Vital Signs (pretest and posttest)

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. **The nurse is most likely to observe the true respiratory pattern (rate, rhythm, and depth) when the client is unaware that they are being assessed. When clients know their respiration is being observed, it is common for them to alter their respiratory pattern either voluntarily or involuntarily.

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. **Respirations of 30/min is above the expected reference range of 12 to 20/min and indicates the need for immediate attention. An adult client who has respirations of 30/min is experiencing shortness of breath, or dyspnea. Without intervention, this can become a life-threatening situation.

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?

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

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

An elevated pulse rate. **A fever increases metabolic rate and peripheral vasodilation, resulting in an increase pulse rate.

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 to 45 to 60 degrees. **This is a comfortable position for most clients and it allows full ventilatory movement. Discomfort can increase a client's respiratory rate.

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. **An insertion depth of 2.5 to 3.5 (1 to 1.5 in) for an adult ensures sufficient exposure of the probe to the blood vessels in the rectal wall. Positioning the probe against the blood vessels enables it to measure heat maximally and accurately.

A nurse is obtaining a client's blood pressure and noticises 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 fifth Korotkoff sound. **Most clinicians consider the fifth Korotkoff sound, which is actually the disappearance of sound, as an adult client's diastolic blood pressure. However, with some clients, there is no distinct fifth sound. You hear sounds all the way to 0mmHg. For these clients, the nurse should record the fourth Korotkoff sound as the diastolic blood pressure.

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 movement during inspiration and expiration. **The nurse can determine the depth of respriation subjectively by evaluating how much chest-wall movement is observed. The movement is generated by the movements of the diaphragm and intercostal muscles as the client breathes. With shallow respiration, the nurse will observe very little movement. Deep respiration involves full expansion of the lungs, which is usually quite visible.

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 fifth intercostal space at the left midclavicular line. **To locate the PMI, the nurse should first locate the angle of Louis, a bony prominence just below the suprasternal notch. The nurse should then slide their fingers down each side of the angle of Louis to locate the second intercostal space. Next, the nurse should gently move their fingers down the left side of the sternum to the fifth intercostal space and laterally to the left midclavicular line. This is the PMI.

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

Place the probe in the posterior lingual pocket lateral to the midline. *The heat produced by superficial blood vessels in the right and the left posterior sublingual pocket is what generates an accurate oral temperature reading. Inserting the prob "sideways" into the back of the area under the tongue on the left or the right will access this area.

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. **Gently pulling the pinna back and upward helps straighten the ear canal and provides optimal access to the tympanic membrane. Good contact with sufficient tympanic membrane is essential for an accurate tympanic temperature measurement.

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 **The difference between the systolic and diastolic pressures is the pulse pressure. If the client's blood pressure is 130/85mmHg, the pulse pressure is 45mmHg. Pulse pressure can be a predictor of heart conditions, especially in older adults. For example, an elevated pulse pressure usually reflects stiffness and reduced elasticity of the aorta, most often due to hypertension or atherosclerosis.

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 a cuff of the appropriate size for the client. **Using the wrong cuff size for the client will result in an erroneous reading. A cuff that is too small will result in a reading that is falsely high and using a cuff that is too big will record a false low. One way to select a cuff is to make sure that the width of the cuff is 40% of the arm circumference where the cuff will be wrapped. The bladder, which is inside the cuff, should surround 80% of the arm circumference.

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 valves close. **The second heart sound, S2, is generated by the closure of the aortic and pulmonic valves, or semilunar valves, and signals the start of diastole. S2 is the "dub" heard in the normal "lub-dub" sound.