Chapter 25 PrepU N204
The nurse is taking the apical pulse of a 6-month-old infant. Upon completion, the nurse tells the parent the baby's pulse is 140 beats per minute. The parent is concerned, stating, "That seems kind of high!" The nurse responds: "Yes, this is termed tachycardia. I will let the doctor know right away." "Yes, it seems fast but actually, normal infant heart rates are 150-200 beats per minute so it is a bit slow." "I know it seems fast, but normal infant heart rates are 100-160 beats per minute." "Yes, this is termed tachypnea. I will let the doctor know right away."
"I know it seems fast, but normal infant heart rates are 100-160 beats per minute."
The nurse is completing the admission assessment on a client with a diagnosis of peripheral arterial disease (PAD). Which assessment finding is most significant?' Hairless, shiny legs 2+ edema to lower extremities Thick overgrown toenails An absent popliteal pulse
An absent popliteal pulse Priority assessments address the ABCs. Absence of a pulse (circulation) is a significant finding, which without intervention could lead to loss of limb. The other listed integumentary changes do not pose a short-term threat, even though they are clinically significant.
Which guideline should the nurse follow when assessing a client's blood pressure using a Doppler ultrasound? Take the measurement with the client in a standing position with the appropriate limb exposed. 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, check to see that the manometer is in the horizontal position and that the mercury is within the zero level. Monitor for serial readings and check the cuffed limb frequently for inadequate arterial perfusion and venous drainage.
Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery. 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.
Which statement describes diastolic blood pressure? During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. To assess diastolic pressure, the blood pressure measured during ventricular contraction. The pressure is highest when the ventricles of the heart eject blood into the aorta and pulmonary arteries. The flow of blood is produced by contractions of the heart and by the resistance to blood flow through the vessels.
During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. 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 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? Apply a blanket on the client. Give the client a bath in tepid water. Increase the client's metabolic rate. Set up a fan to blow warm air on the client.
Give the client a bath in tepid water. 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.
The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next? Record the reading in the chart. Inflate the cuff about 30 mm Hg above the auscultatory gap. Use the bell of the stethoscope to listen for the diastolic sound. Inflate the cuff about 10 mm Hg above the auscultatory gap.
Inflate the cuff about 30 mm Hg above the auscultatory gap. To find the auscultatory gap, palpate the brachial or radial pulse while inflating the cuff. Inflate the cuff about 30 mm Hg above the number where palpable pulsation disappears. In addition to detecting an auscultatory gap, palpation gives an initial estimate of systolic blood pressure and eliminates the need to inflate the cuff to extremely high pressures in people with normal or low blood pressure. Using the bell of the stethoscope to listen for the systolic and diastolic sound is expected. Recording of the blood pressure should occur after the blood pressure is obtained.
The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next? Use the bell of the stethoscope to listen for the diastolic sound. Inflate the cuff about 10 mm Hg above the auscultatory gap. Inflate the cuff about 30 mm Hg above the auscultatory gap. Record the reading in the chart.
Inflate the cuff about 30 mm Hg above the auscultatory gap. To find the auscultatory gap, palpate the brachial or radial pulse while inflating the cuff. Inflate the cuff about 30 mm Hg above the number where palpable pulsation disappears. In addition to detecting an auscultatory gap, palpation gives an initial estimate of systolic blood pressure and eliminates the need to inflate the cuff to extremely high pressures in people with normal or low blood pressure. Using the bell of the stethoscope to listen for the systolic and diastolic sound is expected. Recording of the blood pressure should occur after the blood pressure is obtained.
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. Count the heartbeat for 2 minutes. Count each "lub-dub" as two beats. Palpate the space between the fifth and sixth ribs.
Listen for heart sounds. The apex of the heart is found after palpating between the fifth and sixth ribs, then moving the stethoscope to the left midclavicular line. The apical rate is typically assessed for 1 minute. Each "lub-dub" sound counts as one beat.
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? Ability to read gauge from any direction. No stethoscope is required. Inexpensive depending on quality. Need for readjustment is eliminated.
No stethoscope is required. An electronic manometer eliminates the need for a stethoscope. However, an electronic manometer requires a calibration check and readjustment every 6 months, unlike a mercury manometer which does not require readjustment. An electronic manometer is expensive depending on quality when compared to an aneroid manometer. A nurse can read the gauge of an aneroid manometer, not an electronic manometer, from any direction.
Which action is acceptable for the nurse to perform when assessing blood pressure? During the initial nursing assessment of a client, take the blood pressure on both arms and use the arm with the lower reading for subsequent pressures. Use electronic monitoring devices on clients with irregular heartbeats, tremors, or the inability to hold the arm still. Raise the client's arm over the head for 30 seconds to help relieve congestion of blood in the limb and make the sounds louder and more distinct. In newborns, take the blood pressure in one arm and one leg and document the difference to check for heart defects.
Raise the client's arm over the head for 30 seconds to help relieve congestion of blood in the limb and make the sounds louder and more distinct.
An older adult client monitors her BP at home. Lately she has been experiencing dizziness and nausea, followed by a headache when she arises from lying down for a nap. She was worried it was her BP so she began measuring the BP after she arose from her nap and found that her BP would drop shortly after getting up from her nap. She followed up with her health care practitioner and was diagnosed with orthostatic hypotension. What is the mostappropriate nursing diagnosis to be included in the teaching plan for this client at this time? Acute confusion related to hypotension Knowledge deficit related to the inability to take an accurate BP at home Risk for falls related to inadequate physiologic response to postural (positional) changes Sedentary lifestyle related to frequent afternoon naps
Risk for falls related to inadequate physiologic response to postural (positional) changes Orthostatic hypotension (postural hypotension) is a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing when compared with blood pressure from the sitting or supine position. It results from an inadequate physiologic response to postural (positional) changes in blood pressure. Orthostatic hypotension may be acute or chronic, as well as symptomatic or asymptomatic. It is associated with dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache. Older adults may experience orthostatic hypotension without associated symptoms, leading to falls.
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. Stimulation of the parasympathetic nervous system results in an increase in the pulse rate. Stimulation of the sympathetic nervous system results in a decrease in the pulse rate. The sympathetic nervous system is the dominant activation during resting states.
Sympathetic nervous system activation occurs in response to a variety of stimuli, including changes in intravascular volume. The sympathetic nervous system activation occurs in response to various stimuli, including pain, anxiety, exercise, fever, and changes in intravascular volume. Stimulation of the parasympathetic nervous system results in a decrease in the pulse rate.
When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. Which statement explains this order? The client's respiratory rate is less than 18 breaths per minute. The client's pulse rate is below 60 beats per minute. The client is unable to stay upright when blood pressure is checked. The client's systolic blood pressure is less than 100 mm Hg.
The client's pulse rate is below 60 beats per minute.
A nurse is explaining to a nursing student why blood pressure is a frequently used assessment parameter in a wide variety of care settings. What can be inferred from an assessment of a client's blood pressure? The amount of oxygen available to tissues throughout the body The volume of the venous system relative to the volume of the arterial system The size of the client's heart muscle The resistance that the client's heart must overcome when pumping blood
The resistance that the client's heart must overcome when pumping blood Blood pressure is representative of the amount of resistance that the heart must overcome in order to pump blood; increased BP equates with increased resistance, or afterload. Blood pressure is not necessarily indicative of oxygen supply, the relative volumes of the venous and arterial systems or the size of the heart.
Which client's blood pressure best describes the condition called hypotension? The systolic reading is above 110 and diastolic reading is above 80. The systolic reading is below 100 and diastolic reading is below 60. The systolic reading is above 102 and diastolic reading is above 60. The systolic reading is below 120 and the diastolic reading is below 80.
The systolic reading is below 100 and diastolic reading is below 60. Hypotension is defined by a systolic pressure below 100 mm Hg and diastolic pressure less than 60 mm Hg. The top number refers to the amount of pressure in the arteries during the contraction of heart muscle. This is called systolic pressure. The bottom number refers to the blood pressure when the heart muscle is between beats. This is called diastolic pressure. Ideal blood pressure is less than 140/90.
Which client would the nurse consider at risk for low blood pressure? a client with high blood viscosity a client with decreased elasticity of walls of arterioles a client with low blood volume a client with a strong pumping action of blood into the arteries
a client with low blood volume Low blood volume, such as occurs with hemorrhage, causes hypotension. High blood viscosity and decreased elasticity of the arteriole walls would potentially cause increased blood pressure. A strong pumping action of the heart may not affect the blood pressure, or it may cause the blood pressure to increase.
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 provide the client with a larger blood pressure cuff recommend lower sodium in the client's diet report readings to primary care provider
ask the client to demonstrate self-blood pressure assessment While all of these interventions would be appropriate if the client is hypertensive, it is important to assess whether the client is measuring their BP correctly before assuming that hypertension is present. It would be very rare to have a BP of the exact same measurement with every assessment. Therefore, providing the client with a larger blood pressure cuff, recommending lower sodium in the client's diet, and reporting the readings to the primary care provider are not priority actions at this time.
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 call the health care provider let the client sleep assess blood pressure
assess temperature The client is showing signs of a fever, which can include pinkish, flushed skin that is warm to touch, restlessness or excessive sleepiness, irritability, poor appetite, glassy eyes and sensitivity to light, increased perspiration, headache, above normal pulse and respiratory rate, disorientation and confusion, convulsions in infants and children, and fever blisters. The nurse should first assess the temperature and then take further steps to care for the client, which will include notifying the health care provider. Letting the client continue to sleep after appropriate treatment will be beneficial to the client. It would also be appropriate to assess all the vital signs; however, the temperature would be the priority in this situation.
Which factor is not known to cause false blood pressure readings? having the client's legs crossed at the knee smoking eating being in a warm environment
being in a warm environment In order for the nurse to get an accurate reading, the client should be in a warm, quiet environment. All the other answers, as well as exercise, would cause a false blood pressure reading.
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will: decrease the blood glucose. decrease the blood volume. decrease the apical pulse. decrease the respiratory rate.
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.
A client has an axillary temperature of 102.6 F (39.2°C). Which clinical manifestations would the nurse anticipate?Select all that apply. respiratory rate 30/min headache hunger cold, clammy skin red or flushed skin
respiratory rate 30/min headache red or flushed skin The following are clinical signs associated with a fever: pinkish or red skin (skin that is warm to the touch), headache, and above-normal pulse or respiratory rates. Clients who are febrile may or may not be hungry. Clients who are febrile have warm, not cold and clammy, skin.
The client's blood pressure has gradually decreased in the last 2 days. Which condition would cause this change? the client who has unresolved pain issues the client who has been given 3 units of whole blood the client who has had persistent diarrhea the client who is to be discharged home on hospice
the client who has had persistent diarrhea Vital signs—body temperature (T), pulse (P), respirations (R), and blood pressure (BP)—indicate the function of some of the body's homeostatic mechanisms. Measurement and interpretation of the vital signs are important components of assessment that can yield information about underlying health status.
