Ch 19

A nurse attempts to count the respiratory rate of a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this client?

Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.

The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as:

orthopnea

Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/min. What does this indicate?

Not all of the heartbeats are reaching the periphery.

The nurse is assessing an adult who has a pulse rate of 150 beats/min. Which action should the nurse take next?

Notify the health care provider of tachycardia

A nurse is taking the vital signs of a 9-year old child who is anxious about the procedures. Which nursing action would be appropriate when assessing this child?

Perform the blood pressure measurement last.

The nurse discovers during assessment that the client has an altered temperature.

Radiation: infrared heat waves Conduction: the air itself Evaporation: through sweating Convection: exposure to a fan

After taking vital signs of an older adult, the nurse writes down findings as T = 98.9/37.2 oral, P = 104, R = 18, BP = 120/82. Based on the collected data, which step would the nurse take next?

Take pulse again to assess for tachycardia

Which factor is not known to cause false blood pressure readings?

being in a warm environment

Which pulse site is generally used in emergency situations?

carotid

A nurse is caring for a newborn. The nurse knows that the body temperature of infants and older adults is prone to fluctuations. Which of these is the most probable cause for fluctuations in the infant's body temperature?

great surface area relative to mass and very high metabolic rate

The nurse is assessing a female client for orthostatic hypotension. As the nurse assists the client to a standing position, the client states, "I'm feeling really dizzy." What should the nurse do next?

immediately assist the client back to bed

A student is reading the medical record of an assigned client and notes that the client has been afebrile for the past 12 hours. What does the term "afebrile" indicate?

normal body temperature

The nurse is assessing a client's pedal pulse. The nurse would palpate at which area?

on top of the foot

Which site for taking body temperature with a glass thermometer is contraindicated in clients who are unconscious?

oral

What is an average normal temperature in Celsius for a healthy adult?

oral: 37°C

A nurse is obtaining an oral temperature on a client, using an electronic thermometer. The client notes having an electronic thermometer at home and asks how to care for it. Which response is appropriate?

"When not in use, keep the probe in the storage place within the unit."

While recording the pulse of an infant at 160 beats/min, the parent asks if it is normal for the infant's pulse rate to be so high. Which statement by the nurse best answers the parent's question?

"A heart rate of 160 beats/min is normal for a healthy infant."

A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?

"Dizziness when you change position can occur when fluid volume in the body is decreased."

A nurse is educating a postoperative adult client about taking daily temperatures. What statement by the client best indicates understanding of education?

"If my temperature is above 99.6°F( 38.3°C) I should call the health care provider."

A nurse is assessing a newborn at the health care facility when the mother of the child asks the nurse why the body temperature of her infant is unstable. Which response by the nurse would be most appropriate?

"It is because of the immature ability to regulate temperature in general."

After preparation, the nurse inserts a rectal thermometer into an adult client's rectum. To ensure an accurate reading, the nurse inserts the thermometer to which depth?

1.5 in (3.75 cm)

A nurse is assessing the apical heart rate of a healthy person. In order to hear the heartbeats loud and clear, where should the nurse place the stethoscope?

slightly below the left nipple in line with middle of clavicle

A nurse is assessing the respiratory rate of a sleeping 28-day-old infant. What would the nurse document as a normal finding?

30 to 60 breaths/min

A nurse is assessing the cardiac output of a client at the health care facility. What would the nurse identify as the average cardiac output in a resting person?

5.5 L/min

A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation?

Auscultate the lung sounds and count respirations.

What anatomic site regulates the pulse rate and force?

Cardiac sinoatrial (SA) node

Which statement describes diastolic blood pressure?

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.

A nurse is caring for a client with orthostatic hypotension. The client is currently not taking any antihypertensive medications. Which action(s) will the nurse take to reduce the client's risk of falls? Select all that apply.

Encourage the client to stand up from a sitting position slowly. Ensure that the client is taking an adequate volume of fluids. Assist the client in applying compression stockings to lower extremities. Ask the client to wait 1 hour after meals to engage in physical activity.

While obtaining a client's blood pressure, the nurse hears faint, clear tapping sounds that gradually increase in intensity. The nurse identifies this as which phase of Korotkoff sounds?

I

The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next?

Inflate the cuff about 30 mm Hg above the auscultatory gap.

A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff?

Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared.

The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?

Listen for heart sounds.

Which statement is true regarding the autonomic nervous system and its effect on the rate of a person's pulse?

Sympathetic nervous system activation occurs in response to a variety of stimuli, including changes in intravascular volume.

A nurse is preparing to assess a client's temperature and finds the client to be perspiring profusely. Which method would be least appropriate for the nurse to use to assess this client's temperature?

Temporal artery temperature

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?

The blood pressure increases.

The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this?

The client is covered with a couple of thick blankets.

When assessing a client's vital signs, a nursing student has explained to the client each of their next actions prior to assessing the client's temperature, pulse, and blood pressure. However, the nursing student did not announce their intention to assess the client's respiratory rate prior to measuring it. What is the rationale for the nursing student's decision to withhold this information?

The client may alter the rate of respirations if the client is aware that his breaths are being counted.

The nurse teaches a client diagnosed with hypertension to self-measure blood pressure with an automated device. Which client behavior indicates the need for additional teaching?

The client sits in the chair with feet flat on the floor and arm below the level of the heart.

When administering beta blocker medications, the health care provider adds an order to hold medication when the client is bradycardic. Which statement explains this order?

The client's pulse rate is below 60 beats per minute.

A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse?

The radial pulse is difficult to obtain.

A nurse is assessing the blood pressure on a client with a BMI of 32. What error might occur if the cuff used is too narrow?

The reading will be erroneously high.

Which client's blood pressure best describes the condition called hypotension?

The systolic reading is below 100 and diastolic reading is below 60.

A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which action should the nurse perform to obtain the accurate temperature of the client?

Wait for 30 minutes before measuring the oral temperature

A nurse is assessing clients in the emergency department for body temperature. Which nursing actions reflect proper technique when assessing body temperature by various methods? Select all that apply.

When assessing an oral temperature with an electronic thermometer, place the probe beneath the client's tongue in the posterior sublingual pocket. When assessing rectal temperature with an electronic thermometer, lubricate about 1 in (2.5 cm) of the probe with a water-soluble lubricant. When assessing temperature with an electronic thermometer, hold the thermometer in place in the assessment site until a beep is heard.

The nurse walks into the client's room to pick up the dinner tray and notes the client has not eaten. Which action should the nurse prioritize after noting the client appears sleepy, has perspiration on the forehead, and the face appears flushed?

assess temperature

It is very important to assess for the quality of someone's respirations as well as describe what is heard with auscultation. Which describes stridor?

a harsh, high-pitched inspiratory sound that may be compared to crowing

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 bpm. The nurse notifies the health care provider because the client is exhibiting signs of:

an arrythmia.

The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mmHg. What is the priority nursing intervention?

ask the client to demonstrate self-blood pressure assessment

The nurse is assessing a client's blood pressure and is having difficulty hearing Korotkoff sounds. What is the most appropriate nursing action?

ask the client to make a fist after cuff inflation

Which is not a characteristic used to describe the pulse?

depth

The body loses heat continually through several different processes. Which process is an example of how heat is lost through evaporation?

diaphoresis

The nurse is assessing the pulse amplitude for a client. Documentation by the nurse states, "Pulses are +1 in the lower left extremity." What amplitude is the nurse assessing?

diminished, weaker than expected

A nurse is caring for a middle-age client who looks worried. The client reports difficulty in breathing, even when walking to the bathroom. Which breathing disorder is appropriate to describe the client's condition?

dyspnea

The nurse is educating a client about ways to increase their cardiac output. Which topic does the nurse include in the teaching?

exercise

Before assessing a client's respiratory rate, the nurse should remind the client to breathe normally.

false

A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client reports dizziness and faintness. The client's blood pressure is 90/50 mmHg. What is the name for this condition?

orthostatic hypotension

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem?

peripheral vascular disease

The nurse understands that accurate blood pressure taking is dependent on several factors. Which example will most likely render an accurate blood pressure reading?

placing the client's arm at heart level

The nurse is caring for a 77-year-old client who is recovering from surgery. After notifying the health care provider of the incident recorded in the client's chart (above), what will the nurse anticipate teaching the client?

postural hypotension

A nurse is caring for a client who has a lack of appetite. What is most likely to influence a client's core body temperature?

proteins

A nurse palpates the pulse of a client and documents the following: 6/6/23 pulse 85 and regular, +3, and equal in radial, popliteal, and dorsalis pedis. What does the number +3 represent?

pulse amplitude

Which term indicates a potentially serious client condition?

pyrexia

A nurse is taking a client's temperature and wants the most accurate measurement, based on core body temperature. What site should be used?

rectal

Various sounds are heard when the nurse assesses a blood pressure. What does the first sound heard through the stethoscope represent?

systolic pressure

An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding?

tachycardia

The nurse is preparing discharge teaching for a client admitted for sepsis. The client asks what is included when the nurse checks vital signs. Which assessment(s) is included? Select all that apply.

temperature pulse respiratory rate blood pressure

The home care nurse is assessing a 37-year-old client's vital signs at rest. Which finding requires nursing intervention?

temporal temperature 100.8º F (38.2º C)

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure?

the ability of the arteries to stretch

The nurse has assessed a pulse deficit when taking the pulse of a client. What does this assessment indicate for the client? Select all that apply.

the difference between apical and peripheral pulse rate The apical pulse is higher than the radial pulse. The health care provider should be notified of any increase in pulse deficit.

The nurse is assessing a new client's blood pressure, using a manual sphygmomanometer. Which sound constitutes the client's systolic blood pressure?

the first appearance of faint but distinctive tapping sounds

When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a little bit more pressure. The pulse is beating at 80 bpm. Which of these should the nurse document as the character of the client's pulse?

thready pulse

The nurse is teaching a client about variables that can cause temporary alterations in blood pressure. Which variation(s) will the nurse include when teaching the client? Select all that apply.

time of day physical activity acute pain