tachycardia and increased respiratory rate, but oxygen saturation and blood pressure remain stable, requires monitoring but not immediate action.

Client C has fever, tachycardia, and tachypnea, suggesting infection or dehydration. While assessment is needed, the patient is not in immediate distress compared to Client D.

Client D requires immediate nursing intervention due to the following critical findings: Bradycardia which may indicate poor perfusion, conduction abnormalities, or medication side effects, bradypnea can signal respiratory depression or impending failure, hypotension suggests shock or decreased perfusion, which may lead to organ failure and hypoxia, oxygen saturation below 90% is a critical finding and requires immediate intervention.

Correct Answer is ["39.2"]

Explanation

Calculation:

The formula to convert Fahrenheit (°F) to Celsius (°C) is:

°C = (°F - 32) × 5/9

= (102.5 - 32) × 5/9

= (70.5) × 5/9

= 39.1666...

Rounding to the nearest tenth: 39.2 °C.

Therefore, 102.5 °F is equal to 39.2 °C.

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The nursing student is obtaining the patient's vital signs (VS). The patient has gone to the clinic seeking help because she is having chest pain. Which of the following vital signs are most important to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) recorded the vital signs of four clients. Which client needs immediate nursing intervention? (SEE HANDOUT- PRIORITY VITAL SIGNS) Exhibits

Correct Answer is C

Explanation

Covert 102.5 Fahrenheit to C (round to tenths)

Correct Answer is ["39.2"]

Explanation

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