ATI SM & E: Vital Signs
A nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings, which needs intervention?
A client has a radial pulse of +4 bilateral EXPL: A peripheral pulse strength of +4 is described as bounding and is considered an unexpected finding. The nurse should check further and report the findings to the provider. A pulse strength of +2 is considered an expected finding.
A nurse is obtaining a client's vital signs. The client has a new onset temp of 102 dg F. What other vital signs should the nurse expect?
An elevated pulse rate EXPL; fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate. NOT: A temperature might have a minimal effect on blood pressure, but the nurse should not expect a large variance.
A nurse is preparing to measure a client's vital signs. What factors should the nurse ID as affectors of the method?
, The client has a BMI of 35, The client is reporting a stuffy nose, the client is taking digoxin for an irregular heartbeat, The client had a mastectomy 2 years ago EXPL: The client who has a BMI of 35 is overweight and has a larger-than-average upper-arm circumference. Therefore, the nurse should use a large blood-pressure cuff, instead of a regular-sized cuff, to ensure an accurate blood-pressure reading., The client who has nasal congestion might resort to "mouth breathing," which would alter an oral temperature, measurement. A respiration assessment for a full 60 seconds should also be included, The presence of a cardiovascular condition that warrants pharmacological digoxin therapy would require an assessment of the client's apical pulse for a full 60 seconds.Lymphatic drainage might be altered in the client's affected arm following a mastectomy. The application of pressure from the assessment of blood pressure could result in a painful condition called lymphedema. NOT:The client has had nausea for 2 days is incorrect. Nausea, while uncomfortable and possibly a manifestation of gastrointestinal pathology, has no direct effect on the nurse assessing the client's vital signs., The client has been fasting for blood tests is incorrect. The lack of food has no direct bearing on checking the client's vital signs. However, recent ingestion of foods of extreme temperatures, hot or cold, can affect the accuracy of an oral temperature measurement.
obtaining SaO2 steps
1- select the site 2- apply the sensor probe on the chosen site 3- confirm pulse rate displayed by palpating the radial pulse 4- wait 15 seconds and observe the sao2 % displayed
A nurse is giving info abt peripheral pulses for a group of nurses, what should she include?
A pulse strength of +1 indicates that the pulse is weak or diminished EXPL: The nurse should identify that a pulse strength of +1 indicates that the pulse is weak or diminished upon palpation. This is an expected finding and requires no further evaluation.
A nurse is assessing a client's respiration. What action should the nurse take?
Elevate the bed to semi-fowlers, 45-60 dg EXPL: This is a comfortable position for most clients and it allows full ventilatory movement. Discomfort can increase a client's respiratory rate. NOT: Lying flat in bed prevents full chest expansion and can make it difficult for clients who have certain medical conditions such as COPD, CHF, or obesity to breathe normally. This is called orthopnea, which is the inability to breathe easily without sitting up straight or standing erect.
a nurse is obtaining a clients BP and notices the pressure reading on the manometer when listening to the 4th korotkoff sound. what factor does this pressure reading correlate to?
It might not be followed w/ a fifth Korotkoff sound EXPL: 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 0 mm Hg. 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. What action should the nurse take to determine the depth of the clients respiration?
Observe the degree of chest-wall movement during inspiration and experation EXPL; The nurse can determine the depth of respiration 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). What location should the nurse position the stethoscope?
Over the 5th intercostal space at the left midclavicular line EXPL: 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 obtaining vital signs from a client. What findings are the priority for the nurse to report to the provider?
Respirations 30/min EXPL: 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 obtain a clients BP. What action should the nurse take to measure the BP accurately?
Use a cuff of the appropriate size for the client EXPL: 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. NOT: Blood pressure can vary considerably with the time of day. This phenomenon is called diurnal variation. Blood pressure is typically lowest in the morning; however, this varies widely from client to client. Additionally, the clinician might not necessarily seek the lowest possible reading. Of more concern in clients who have hypertension are the higher readings. In any case, with proper technique, the reading will still be accurate no matter what time of day the blood pressure is measured. When obtaining a blood pressure reading, it is best to make sure the client has been relaxing for at least 5 min prior to measurement. This helps avoid elevated readings. However, there are times when the clinician might want to assess for blood pressure spikes under a variety of circumstances.
A nurse is discussing the use of a client's thigh for blood pressure measurements w/ an AP. what info should the nurse include
Use the thigh to obtain BP when a client has severe edema in their arms EXPL: The nurse should instruct the AP to obtain blood pressure measurements in the thigh when a client has severe edema in the arms or a shunt in place for dialysis.
A nurse is preparing an in-service for a group of newly hired AP abt body temp. What info should the nurse include?
a temporal probe thermometer uses infrared scanning to determine a client's temp
a nurse is caring for a client who has an increase in cardiac afterload, what findings should the nurse expect?
increase in BP EXPL: The nurse should identify that a client who has an increase in afterload increases the risk for hypertension. Afterload is the resistance of the ventricle to pump the heart muscle and eject blood into the client's bloodstream during systole.
A nurse is establishing baseline for a client's respirations. What action should the nurse take?
observe the clients chest movements while appearing to assess their pulse EXPL: 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 measuring a client's temp orally. What action should the nurse take?
place the probe in the posterior lingual pocket lateral to the midline EXPL: 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 probe "sideways" into the back of the area under the tongue on the left or the right will access this area.
A nurse is reviewing documentation of vital signs by a newly licensed nurse for an assigned client. What entry in the chart would require follow up by the nurse
pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hallway EXPL: This client's pulse rate is higher than the expected reference range. While the notation of the client ambulating in the hall can be a factor in the tachycardia, the nurse does not indicate they will re-evaluate the pulse rate after the client has rested. The nurse should use clinical judgment when evaluating vital signs and wait 15 to 30 min following exercise.
a charge nurse is teaching a group of AP about the important of documenting accurate vital signs. What info should the charge nurse include in the teaching?
recording vital signs provides critical info regarding a client's condition EXPL: Vital signs, including blood pressure, temperature, pulse, respiratory rate, and SaO2, reflect the client's current health status and will vary according to changes in the client's health condition, such as infection, stress, pain, or bleeding, and should be recorded accurately and in a timely manner.
a nurse is reviewing orthostatic hypotension, what statement should the nurse make?
A decrease of 20 millimeters of mercury in the systolic pressure w/ a position change indicates orthostatic hypotension EXPL: The charge nurse should include that a decrease of at least 20 mm Hg in the systolic pressure with a position change indicates orthostatic hypotension.
A nurse is taking an adult client's temp rectally. What action should the nurse take?
Insert the probe about 2.5 cm(1 inch) into the client's anus EXPL: An insertion depth of 2.5 to 3.5 cm (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. NOT: rotate-> can cause trauma to mucosa
a nurse is planning care for a client who has hypertension. what interventions should the nurse include in the plan?
Provide the client w/ low sodium meals and snacks, encourage the client to participate in physical activity each day, instruct the client in the use of relaxation techniques, inform the client of the importance of abstaining from using products w/ nicotine NOT: anticipate a prescription of a 1L fluid bolus
A nurse is preparing to use a tympanic thermometer to acquire a client's temp. What should the nurse take to ensure an accurate reading?
Pull the pinna back and upward gently EXPL: 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. What terms defines this info when documenting?
Pulse Pressure EXPL: The difference between the systolic and diastolic pressures is the pulse pressure. If the client's blood pressure is 130/85 mm Hg, the pulse pressure is 45 mm Hg. 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. NOT: pulse deficit, The pulse deficit is the difference between a client's radial and apical pulse rates. Pulse deficits often reflect abnormal heart rhythms.
A nurse is auscultating a client's apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when what occurs?
When the semilunar valve closes EXPL: 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.
