(PrepU) Chapter 25: Vital Signs

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. If a radial pulse is difficult to assess accurately because it is irregular, feeble, or extremely rapid, the nurse would need to assess the apical pulse rate. By assessing the apical rate the nurse can hear the rate instead of trying to feel the rate. Assessing the carotid pulse would also be done through touch, so the outcome would be the same and not accurate. If the nurse is concerned about the client, it does not hurt to have another nurse check the pulse, but the nurse should assess the apical pulse first. The findings should be documented, but only after all assessments have been completed.

The nurse needs to obtain an admission weight for a client diagnosed with end-stage lung cancer. To obtain the client's weight, what should the nurse do first?

Assess the client's ability to stand or sit. The nurse must first assess the client's ability to sit, stand, or lie still to identify the appropriate type of scale to use. Evaluating pain or presence of lines would be done after identifying the type of scale to use. If a portable bed scale is indicated, the nurse would place a cover over the sling of the bed scale.

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. 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.

When assessing a client's radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next?

Auscultate the apical pulse for 60 seconds Palpating the radial pulse is the most convenient method for assessing the pulse but not always the most accurate. Because the rhythm is irregular, a more accurate assessment method is required for a full minute. Auscultating the apical pulse for a full minute provides more accuracy. The other interventions would be implemented after a more accurate assessment is obtained.

The nurse has palpated the client's radial artery and identified a heart rate of 88 beats per minute with an irregular rate. What is the nurse's most appropriate action?

Auscultate the client's apical heart rate. Palpation of an irregular radial pulse should be followed by assessment of the apical pulse in order to confirm the finding. Informing the health care provider is generally necessary only when this is a new finding.

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. 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.

A client presents to the emergency department with profuse bleeding from a crushing injury while at work. Which set of vital signs does the nurse anticipate finding in such this client?

Blood pressure 80/50 mm Hg, heart rate 120 beats/min, respiratory rate 24 breaths/min Profuse bleeding would cause a drop in blood pressure as the client enters hypovolemic shock, which causes the pulse to increase and become thready and respirations to become quick and shallow. Therefore, of the given options, a blood pressure of 80/50 mm Hg, heart rate of 120 beats/min and respiratory rate of 24 breaths/min should be anticipated.

While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute. How will the nurse interpret this finding?

Bradypnea is a response to IICP. The normal respiratory rate for adults is 12 to 20 breaths/min. Bradypnea, a decrease in respiratory rate, characteristically occurs in some pathologic conditions. An increase in intracranial pressure depresses the respiratory center, resulting in slow breathing.

When assessing a client's respiratory rate, the nurse should take which action?

Do it immediately after the pulse assessment so the client is unaware of it. Move immediately from the pulse assessment to counting the respiratory rate to avoid letting the client know the nurse is counting respirations. Clients should be unaware of the respiratory assessment because, if they are conscious of the procedure, they might alter their breathing patterns or rate. Thus, the nurse should not tell the client to breathe normally or deeply. Using a watch with a second hand, count the number of respirations for 30 seconds. Multiply this number by 2 to calculate the respiratory rate per minute.

Which pathologic condition would result in release of antidiuretic hormone (ADH) by the posterior pituitary?

Hemorrhage ADH is released from the posterior pituitary when stimulated by decreased blood volume and blood pressure (such as with hemorrhage) or increased osmolarity of the blood. Its effect is to retain water to increase circulatory fluid volume and, in turn, increase blood pressure. ADH release is not stimulated by allergies, obesity, or asthma.

The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct?

Lightly compress the client's radial artery using the first, second, and third fingers. The radial artery is the most common place to assess a peripheral pulse on an adult. The fingertips are sufficiently sensitive to palpate arterial pulsations using light compression and thus should be used, not the thumbs. The first, second, and third fingers of one hand are used to assess peripheral pulse, not the first fingers of each hand. Take care to avoid completely compressing the artery.

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. The apex of the heart is found by 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 who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?

Over the client's thigh The nurse should measure the blood pressure over the client's thigh or the popliteal artery behind the knee. It is inadvisable following a mastectomy to assess blood pressure at the normal site, which is over the brachial artery at the inner aspect of the elbow. In normal cases, the blood pressure may also be assessed at the lower arm and radial artery.

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 blood pressure reading is the most invasive procedure performed when measuring vital signs. If the nurse were to perform it first it may upset the child further and could prevent obtainment of the remainder of the vital signs. Allowing the child to touch the assessment equipment often helps the child be more relaxed for the remainder of the assessment. Lying on the exam table is not necessary for vital signs and will likely cause more anxiety. Being quick with a serious demeanor does not help decrease the child's anxiety.

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

Pulse is felt with difficulty and disappears with slight pressure. A thready pulse is felt with difficulty or not easily felt, and slight pressure causes it to disappear. A weak pulse is stronger than a thready pulse, and light pressure causes it to disappear. A normal pulse is felt easily, and moderate pressure causes it to disappear. A bounding pulse is strong and does not disappear with moderate pressure.

A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature?

Rectum The rectal temperature, a core temperature, is considered to be one of the most accurate routes.

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. 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.

The nurse observes the client's frequent use of the incentive spirometer. The client states "I do not want to have pneumonia while in the hospital." Which vital sign reading demonstrates effectiveness of this intervention?

Temperature of 98.2°F (36.7°C) Emotional or physical stress can elevate body temperature. When stress stimulates the sympathetic nervous system, circulating levels of epinephrine and norepinephrine increase. As a result, the metabolic rate increases, which, in turn, increases heat production. Stressed or anxious clients may have an elevated temperature with no underlying pathology.

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. The client behavior that indicates the need for additional teaching is client sitting in the chair with feet flat on the floor and arm below the level of the heart. Taking a blood pressure with the arm in that position can give a falsely high reading. The client placing the blood pressure on the upper arm just above the antecubital space, the client sitting in the chair with feet flat on the floor and arm supported at the level of the heart, and the client using a blood pressure cuff width at least 40% of the circumference of the midpoint of the arm all indicated correct methodology for self-measuring blood pressure and thus require no need for further teaching.

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 pulse rate is below 60 beats per minute. An abnormally slow pulse rate is called bradycardia. In adults, a pulse rate below 60 beats per minute is considered bradycardic. The normal respiratory rate is 12 to 24 breaths per minute. A client with a systolic blood pressure less than 100 mm Hg would be hypotensive as the normal systolic blood pressure is less than 140 mm Hg. Bradycardia is not associated with a client having to sit upright when the blood pressure is checked.

A nurse is assessing a client's blood pressure manually. The nurse should identify the client's systolic blood pressure (SBP) when which event occurs?

The first faint, but clear, sound appears. The first faint, but clear, sound that appears and slowly increases in intensity constitutes the systolic pressure. Each of the other listed sounds would yield an inaccurate SBP reading.

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. Auscultation of the apical pulse provides the most accurate assessment of the pulse rate and is the preferred site when the peripheral pulses are difficult to assess or the pulse rhythm is irregular. While this is an excellent method to determine baseline pulse, it is not the reason for using the apical pulse method. Elevated blood pressure and bounding carotid pulse are not reasons to obtain an apical pulse.

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 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.

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. 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. 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. Using the bell will not facilitate palpation but an auditory assessment. The nursing student should be familiar with other assessment devices such as the Doppler and not asking another nursing student to assess. Connecting the client to the oxygen saturation device does not assist in the assessment of pedal pulses.

A nurse is teaching a client how to monitor the radial pulse after discharge from the hospital. Which instruction by the nurse is most appropriate?

Use the fingertips of your second and third fingers. The radial pulse is palpated on the thumb side of the inner aspect of the wrist. The pulse should be palpated with the fingertips of the second and third fingers. Using the thumb may result in an inaccurate reading. The pulse should be counted for 1 full minute.

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 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.

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." Dehydration is a cause for orthostatic hypotension, which causes a temporary drop in BP when the client rises from a reclining position. Dizziness is not associated with environmental changes. Dizziness or changes in orthostatic BP occurs when baroreceptors do not respond quickly enough to restore adequate circulation to the brain. Dizziness may be caused by low blood pressure. However, the client is dizzy with ambulation not when lying down.

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

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

Which client should not have a temperature assessed rectally?

Client with diarrhea 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.

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. 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.

A client has smoked most of his life and has labored respirations. He is experiencing:

dyspnea Dyspnea describes respirations that require excessive effort.

A nurse is caring for an adult with fever. The nurse determines that which site is most accurate for obtaining the client's core body temperature?

rectum The rectal temperature, a core temperature, is considered to be one of the most accurate routes.

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." The average pulse rate of an infant ranges from 100 to 160 beats/min. There is no need to refer the parent to the health care provider for an answer.

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." Use judgment when selecting the route to measure temperature. The most commonly used sites are the mouth, rectum, ear (tympanic), forehead (temporal artery), and axilla. The least accurate temperature measurement is the axilla because it can register up to a degree lower than rectal or other methods of taking the internal temperature. Rectal temperature is contraindicated for cardiac clients as it can cause the client to vasovagal and cause a lethal arrhythmia. The use of disposable probes is important when taking temperature as it reduces transmission of pathogens between clients. The oral temperature should be avoided in children as they are mouth breathers and this would affect the temperature.

The home care nurse notices that the client only has a glass thermometer. What is the best response by the nurse?

"Would you consider using a digital thermometer?" Assessing if the client is willing to use a digital thermometer is the most appropriate response. Telling the client to throw away their property is disrespectful and presumptuous. Cleaning should be done with a mixture of alcohol and water. and the thermometer should be rinsed with cold water only.

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

1°F (0.5°C) lower than an oral temperature. Rectal temperatures may be 1°F (0.5°C) higher than oral temperatures and axillary temperatures are 1°F (0.5°C) lower than oral temperatures.

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 difference between systolic blood pressure and diastolic blood pressure is called the pulse pressure; 132 − 92 = 40.

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 from 124/82 to 102/70. She called the nurse concerned about her BP. What is the most appropriate information for the nurse to give this client?

You may have orthostatic hypotension and should be seen by your health care provider as soon as you can. 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.

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 The apical pulse is assessed when a client is being given medications that alter heart rate and rhythm.

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. Certain cardiac medications, such as digoxin, decrease the heart rate.

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 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 When the probe rests deep in the posterior sublingual pocket, it is in contact with blood vessels lying close to the surface. None of the other areas provides as much contact with blood vessels and therefore is not an appropriate location to place the thermometer probe.

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 +1 pulse amplitude indicates that the pulse is diminished and weaker than expected. An absent pulse is a 0. A pulse that is brisk is a +2, and a bounding pulse is +3.

Which condition will lead to an increase in cardiac output?

exercise Cardiac output increases during exercise and decreases during sleep. When cardiac output is decreased, blood pressure falls. Hemorrhage and dehydration can result in decreased cardiac output and decreased blood pressure.

A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs?

immediately Vitals signs should be assessed whenever there is a change in the client condition. Because the client reports feeling "different," this indicates an immediate vital sign assessment. Therefore, it is not appropriate to assess vital signs once per day, according to medical orders, or every 4 hours.

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 Orthostatic hypotension is associated with weakness or fainting when one rises to an erect position. Hypertension and dyspnea do not typically result in loss of balance and/or consciousness. Dyspnea is difficult or labored breathing. Essential or primary hypertension is high blood pressure. Secondary hypertension (secondary high blood pressure) is high blood pressure that's caused by another medical condition.

Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"?

palpation of the radial pulse on the thumb side of the inner aspect of the wrist. The radial artery is the site most commonly assessed in the clinical setting. The radial pulse is palpated on the thumb side of the inner aspect of the wrist.

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 should measure blood pressure with the arm at heart level. Elevating the arm above heart level results in a falsely low measurement; positioning the arm below heart level results in a falsely high reading. The ear tip or bell can be pointed in any direction when taking a blood pressure. Using a small cuff is recommended for a 10-year-old normal-sized child. Pain can increase the blood pressure causing a false elevated reporting.

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 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 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 pulse and the radial pulse rates. When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate.

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 Korotkoff sounds (or K-Sounds) are the "tapping" sounds heard with a stethoscope as the cuff is gradually deflated. Traditionally, these sounds have been classified into five different phases (K-1, K-2, K-3, K-4, K-5). The systolic blood pressure reading occurs during phase I, which is characterized by the appearance of faint but clear tapping sounds that gradually increase in intensity (K1). The last sound before there is complete and continuous silence is congruous with the diastolic blood pressure measurement (K5). In some patients, sounds may disappear altogether for a short time between Phase II and III, which is referred to as auscultatory gap. The transition from tapping sounds to muffled sound is K4. K-1 (Phase 1): The appearance of the clear "tapping" sounds as the cuff is gradually deflated. The first clear "tapping" sound is defined as the systolic pressure. K-2 (Phase 2): The sounds in K-2 become softer and longer and are characterized by a swishing sound. since the blood flow in the artery increases. K-3 (Phase 3): The sounds become crisper and louder in K-3, which is similar to the sounds heard in K-1. K-4 (Phase 4): As the blood flow starts to become less turbulent in the artery, the sounds in K-4 are muffled and softer. Some professionals record diastolic during Phase 4 and Phase 5 K-5 (Phase 5): In K-5, the sounds disappear completely, since the blood flow through the artery has returned to normal. The last audible sound is defined as the diastolic pressure.