Chapter 25 PrepU

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 Explanation: Dyspneic people can often breathe more easily in an upright position, a condition known as orthopnea, because sitting or standing allows gravity to lower organs from the abdominal cavity away from the diaphragm. Bradypnea is a decrease in respiratory rate. Tachypnea is an increased respiratory rate. Apnea refers to periods during which there is no breathing.

When taking the client's temperature, the student nurse will require further education when they state:

"The axillary route is the most accurate of all routes."

When assessing an infant's axillary temperature, it will be:

1°F (0.5°C) lower than an oral temperature.

The nurse has completed an assessment and notes that the client's blood pressure is 132/92 mmHg. What is this client's pulse pressure?

40 mmHg

The nurse is attempting to assess a client's radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurse take next?

Assess the apical pulse.

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. Explanation: Sometimes it is easier to count respirations by auscultating the lung sounds for 30 seconds and multiplying the result by 2. Palpating the posterior thorax excursion detects vibrations in the lungs. Pulse oximeter and arterial blood gas results assess respiratory effectiveness, not respiratory rate.

Which client should not have a temperature assessed rectally?

Client with diarrhea Explanation: The rectal route is contraindicated in clients with diarrhea, those who have undergone rectal surgery, those with rectal diseases, and those with cancer who are neutropenic.

Which statement describes diastolic blood pressure?

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. Explanation: Diastolic blood pressure occurs when ventricular relaxation happens, and blood pressure is due to elastic recoil of the vessels. Systolic blood pressure is measured during ventricular contraction. Systolic blood pressure is highest when the ventricles of the heart eject blood into the aorta and pulmonary arteries. Blood pressure in general is measured by taking the flow of blood produced by contractions of the heart and multiplying it by the resistance to blood flow through the vessels (P = F × R).

The nurse has just measured an adult client's oral temperature and obtained a result of 102.4ºF (39.1ºC). The client states, "I just finished my coffee right before you came in. Can I have another cup?" Which response by the nurse is most appropriate?

I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return."

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.

A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?

Over the client's thigh

The nurse is obtaining and recording vital signs of an adult client in the emergency department. Which finding should be reported to the health care provider?

Pulse 51 beats/min

The nurse prepares to take a temperature of a client admitted with a myocardial infarction. The client is eating breakfast. Which action should the nurse choose?

Take the temperature using the axillary route.

The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that would explain the tachycardia? Select all that apply.

The client has reports of pain of 8 on a scale of 0 to 10 The client just finished ambulating with physical therapy The client has a temperature of 101.8°F (38.8°C) Explanation: There are several factors that may cause an increase in heart rate due to an increase in metabolic rate. This can occur with pain, exercise, fever, medications, and strong emotions. A blood pressure of 120/70 mm Hg does not indicate an association with tachycardia or that a client has been drinking water. Caffeinated beverages may cause an increase in heart rate but water would not.

The nurse is assessing the pulse of a young adult who is training for a triathlon competition. The pulse rate is 48 beats/min. What education should the nurse provide to the client?

The heart rate is within normal limits due to the exercise regimen the client is following.

The nurse is preparing to administer a medication that the client takes to treat a cardiac dysrhythmia. Which site should the nurse use to assess pulse in this client?

apical

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?

auscultate the client's apical pulse Explanation: When peripheral pulses are difficult to palpate, it is appropriate to auscultate the apex. This is preferable to auscultating a peripheral site, such as the brachial artery, and more accurate than attempting to palpate the apical pulse.

Which are considered vital signs? Select all that apply.

blood pressure respiratory rate temperature pulse

Which pulse site is generally used in emergency situations?

carotid Explanation: The carotid artery is lightly palpated to obtain a pulse in emergency assessments, such as in a client in shock or cardiac arrest. The brachial pulse site is used for infants who have had a cardiac arrest. The apical pulse is the fifth intercostal space for adults and the fourth intercostal space for a young child or infant. Using a stethoscope at the apex of the heart, a nurse can assess the lub dub of the heart sounds. Radial pulse is too distant to assess a pulse in an emergency assessment. Temporal pulse is difficult to assess.

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:

decrease the apical pulse. Some cardiac medications, such as digoxin, whose action is specific to the work of the heart, slow the heart rate while also strengthening the force of contraction to increase cardiac output.

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?

deep in the posterior sublingual pocket

Which condition will lead to an increase in cardiac output?

exercise

The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:

increased temperature.

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which health problem should the nurse consider when client falls occur?

orthostatic hypotension

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

temperature 100.0º F (37.78º C)

The nurse has requested the unlicensed assistive personnel (UAP) check the temperature of a 19-month-old client who has been admitted for pneumonia. Which reading should the nurse question if noted in the record?

102.4°F/39.1°C (T) Explanation: There are several ways to assess the temperature of a client: oral (O), rectal (R), axillary (AX), tympanic (T), and temporal artery (TA). The nurse should question the use of the tympanic thermometer. It is contraindicated for children younger than 2 years due to the smaller size of the ear canal. It is too small for the probe and an accurate reading cannot be obtained. In normal healthy adults the shell temperature generally ranges from 96.6°F to 99.3°F (35.8°C to 37.4°C); core body temperatures ranges from 97.0°F to 99.5°F (36.0°C to 37.5°C). Rectal and arterial temperatures are generally 1°F (0.5°C) higher than oral and 2°F (1°C) higher than axillary. The baseline temperatures for each method are: oral 98.5°F (37.0°C), rectal 99.5°F (37.5°C), axillary 97.5°F (36.4°C), tympanic 99.5°F (37.4°C), and temporal artery 99.4°F (37.4°C). Each of these temperatures would need to be assessed further for the possibility of a fever; however, the one assessed via the tympanic membrane would need to be assessed for accuracy and ensure the UAP does not need further training.

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?

1700 Explanation: Body temperature fluctuates throughout the day. Temperature is usually lowest around 0300 and highest from 1700 to1900.

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. Explanation: If the respirations are too shallow to count it is easier to count respirations by auscultating the lung sounds. The nurse should auscultate lung sounds and count respirations for 30 seconds, then multiply by 2 to calculate the respiratory rate per minute. If the respiratory rate is irregular, the nurse should count for a full minute. The nurse notifies the health care provider of the respiratory rate and the shallowness of the respirations following assessment. Pain typically causes vital signs to elevate. The nurse cannot administer oxygen without a health care provider's prescriptions.

Which guideline should the nurse follow when assessing a client's blood pressure using a Doppler ultrasound?

Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery. Explanation: When performing blood pressure assessment via Doppler ultrasound, the nurse will have the client assume a comfortable lying or sitting position with the appropriate limb exposed and center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery. If using a mercury manometer, the nurse will check to see that the manometer is in the vertical position and that the mercury is within the zero level with the gauge at eye level. The nurse then hold the Doppler in the nondominant hand. Using the dominant hand, the nurse places the Doppler tip in the gel, adjusts the volume as needed, and moves the Doppler tip around until hearing the pulse.

The nurse is assessing the client's blood pressure (BP) and heart rate (HR) for orthostatic hypotension. In which step should this nurse intervene because of potential danger?

Client stands at bedside, becomes pale, diaphoretic. Explanation: Orthostatic hypotension is assessed in three positions, with the client resting in each position 3 minutes before measuring the blood pressure and heart rate. The client is positive for orthostatic hypotension when there is a decrease of 20 mm Hg BP or greater and the heart rate increases as the body's means to help compensate for the postural change. In this case, it is part of the assessment to leave the client in the supine position for 3 minutes; the BP and HR are within a normal range and the client is asymptomatic so the nurse would not intervene. The nurse need not intervene while the client is dangling at the bedside and is asymptomatic. After 3 minutes of sitting, there was a positive orthostatic change, but the client is not exhibiting symptoms, so the nurse would finish the assessment by standing the client at the bedside to determine the extent of the postural changes. The nurse would intervene because the client is exhibiting symptoms of low cardiac output: pallor and diaphoresis. The nurse would immediately place the client in a supine position to increase the BP and report the findings to the primary care provider so adjustments in treatment may be made.

The nurse notes that the temperature of an ill client is 101°F (38.3°C). Which intervention would the nurse take to regulate the client's body temperature?

Give the client a bath in tepid water. Explanation: The body loses heat to the water through conduction during tepid baths. Applying a blanket would reduce radiant heat loss and would raise the client's temperature. Increasing the body's metabolic rate will result in an increase in temperature. Blowing warm air over the client will increase the temperature.

A nurse is assessing an adult client's blood pressure. How should the nurse estimate the client's systolic blood pressure (SBP)?

Inflate the blood pressure cuff while palpating the client's brachial or radial artery.

A nurse has been unable to palpate a client's dorsalis pedis pulse. The nurse attempted to identify the pulse using Doppler ultrasound and is still unable to identify a pulse. What is the nurse's most appropriate action?

Inform the client's primary care provider of this assessment finding. Explanation: If you cannot find the pulse using a Doppler ultrasound, notify the primary care provider. Reassessment is necessary, but this is an important assessment finding that should be promptly reported.

A nurse needs to measure the blood pressure of a client with an electronic manometer. Which of the following advantages does an electronic manometer provide over an aneroid manometer or mercury manometer?

No stethoscope is required.

Which is a characteristic used to describe the pulse?

Rate or frequency refers to the number of pulsations per minute. Rhythm refers to the regularity with which pulsation occurs. Quality refers to the strength of the palpated pulsation.

The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation?

Remove the thermometer and assess the blood pressure and heart rate. Vagal nerve stimulation may occur when obtaining a rectal temperature. Vagal nerve stimulation can cause the pulse and blood pressure to drop significantly, causing the client to feel lightheaded; therefore, the thermometer should be removed immediately and the pulse and blood pressure assessed. The physician can be called after assessing the client. The temperature is not the priority at this time. Assistance for CPR would be determined if the client's condition worsens.

A client who has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong?

She should place her three fingers just below the wrist on the outside of the arm with the palm up.

The nurse assesses a client admitted with multiple trauma including basilar skull fracture and rhinorrhea (drainage from nose), bilateral otorrhea (drainage from ear), and multiple fractures requiring a full body cast. The client is on a 40% Venturi oxygen mask. What is the best way to evaluate the client's temperature?

Temporal artery

The experienced nurse teaching a student to measure an apical pulse includes which critical information? Select all that apply.

The diaphragm of the stethoscope is placed at the fifth intercostal space at the midclavicular line. To determine the apical pulse, count the heartbeats for 1 full minute. Explanation: Auscultation of the apical pulse requires a stethoscope. The nurse will assess the apical pulse by placing the diaphragm of the stethoscope over the apex of the heart, which is located at the fifth intercostal space at the midclavicular line. To determine the apical pulse, the nurse will count the heartbeats for 1 full minute. A Doppler ultrasound device is not required to measure an apical pulse; a stethoscope is most often used to measure an apical pulse. In adults, the normal rate is 60 to 100 pulsations per minute; not 80 to 120 pulsations per minute.

The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate?

The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse. Explanation: If a peripheral pulse is difficult to assess accurately because it is irregular, weak, or very rapid, the apical rate should be assessed using a stethoscope. An apical pulse is also assessed when giving medications that alter heart rate and rhythm. Apical pulse measurement is also the preferred method of pulse assessment for infants and children younger than 2 years of age. Families can be taught to use a stethoscope to check a pulse

A 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client?

To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns. Explanation: HBPM readings are the ideal method for monitoring response to treatment for high BP. This client's average BP after not taking her medication is 138/87 and is not 10 more than what her HBPM reading has been. Clients should be taught when performing HBPM that they should call the health care provider if the averages of HBPM readings increase/decrease by 10, or if she has any concerns. The client should not be told to take double the dose of medication or to take the doses she missed; this is unsafe advice without consulting a health care provider.

The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next?

Use the Doppler ultrasound device. Explanation: Peripheral pulses that cannot be detected by palpation may be assessed with an ultrasonic Doppler device. A conductive gel is first applied to the skin to reduce resistance to sound transmission. The transmitter of the device is then placed over the artery to be assessed. High-frequency waves directed at the artery from the transmitter are disturbed by the pulsating flow of blood and are reflected back to the ultrasound device. The sound disturbances (Doppler shifts) are amplified and heard through earpieces or a speaker attached to the device. The bell effect is created by light pressure on the stethoscope.

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 Explanation: The nurse should wait for 15 to 30 minutes and then measure the oral temperature of the client since hot and cold liquids cause slight variations in temperature. Giving the client a glassful of cold water to drink will not help because the thermometer will still show temperature variation, not the accurate body temperature. The rectal route is contraindicated in clients with diarrhea, because it can cause mucosal tearing or perforation. Hence, the nurse should not lubricate the client's rectum or measure the rectal temperature. The axillary route is the least accurate and least reliable site.

An ultrasonic Doppler is used for:

auscultating a pulse that is difficult to palpate.

The community nurse working at a community health fair is assessing a client's vital signs at rest. Which finding requires nursing intervention?

blood pressure 180/90 mmHg

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?

listen with the stethoscope at the fifth intercostal space left mid-clavicular line Explanation: To assess the apical pulse, the nurse places the stethoscope over the left ventricle. The stethoscope is placed at the level of the fifth intercostal space, left mid-clavicular line.

A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing?

prodromal Explanation: Often, the child will experience symptoms prior to the fever surfacing, which is called the prodromal phase and includes the nonspecific symptoms that occur before the body temperature rises. The onset or invasion phase indicates an elevation in body temperature, as well as symptoms related to the fever such as shivering. The stationary phase is when the fever is sustained. The final phase is the resolution or defervescence phase when the temperature abates and returns to the child's baseline temperature.

A nurse needs to assess the temperature of a client with high fever. Which site will most closely reflect core body temperature of the client?

rectum Explanation: The rectal temperature, a core temperature, is considered to be one of the most accurate routes. The most practical and convenient sites for temperature measurement are the ear, mouth, and axilla. These areas are anatomically close to superficial arteries containing warm blood, enclosed areas where heat loss is minimal, or both.

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 Explanation: Measuring the blood pressure helps to assess the efficiency of the client's circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood. Measuring the blood pressure does not help in assessing the thickness of blood, oxygen level in the blood, or the volume of air entering the lungs.

A pulse deficit is the difference between:

the apical and the radial pulse rates.