PrepU Chapter 25: Vital Signs Quiz

A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client? "Dizziness can occur when baroreceptors overreact to the changes in BP." "Dizziness is caused by very low blood pressure when you lie down." "Dizziness can occur due to changes in the hospital environment." "Dizziness when you change position can occur when fluid volume in the body is decreased."

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

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 dyspnea primary hypertension secondary hypertension

orthostatic hypotension

During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant. True False

true

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 tachypenea. I will let the doctor know right away."

"I know it seems fast, but normal infant heart rates are 100-160 beats per minute."

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. Perform a pain assessment. Administer oxygen. Notify the primary care provider.

Auscultate the lung sounds and count respirations.

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? "You will need to remain NPO until I notify your health care provider about your increased temperature." "I'll be right back with your coffee and a different thermometer. I'm not sure this one measured your temperature correctly." "Before you drink another hot beverage, drink some cool water so I can obtain an accurate oral temperature." 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."

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."

The nurse places the client on a hypothermia blanket to manage the client's temperature. Which action does the nurse take? Insert a rectal thermometer probe and secure it in place. Turn the client every 2 hours and as needed. Document the client's vital signs once every hour. Ensure all body surface areas are in contact with the cooled surface.

Insert a rectal thermometer probe and secure it in place.

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? Palpate the space between the fifth and sixth ribs. Count the heartbeat for 2 minutes. Listen for heart sounds. Count each "lub-dub" as two beats.

Listen for heart sounds.

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.

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 should be encouraged to get a neighbor or family member to help them check their infant's pulse. This infant will need a home cardiac monitor set up. The parents will not be able to check the pulse accurately; the nurse will need to do home health checks on this infant on a periodic basis. 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.

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.

The experienced nurse teaching a student to measure an apical pulse includes which critical information? Select all that apply. To determine the apical pulse, count the heartbeats for 1 full minute A Doppler ultrasound device is required to measure an apical pulse at the fourth intercostal space at the midclavicular line. In adults, the normal rate is 80 to 120 pulsations per minute The diaphragm of the stethoscope is placed at the fifth intercostal space at the midclavicular line. Auscultation of the apical pulse requires a cardiac stethoscope placed at the apex of the heart found at the second intercostal space.

To determine the apical pulse, count the heartbeats for 1 full minute The diaphragm of the stethoscope is placed at the fifth intercostal space at the midclavicular line.

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 mostappropriate thing for this nurse to advise this client? Not to worry and to take double the dose of BP medication To call her health care provider To take the medication that she missed and retake her BP 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.

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

Clients demonstrating apnea have what? a temporary cessation of breathing decreased rate and depth of respirations increased rate and depth of respirations normal respiratory rate of 20

a temporary cessation of breath

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? a. bradypnea is a response to IICP b. IICP most commonly results in tachypnea c. bradypnea is uncommon in a client with IICP d. This is a normal respiratory rate

a. bradypnea is a response to IICP

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? brachial radial carotid apical

apical

The nurse has completed an assessment and notes that the client's BP is 132/92 mmHg. What is the client's pulse pressure? a. 224 mmHg b. 112 mmHg c. 40 mmHg d. 132 mmHg

c. 40 mmHg

The nurse is preparing to assess the peripheral pulse of an adult patient. Which of the actions is correct? a. grasp the client's inner wrist with the non-dominant thumb positioned over the radial artery b. compress the radial artery until no pulsation is felt, then gently remove the fingertips until the pulsation returns c.Lightly compress the patients radial artery using the first second and third fingers d. encircle the client's antecubital fossa with both hands and lightly compress the brachial artery with the first fingers of both hands

c. Lightly compress the patients radial artery using the first second and third fingers

Which peripheral pulse site is generally used in emergency situations? Carotid Apical Radial Temporal

carotid

Which fact is not known to cause false blood pressure readings? a. smoking b. eating c. having the client's legs crossed at the knee d. being in a warm environment

d. being in a warm environment

Which condition will lead to an increase in cardiac output? exercise sleep decrease in blood pressure dehydration

exercise

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. light palpation of the femoral pulse below the inguinal area firm palpation of bilateral carotid artery for one minute firm placement of thumb on the inner wrist of the opposite arm

palpation of the radial pulse on the thumb side of the inner aspect of the wrist.

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 mouth ear axilla

rectum

Which are considered vital signs? Select all that apply. temperature pulse respiratory rate blood pressure weight allergies

temperature pulse respiratory rate blood pressure

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 thickness of circulating blood the oxygen levels in the blood the volume of air entering the lungs

the ability of the arteries to stretch