Vital Signs

A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of 39° C (102° F). Which of the following other vital signs should the nurse expect?

An elevated pulse rate

A nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading correlate to?

It might not follow with a 5th Korotkoff sound

A nurse is preparing to obtain a client's blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately?

Use of cuff of the appropriate size for the client

A nurse is preparing to measure a client's vital signs. The nurse should identify that which of the following factors will affect the methods that are used?

- Client who has a BMI of 35 - Client is reporting a "stuffy nose" - The client is taking digoxin for an irregular heart rate - Client had a mastectomy 2 years ago

A nurse is assessing a client's respiration. Which of the following actions should the nurse take?

Elevate the head of the client's bed 45° to 60°

A nurse is taking an adult client's temperature rectally. Which of the following actions should the nurse take?

Insert the probe about 2.5 cm (1 in) into the client's anus.

A nurse is establishing baseline for a client's respirations. Which of the following actions should the nurse take?

Observe the client's chest movements while appearing to assess their pulse

A nurse is collecting data about a client's respiratory condition. Which of the following actions should the nurse take to determine the depth of the client's respiration?

Observe the degree of chest-wall movements during inspiration and expiration

A nurse is preparing to auscultate a client's apical pulse at the point of maximal impulse (PMI). In which of the following locations should the nurse position the stethoscope?

Over the 5th intercostal space on the left midclavicular line

A nurse is measuring a client's temperature orally. Which of the following actions should the nurse take?

Place probe in the posterior lingual pocket lateral to the midline

A nurse is preparing to use a tympanic thermometer to acquire a client's temperature. Which of the following actions should the nurse take to ensure an accurate reading?

Pull the pinna back and upward gently

A nurse is preparing to record the difference between a client's systolic and diastolic blood pressure. Which of the following terms defines this information when documenting?

Pulse pressure

A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider?

Respirations 30/min

A nurse is auscultating a client's apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs?

When the semilunar valve closes