Ch 25 - Vital Signs

The nurse is preparing discharge teaching for a client admitted for sepsis. The client asks what is included when the nurse checks vital signs. Which assessment(s) is included? Select all that apply. A. temperature B. pulse C. respiratory rate D. blood pressure E. weight F. allergies

A, B, C, D: temperature, pulse, respiratory rate, blood pressure Vital signs consist of temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation. Pain is considered the sixth vital sign that a nurse should assess. Weight and allergies are other assessment parameters but are not part of the 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? A. Assess the apical pulse. B. Assess the carotid pulse. C. Get another nurse for validation. D. Document the findings.

A. 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 is assessing a client's blood pressure and obtains a falsely low pressure reading. Which nursing actions might have contributed to this false reading? Select all that apply. A. The nurse performed the assessment in a noisy environment. B. The nurse misplaced the bell beyond the direct area of the artery. C. The nurse used a manometer not calibrated at the zero mark. D. The nurse viewed the meniscus from below eye level. E. The nurse failed to pump the cuff 20 to 30 mm Hg above disappearing pulse. F. The nurse applied a cuff that is too narrow.

A, B, E: The nurse performed the assessment in a noisy environment; The nurse misplaced the bell beyond the direct area of the artery; The nurse failed to pump the cuff 20 to 30 mm Hg above disappearing pulse. A noisy environment may prevent the nurse from hearing the systolic measurement, leading to a falsely low systolic measurement. The systolic and/or diastolic pressure may be inaccurately heard if the bell or diaphragm is not placed directly over the artery. If the cuff is not pumped to at least 20 to 30 mm Hg above the disappearing pulse, the systolic pressure may have started without the nurse hearing the first distinct sound.Using a manometer not calculated at zero will yield an inaccurately high measurement, as will the nurse viewing the meniscus from below eye level. A cuff that is too narrow will lead to a falsely high reading.

The rectal temperature, a core temperature, is considered to be one of the most accurate routes. In which cases would taking a rectal temperature be contraindicated? Select all that apply. A. A newborn who has hypothermia B. A child who has pneumonia C. An older adult who is post MI (heart attack) D. A teenager who has leukemia E. A patient receiving erythropoietin to replace red blood cells F. An adult patient who is newly diagnosed with pancreatitis

A, C, D, E: A newborn who has hypothermia; An older adult who is post MI (heart attack); A teenager who has leukemia; A patient receiving erythropoietin to replace red blood cells The rectal site should not be used in newborns, children with diarrhea, and in patients who have undergone rectal surgery. The insertion of the thermometer can slow the heart rate by stimulating the vagus nerve, thus patients post-MI should not have a rectal temperature taken. Assessing a rectal temperature is also contraindicated in patients who are neutropenic (have low white blood cell counts, such as in leukemia), in patients who have certain neurologic disorders, and in patients with low platelet counts.

The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that would explain the tachycardia? Select all that apply. A. The client has reports of pain of 8 on a scale of 0 to 10 B. The client has a blood pressure of 122/70 mm Hg C. The client just finished ambulating with physical therapy D. The client has a temperature of 101.8°F (38.8°C) E. The client has been drinking water

A, C, D: The client has reports of pain of 8 on a scale of 0 to 10; The client just finished ambulating with physical therapy; The client has a temperature of 101.8°F (38.8°C) There are several factors that may cause an increase in heart rate due to an increase in metabolic rate. This can occur with pain, exercise, fever, medications, and strong emotions. A blood pressure of 120/70 mm Hg does not indicate an association with tachycardia or that a client has been drinking water. Caffeinated beverages may cause an increase in heart rate but water would not.

A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variations in normal vital signs, which patients would the nurse document as having a vital sign within normal limits? Select all that apply. A. A 4-month-old infant whose temperature is 38.1°C (100.5°F) B. A 3-year-old whose blood pressure is 118/80 C. A 9-year-old whose temperature is 39°C (102.2°F) D. An adolescent whose pulse rate is 70 beats/min E. An adult whose respiratory rate is 20 beats/min F. A 72-year-old whose pulse rate is 42 beats/min

A, D, E, F: A 4-month-old infant whose temperature is 38.1°C (100.5°F); An adolescent whose pulse rate is 70 beats/min; An adult whose respiratory rate is 20 beats/min; A 72-year-old whose pulse rate is 42 beats/min The normal temperature range for infants is 37.1° to 38.1°C (98.7° to 100.5°F). The normal pulse rate for an adolescent is 55 to 105. The normal respiratory rate for an adult is 12 to 20 breaths/min and the normal pulse for an older adult is 40 to 100 beats/min. The normal blood pressure for a toddler is 89/46 and the normal temperature for a child is 36.8° to 37.8°C (98.2° to 100°F).

A patient reports severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments? Select all that apply. A. An increase in the pulse rate B. A decrease in body temperature C. A decrease in blood pressure D. An increase in respiratory depth E. An increase in respiratory rate F. An increase in body temperature

A, E: An increase in the pulse rate; An increase in the respiratory rate The pulse often increases when a person is experiencing pain. Pain does not affect body temperature and may increase (not decrease) blood pressure. Acute pain may increase respiratory rate but decrease respiratory depth.

The nurse instructs a parent of young children how to properly use a nonmercury glass thermometer. Which statement made by the parent indicates a need for further instruction? A. "I will clean the thermometer in the dishwasher." B. "I will store the thermometer in the case that it came with." C. "I will wait 30 minutes before taking an oral temperature if my child ate or drank." D. "The thermometer is placed under the tongue with mouth and lips closed."

A. "I will clean the thermometer in the dishwasher." The nurse needs to provide further instruction because cleaning the glass thermometer in the dishwasher will lead to breakage. The thermometer should be washed in warm, sudsy water and then dried and placed into its protective case. The client is correct to wait to take a temperature 30 minutes after food or drink. The client is correct in that the child must be able to follow directions, so the parent can place the thermometer under the tongue and have the child close their mouth around it.

When assessing an infant's axillary temperature, it will be: A. 1°F (0.5°C) lower than an oral temperature. B. 1°F (0.5°C) higher than a rectal temperature. C. 1°F (0.5°C) higher than an oral temperature. D. the same as the tympanic temperature.

A. 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 takes a client's vital signs and notes a blood pressure of 88/56 mm Hg with a pulse rate of 60 beats/min. Which action should the nurse take first? A. Assess the client for dizziness. B. Retake the client's blood pressure. C. Place the client in a supine position. D. Notify the health care provider

A. Assess the client for dizziness. The nurse should first assess the condition of the client and determine if physical signs of hypotension are present. After assessing the client's condition, the nurse should retake the blood pressure for accuracy. The client should remain in bed and not get up since dizziness and further drop in blood pressure could occur. Placing the client in the supine position (or flat on their back) will not assist with improving the blood pressure. Placing the client in the Trendelenburg (flat on the back with the feet higher than the head by 15-30 degrees) is appropriate. The nurse can check the chart to determine the client's normal range of blood pressure and notify the health care provider if there are symptoms associated with the hypotension.

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? A. Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2. B. Palpate the posterior thorax excursion, count respirations for 30 seconds, and multiply by 2. C. Use a pulse oximeter to count the respirations for 1 minute. D. Monitor arterial blood gas results for 1 minute.

A. 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 int eh lungs. Pulse oximeter and arterial blood gas results assess respiratory effectiveness, not respiratory rate.

A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient? A. Follow-up measurements of blood pressure B. Immediate treatment by a health care provider C. No action, because the nurse considers this reading is due to anxiety D. A change in dietary intake

A. Follow-up measurements of blood pressure A single blood pressure reading that is mildly elevated is not significant, but the measurement should be taken again over time to determine if hypertension is a problem. The nurse would recommend a return visit to the clinic for a recheck.

A nurse notices a student is taking a blood pressure measurement on a patient with a cuff that is too large. What should be the nurse's response to the student? A. If you use the wrong cuff you will get an incorrect reading. B. If you use the wrong cuff you will cause injury to the patient. C. If you use the wrong cuff you will cause dangerous pressure on the arm. D. If you use the wrong cuff you will cause the loss of Korotkoff sounds.

A. If you use the wrong cuff you will get an incorrect reading. A blood pressure cuff that is not the right size may cause an incorrect reading. It will not cause serious injury to the patient, but a small amount of pressure may be felt on the arm from a too tight cuff. It will not cause the loss of Korotkoff sounds.

A nurse is assessing an adult client's blood pressure. How should the nurse estimate the client's systolic blood pressure (SBP)? A. Inflate the blood pressure cuff while palpating the client's brachial or radial artery. B. Simultaneously compare the amplitude of the client's left and right radial pulses. C. Palpate the client's brachial pulse while having the client slowly raise his or her arm. D. Note the SBP that was documented during the client's last vital signs assessment.

A. Inflate the blood pressure cuff while palpating the client's brachial or radial artery. The point where the brachial or radial pulse disappears provides an estimate of the systolic pressure. Previous baselines are important to know, but these do not provide an estimate of current SBP. Simultaneous palpation of radial pulses and having the client raise his or her arms does not provide an estimate of SBP.

A nurse has been unable to palpate a client's dorsalis pedis pulse. The nurse attempted to identify the pulse using Doppler ultrasound and is still unable to identify a pulse. What is the nurse's most appropriate action? A. Inform the client's primary care provider of this assessment finding. B. Inform the client's primary care provider of this assessment finding. C. Reassess after placing the client's leg in a dependent position for 15 minutes. D. Have the client perform foot flexion and extension exercises to promote circulation.

A. Inform the client's primary care provider of this assessment finding. If you cannot find the pulse using a Doppler ultrasound, notify the primary care provider. Reassessment is necessary, but this is an important assessment finding that should be promptly reported.

A client monitoring his BP at home notices that his BP is higher in one arm than the other. He calls his health care provider for guidance. What is the most appropriate information for the nurse to give this client? A. It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results. B. It has been found that most people have differences in BP between arms and that he should use the arm that gives him the lowest reading for accurate results. C. This has no impact on BP readings and he should continue doing what he has been doing. D. This is unusual and he should be seen by the physician as soon as possible.

A. It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results. It has been found that most people have differences in BP between arms. For accurate results, the initial reading should be obtained from both arms and where there is a consistent interarm difference, the client should use the arm that gives the highest reading. However, there will be situations when the arm with the highest reading may not be used doe to surgery, IV lines, or other issues. The nurse should continue to monitor the client to ensure the best reading is obtained.

The nurse is caring for a 77-year-old client who is recovering from surgery. After notifying the health care provider of the incident recorded in the client's chart (above), what will the nurse anticipate teaching the client? A. postural hypotension B. lack of exercising C. poor dietary choices D. new blood pressure medications

A. postural hypotension The drop of blood pressure of more than 20 mm Hg between lying and standing, 1 to 2 hours after eating; the report of dizziness; and almost falling indicate the client has possibly developed postural or postprandial hypotension. The other choices may contribute to the situation, but are not the main concern.

The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct? A. Lightly compress the client's radial artery using the first, second, and third fingers. B. Encircle the client's antecubital fossa with both hands and lightly compress the brachial artery with the first fingers of both hands. C. Grasp the client's inner wrist with the nondominant thumb positioned over the radial artery. D. Compress the radial artery until no pulsation is felt, then gently remove the fingertips until the pulsation returns.

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

A. 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.

Two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 beats/min. How will the nurse document this difference? A. Pulse deficit B. Pulse amplitude C. Ventricular rhythm D. Heart arrhythmia

A. Pulse deficit The difference between the apical and radial pulse rate is called the pulse deficit.

Upon assessment of a patient, the nurse determines that a patient is at risk of losing body heat through the process of convection. What would be the nurse's best response? A. Turn off the overhead fan in the patient's room. B. Remove the patient's ice pack. C. Reduce the temperature in the room. D. Increase the temperature in the room.

A. Turn off the overhead fan in the patient's room. With convection, the head is disseminated by motion between areas of unequal density, for example, the action of a fan blowing cool air over the body. Turning off the fan would reduce heat loss via convection. Removing the patient's ice pack is an intervention to prevent heat loss via conduction. Reducing the temperature in the room may decrease heat loss via perspiration (evaporation); increasing the temperature in the room might increase heat loss via evaporation.

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

A. a temporary cessation of breathing Apnea, the absence of respirations, is often described by the length of time in which respirations do not occur.

The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mmHg. What is the priority nursing intervention? A. ask the client to demonstrate self-blood pressure assessment B. provide the client with a larger blood pressure cuff C. recommend lower sodium in the client's diet D. report readings to primary care provider

A. ask the client to demonstrate self-blood pressure assessment While all of these interventions would be appropriate if the client is hypertensive, it is important to assess whether the client is measuring their BP correctly before assuming that hypertension is present. It would be very rare to have a BP of the exact same measurement with every assessment. Therefore, providing the client with a larger blood pressure cuff, recommending lower sodium in the client's diet, and reporting the readings to the primary care provider are not priority actions at this time.

An ultrasonic Doppler is used for: A. auscultating a pulse that is difficult to palpate. B. auscultating diastolic blood pressure. C. aiding palpation of pulse and rhythm. D. aiding palpation of diastolic blood pressure.

A. auscultating a pulse that is difficult to palpate. A Doppler device can be used to detect a pulse that is not easily palpable.

The nurse is educating a client about ways to increase their cardiac output. Which topic does the nurse include in the teaching? A. exercise B. sleep C. decrease in blood pressure D. dehydration

A. 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.

The nurse discovers during assessment that the client has an altered temperature. Select a causative factor for heat loss due to convection: A. exposure to a fan B. insensible loss of body fluids C. by "goose bumps" or piloerection

A. exposure to a fan Convection facilitates heat loss via passing air, such as with a breeze or a fan.

The nurse knows that a client who is being taught to perform home blood pressure monitoring (HBPM) understands the teaching plan when he makes which statement about the size of the BP cuff? The cuff should: A. fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow. B. fit snug around the upper arm with room to slip a fingertip under the cuff and should be touching the crease of the elbow. C. fit snug around the upper arm with room to slip three fingertips under the cuff and should be 1 in (2.5 cm) above the crease of the elbow. D. fit snug around the upper arm with no room to slip a fingertip under the cuff and should be 2 in (5 cm) above the crease of the elbow.

A. fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow. When teaching a client to perform home blood pressure monitoring (HBPM), he or she should be taught that the proper fitting cuff should fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow.

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem? A. peripheral vascular disease B. coronary artery disease C. pulmonary embolism D. chronic obstructive pulmonary disease (COPD)

A. peripheral vascular disease A pulse deficit indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated, a finding that is congruent with peripheral vascular disease. It does not signal a lack of circulation to the heart muscle (coronary artery disease), a pulmonary embolism, or COPD.

A nursing student is assessing blood pressure in an adult client. Which action by the nursing student would require intervention from the nursing instructor? A. pumping the blood pressure cuff up to 200 mm Hg routinely B. placing the ear tips of the stethoscope forward into the ear C. using light pressure over the anatomic site for assessment D. placing the client's arm in a comfortable resting position

A. pumping the blood pressure cuff up to 200 mm Hg routinely The instructor should intervene if the student is routinely inflating the cuff to 200 mg Hg. This may be very uncomfortable for the client, and there is no reason to do so unless the Korotkoff sounds are heard when inflating. All other options are correct and do not require intervention.

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? A. the ability of the arteries to stretch B. the thickness of circulating blood C. the oxygen levels in the blood D. the volume of air entering the lungs

A. 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.

The nurse discovers during assessment that the client has an altered temperature. Select a causative factor for heat loss due to conduction: A. the air itself B. sympathetic nervous system C. by shivering

A. the air itself Conduction describes heat that is lost by transferring from one object to the next. For example, heat is lost from the skin to the air or to water.

The nurse is assessing a new client's blood pressure, using a manual sphygmomanometer. Which sound constitutes the client's systolic blood pressure? A. the first appearance of faint but distinctive tapping sounds B. the last sound before there is complete and continuous silence C. the first sound that is audible after the auscultatory gap D. the transition from tapping sounds to muffled sounds

A. 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 clients, 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.

The nurse instructor is teaching student nurses about the factors that may affect a patient's blood pressure. Which statements accurately describe these factors? Select all that apply. A. Blood pressure decreases with age. B. Blood pressure is usually lowest on arising in the morning. C. Women usually have lower blood pressure then men until menopause. D. Blood pressure decreases after eating food. E. Blood pressure tends to be lower in the prone or supine position. F. Increased blood pressure is more prevalent in African Americans.

B, C, E, F: Blood pressure is usually lowest on arising in the morning; Women usually have lower blood pressure then men until menopause; Blood pressure tends to be lower in the prone or supine position; Increased blood pressure is more prevalent in African Americans. Blood pressure increases with age due to a decreased elasticity of the arteries, increasing peripheral resistance. Blood pressure is usually lowest on arising in the morning. Women usually have lower blood pressure than men until menopause occurs. Blood pressure increases after eating food. Blood pressure tends to be lower in the prone or supine position. Increased blood pressure is more prevalent and severe in African American men and women.

A nurse is assessing the respiratory rate of a sleeping 28-day-old infant. What would the nurse document as a normal finding? A. 12 to 20 breaths/min B. 30 to 60 breaths/min C. 60 to 80 breaths/min D. 80 to 100 breaths/min

B. 30 to 60 breaths/min When assessing the respiratory rate of an infant less than 1 month of age, the nurse knows that the normal respiratory rate of an infant at rest is approximately 30 to 60 breaths/min. The normal respiratory rate of an adult is 12 to 20 breaths/min. A respiratory rate of 60 to 80 breaths/min or 80 to 100 breaths/min is abnormal and is not seen in infants or adults when they are at rest.

The normal adult temperature obtained through the oral route ranges from: A. 96.6°F to 98.6°F (35.9°C to 37.0°C). B. 97.6°F to 99.6°F (36.4°C to 37.6°C). C. 98.6°F to 100.4°F (37.0°C to 38.0°C). D. 98.2°F to 100.2°F (36.8°C to 37.9°C).

B. 97.6°F to 99.6°F (36.4°C to 37.6°C). Normal adult oral temperature ranges from 97.6°F to 99.6°F (36.4°C to 37.6°C).

A nurse assesses orthostatic hypotension in an older adult. What would be an appropriate intervention for this patient? A. Encourage the patient to rise from a sitting position quickly to improve blood flow. B. Allow the patient to "dangle" for a few minutes prior to rising to a standing position. C. If the patient feels faint or dizzy, return the patient to bed and place in Fowler's position. D. Administer a beta-adrenergic blocker to increase blood pressure.

B. Allow the patient to "dangle" for a few minutes prior to rising to a standing position. Allowing the patient to "dangle" on the edge of the bed prior to rising might prevent orthostatic hypotension. Arising and moving about slowly, especially after a period of bed rest, might also prevent orthostatic hypotension. If a patient becomes dizzy or feels faint, the nurse should return the patient to bed and place in a supine position, which restores blood flow to the brain. A beta blocker is given to decrease blood pressure for a patient with hypertension. There are several medications that raise blood pressure and are used to treat orthostatic hypotension.

Which guideline should the nurse follow when assessing a client's blood pressure using a Doppler ultrasound? A. Take the measurement with the client in a standing position with the appropriate limb exposed. B. Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery. C. If using a mercury manometer, check to see that the manometer is in the horizontal position and that the mercury is within the zero level. D. Monitor for serial readings and check the cuffed limb frequently for inadequate arterial perfusion and venous drainage.

B. Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery. When performing blood pressure assessment via Doppler ultrasound, the nurse will have the client assume a comfortable lying or sitting position with the appropriate limb exposed and center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery. If using a mercury manometer, the nurse will check to see that the manometer is in the vertical position and that the mercury is within the zero level with the gauge at eye level. The nurse then hold the Doppler in the nondominant hand. Using the dominant hand, the nurse places the Doppler tip in the gel, adjusts the volume as needed, and moves the Doppler tip around until hearing the pulse.

A patient is experiencing dyspnea. What is the nurse's priority action? A. Remove pillows from under the head. B. Elevate the head of the bed. C. Elevate the foot of the bed. D. Take the blood pressure.

B. Elevate the head of the bed. Elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm greater room for expansion and facilitating lung expansion.

The nurse notes that the temperature of an ill client is 101°F (38.3°C). Which intervention would the nurse take to regulate the client's body temperature? A. Apply a blanket on the client. B. Give the client a bath in tepid water. C. Increase the client's metabolic rate. D. Set up a fan to blow warm air on the client.

B. Give the client a bath in tepid water. The body loses heat to the water through conduction during tepid baths. Applying a blanket would reduce radiant heat loss and would raise the client's temperature. Increasing the body's metabolic rate will result in an increase in temperature. Blowing warm air over the client will increase the temperature.

The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next? A. Record the reading in the chart. B. Inflate the cuff about 30 mm Hg above the auscultatory gap. C. Use the bell of the stethoscope to listen for the diastolic sound. D. Inflate the cuff about 10 mm Hg above the auscultatory gap.

B. Inflate the cuff about 30 mm Hg above the auscultatory gap. To find the auscultatory gap, palpate the brachial or radial pulse while inflating the cuff. Inflate the cuff about 30 mm Hg above the number where palpable pulsation disappears. In addition to detecting an auscultatory gap, palpation gives an initial estimate of systolic blood pressure and eliminates the need to inflate the cuff to extremely high pressures in people with normal or low blood pressure. Using the bell of the stethoscope to listen for the systolic and diastolic sound is expected. Recording of the blood pressure should occur after the blood pressure is obtained.

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? A. Ability to read gauge from any direction. B. No stethoscope is required. C. Inexpensive depending on quality. D. Need for readjustment is eliminated.

B. No stethoscope is required. An electric manometer eliminates the need for a stethoscope. However, an electronic manometer requires a calibration 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 electric manometer, from any direction.

The nurse needs to assess the carotid arteries of the client. Which assessment technique would be appropriate for the nurse to use? A. Palpate both arteries at the same time. B. Palpate one artery at a time. C. Measure the rate for 1 full minute. D. Measure the rate for 30 seconds and multiply by 2.

B. Palpate one artery at a time. To palpate the carotid arteries, the nurse would lightly press on one side of the neck at a time. Never attempt to palpate both carotid arteries at the same time as bilateral palpation could result in reduced cerebral blood. It is not necessary to count the carotid rate.

After taking vital signs of an older adult, the nurse writes down findings as T = 98.9/37.2 oral, P = 104, R = 18, BP = 120/82. Based on the collected data, which step would the nurse take next? A. Recheck BP level to ensure accuracy. B. Take pulse again to assess for tachycardia. C. Wait 20 minutes and recheck oral temperature. D. Talk with client to allow them to relax before retaking vital signs.

B. Take pulse again to assess for tachycardia. Normal ranges of vital signs for older adults are as follows: Pulse 60-100 Respiration 12-20 Temperature 96.4-99.5F (35.8-37.5C) Blood Pressure 90-120 /60-80. Reassessing pulse would be justified to determine if there is a tachycardia issue or if the client has situational anxiety, etc. that may affect the pulse rate. Talking with the client to help relax them is a common practice, but not warranted in this situation. The oral temperature is within normal limits so there is not need to retake it.

A patient has intravenous fluids infusing in the right arm. How should the nurse obtain the blood pressure on this patient? A. Take the blood pressure in the right arm. B. Take the blood pressure in the left arm. C. Use the smallest possible cuff. D. Report inability to take the blood pressure.

B. Take the blood pressure in the left arm. The blood pressure should be taken in the arm opposite the one with the infusion.

When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. Which statement explains this order? A. The client's respiratory rate is less than 18 breaths per minute. B. The client's pulse rate is below 60 beats per minute. C. The client is unable to stay upright when blood pressure is checked. D. The client's systolic blood pressure is less than 100 mm Hg.

B. 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 20 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 120 mm Hg. Bradycardia is not associated with a client having to sit upright when the blood pressure is checked.

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? A. Ask the client to drink a glass of cold water before measuring the oral temperature B. Wait for 30 minutes before measuring the oral temperature C. Obtain the client's temperature rectally after lubricating the rectum D. Use the axillary site for an alternate measurement site

B. 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.

Which client would the nurse consider at risk for low blood pressure? A. a client with high blood viscosity B. a client with low blood volume C. a client with decreased elasticity of walls of arterioles D. a client with a strong pumping action of blood into the arteries

B. a client with low blood volume Low blood volume, such as occurs with hemorrhage, causes hypotension. High blood viscosity and decreased elasticity of the arteriole walls would potentially cause increased blood pressure. A strong pumping action of the heart may not affect the blood pressure, or it may cause the blood pressure to increase.

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? A. absent, unable to palpate B. diminished, weaker than expected C. brisk, expected (normal) D. bounding

B. 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 outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"? A. firm placement of thumb on the inner wrist of the opposite arm B. palpation of the radial pulse on the thumb side of the inner aspect of the wrist. C. light palpation of the femoral pulse below the inguinal area D. firm palpation of bilateral carotid artery for one minute

B. 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.

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? A. ear B. rectum C. axilla D. mouth

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

The nurse discovers during assessment that the client has an altered temperature. Select a causative factor for heat loss due to evaporation: A. by uncovered body surfaces B. through sweating C. a tepid bath

B. through sweating Evaporation consists of heat loss that occurs as water is transformed into a gas, such as with sweating.

The nurse is teaching an adult client how to monitor the pulse rate. Which statement by the client demonstrates understanding of a normal pulse rate? A. "The normal pulse rate is 12 to 20 beats/min." B. "I will call the health care provider if my pulse is below 80 beats/min." C. "If my pulse is higher than 100 beats/min at rest, that is considered abnormal." D. "It is normal for my pulse to be lower than 40 beats/min while sleeping."

C. "If my pulse is higher than 100 beats/min at rest, that is considered abnormal." The normal pulse rate for an adult is 60 to 100 beats/min. The statement, "If my pulse is above 100 beats/min at rest, that is considered abnormal" demonstrates understanding of the normal pulse rate. The normal respiratory rate is 12 to 20 breaths/min. Calling the health care provider for a pulse rate lower than 80 beats/min is incorrect, as a pulse of 60 beats/min is within normal range. The pulse often lowers at night during sleep; however, a rate of 40 beats/min should be investigated.

A nurse is assessing a newborn at the health care facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be most appropriate? A. "The baby is showing how it is adapting to the environmental temperature." B. "It is common for newborns to have body temperatures less than 36.4°C (97.6°F)." C. "It is because of the immature ability to regulate temperature in general." D. "It is because of the closely woven dark fabric wrapped around the baby."

C. "It is because of the immature ability to regulate temperature in general." The nurse should explain to the mother that newborns have unstable body temperatures because their thermoregulatory mechanisms are immature. It is not uncommon for an older adult's body temperature to be less than 36.4°C (97.6°F), because normal temperature drops as a person ages. Newborns and infants lack the ability to decrease heat loss in response to environmental temperatures and cannot usually mount a robust fever response to infection. Changes in environmental temperatures do not affect core body temperature. Covering the body with closely woven dark fabric helps reduce radiant heat loss, but it is not responsible for unstable body temperatures in newborns.

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? A. Reassess the client's radial pulse in 15 minutes. B. Page the client's primary care provider. C. Auscultate the client's apical heart rate. D. Palpate the radial pulse on the opposite wrist.

C. Auscultate the client's apical heart rate. Palpation of an irregular 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 nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff? A. Place cuff 8 cm above the elbow. B. Fully inflate cuff for about 1 minute. C. Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared. D. Elevate arm above heart level before inflating the cuff.

C. Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared. Inflating the cuff to 30 mm Hg above reading where brachial pulse disappeared ensures accurate assessment of systolic blood pressure. The arm does not need to be elevated above the heart level before inflation as this would give an inaccurate systolic blood pressure. The cuff should be placed in the elbow fold and not 8 cm above the elbow. Inflating the cuff for 1 minute before taking a blood pressure can cause an elevation of the systolic blood pressure.

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? A. Over the lower arm B. Brachial artery C. Over the client's thigh D. Radial artery

C. 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.

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? A. The client places the blood pressure cup on the upper arm just above the antecubital space. B. The client sits in the chair with feet flat on the floor and arm supported at the level of the heart. C. The client sits in the chair with feet flat on the floor and arm below the level of the heart. D. The client uses a blood pressure cuff width at least 40% of the circumference of the midpoint of the arm.

C. 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.

The nurse is assessing the pulse of a young adult who is training for a triathlon competition. The pulse rate is 48 beats/min. What education should the nurse provide to the client? A. A medication regimen to bring the heart rate up will be required. B. The client will have to be very careful when changing positions since the heart rate is low. C. The heart rate is within normal limits due to the exercise regimen the client is following. D. There is a conduction abnormality that is most likely congenital since the client is young.

C. The heart rate is within normal limits due to the exercise regimen the client is following. The client who is young and athletic is exhibiting a training effect where the heart rate is lower than the normal 60 to 100 beats/min. The heart becomes more efficient at supplying body cells with sufficient oxygenated blood with fewer beats. There is no indication that the client should be placed on medications to increase the heart rate since this is most likely a normal state for the client.

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? A. This infant will need a home cardiac monitor set up. B. The parents should be encouraged to get a neighbor or family member to help them check their infant's pulse. C. 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. D. 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. TAKE ANOTHER QUIZ

C. 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. If a peripheral pulse is difficult to assess accurately because it is irregular, weak, or very rapid, the apical rate should be assessed using a stethoscope. An apical pulse is also assessed when giving medications that alter heart rate and rhythm. Apical pulse measurement is also the preferred method of pulse assessment for infants and children younger than 2 years of age. Families can be taught to use a stethoscope to check a pulse. This infant does not need a cardiac monitor, the parents should not be encouraged to get a neighbor or family friend to help, and these parents can be taught to check this infant's pulse accurately.

A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record? A. There is a nonauscultatory gap. B. There is a widening in the diameter of the artery. C. There is an auscultatory gap. D. There is an adult diastolic pressure.

C. There is an auscultatory gap. An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff sound technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff sound technique.

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: A. decrease the blood glucose. B. decrease the blood volume. C. decrease the apical pulse. D. decrease the respiratory rate.

C. 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.

Which is not a characteristic used to describe the pulse? A. frequency B. quality C. depth D. rhythm

C. depth Rate or frequency refers to the number of pulsations per minute. Rhythm refers to the regularity with which pulsation occurs. Quality refers to the strength of the palpated pulsation.

A client informs the nurse that a mercury thermometer is used at home to take the temperature of her children when they are sick. What health education by the nurse is most appropriate? A. educate the client about safety related to accidental breakage of the thermometer B. encourage the client to dispose of the thermometer in the trash and buy a new type C. encourage the client to use an alternative type of thermometer to assess temperature in the home D. instruct the client that mercury thermometers should be used only in a hospital setting with appropriate safeguards

C. encourage the client to use an alternative type of thermometer to assess temperature in the home It is important to note that glass thermometers with mercury bulbs have been used in the past for measuring body temperature. They are not currently used in health care institutions, in keeping with federal safety recommendations. However, clients may still have mercury thermometers at home and may continue to use them. Nurses should encourage clients to use alternative devices to measure body temperature. Mercury thermometers should not be thrown in the trash, because mercury is toxic. Educating clients about the safety is not the first priority.

The nurse discovers during assessment that the client has an altered temperature. Select a causative factor for heat loss due to radiation: A. open arteriovenous shunts B. a passing breeze C. infrared heat waves

C. infrared heat waves Radiation is heat that is lost to infrared heat waves. It can be accelerated by exposing the skin to the heat waves or prevented by covering the skin.

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? A. ear B. mouth C. rectum D. axilla

C. 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 documenting a blood pressure of 120/80 mm Hg. The nurse interprets the 120 to represent: A. the rhythmic distention of the arterial walls as a result of increased pressure due to surges of blood with ventricular contraction. B. the lowest pressure present on arterial walls while the ventricles relax. C. the highest pressure present on arterial walls while the ventricles contract. D. the difference between the pressure on arterial walls with ventricular contraction and relaxation.

C. the highest pressure present on arterial walls while the ventricles contract. The systolic pressure is 120 mm Hg. The diastolic pressure is 80 mm Hg, the lowest pressure present on arterial walls when the heart rests between beats. The difference between the systolic and diastolic pressures is called the pulse pressure. The rhythmic distention of the arterial walls as a result of increased pressure due to surges of blood with ventricular contraction is the pulse.

Prioritization: Place the following descriptions of the phases of Korotkoff sounds in order from phase I to phase V. A. Characterized by muffled or swishing sounds that may temporarily disappear; also known as the auscultatory gap B. Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery C. The last sound heard before a period of continuous silence, known as the second diastolic pressure D. Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; known as the systolic pressure E. Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; considered to be the first diastolic pressure

D, A, B, E, C: Logic follows. Phase I is characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; the first tapping sound is the systolic pressure. Phase II is characterized by muffled or swishing sounds, which may temporarily disappear, especially in hypertensive people; the disappearance of the sound during the latter part of phase I and during phase II is called the auscultatory gap. Phase III is characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery. Phase IV is characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; in adults, the onset of this phase is considered to be the first diastolic pressure. Phase V is the last sound heard before a period of continuous silence; the pressure at which the last sound is heard is the second diastolic pressure.

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period? A. 0300 B. 1100 C. 1500 D. 1700

D. 1700 Body temperature fluctuates throughout the day. Temperature is usually lowest around 0300 and highest from 1700 to 1900.

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? A. 224 mm Hg B. 132 mm Hg C. 112 mm Hg D. 40 mm Hg

D. 40 mm Hg The difference between systolic blood pressure and diastolic blood pressure is called the pulse pressure; 132-92 = 40.

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? A. Report the findings to the health care provider B. Obtain a bedside electrocardiogram C. Compare with previously documented findings D. Auscultate the apical pulse for 60 seconds

D. 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.

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? A. Notify the health care provider. B. Perform a pain assessment. C. Administer oxygen. D. Auscultate the lung sounds and count respirations.

D. 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.

The nurse is assessing the client's blood pressure (BP) and heart rate (HR) for orthostatic hypotension. In which step should this nurse intervene because of potential danger? A. Client in supine position for 3 minutes and BP 120/70; HR 70; asymptomatic. B. Client sitting at edge of bed, feet dangling for 3 minutes; asymptomatic C. After 3 minutes of sitting, BP 100/50; HR 90. D. Client stands at bedside, becomes pale, diaphoretic.

D. Client stands at bedside, becomes pale, diaphoretic. Orthostatic hypotension is assessed in three positions, with the client resting in each position 3 minutes before measuring the blood pressure and heart rate. The client is positive for orthostatic hypotension when there is a decrease of 20 mm Hg BP or greater and the heart rate increases as the body's means to help compensate for the postural change. In this case, it is part of the assessment to leave the client in the supine position for 3 minutes; the BP and HR are within a normal range and the client is asymptomatic so the nurse would not intervene. The nurse need not intervene while the client is dangling at the bedside and is asymptomatic. After 3 minutes of sitting, there was a positive orthostatic change, but the client is not exhibiting symptoms, so the nurse would finish the assessment by standing the client at the bedside to determine the extent of the postural changes. The nurse would intervene because the client is exhibiting symptoms of low cardiac output: pallor and diaphoresis. The nurse would immediately place the client in a supine position to increase the BP and report the findings to the primary care provider so adjustments in treatment may be made.

A nurse assesses an oral temperature for an adult patient and records that the patient is "afebrile." What would be the nurse's best response to this finding? A. Check the patient record for prescribed antipyretic medication. B. Report the finding to the primary care provider. C. Take the patient temperature using a different method. D. No action is necessary; this is a normal finding.

D. No action is necessary; this is a normal finding. Afebrile means without fever. Therefore the temperature assessed is within the normal range for an adult. The nurse does not need to perform any other actions based on this finding.

While taking an adult patient's pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next? A. Check the pulse again in 2 hours. B. Check the blood pressure. C. Record the information. D. Report the rate to the primary care provider.

D. Report the rate to the primary care provider. A rate of 140 beats/min in an adult is an abnormal pulse and should be reported to the primary care provider or the nurse in charge of the patient.

A client who has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong? A. She needs to press harder until she feels a pulse. B. She needs to take her pulse after her medication so that her pulse is stronger. C. She should stand when taking her pulse to increase blood flow.

D. She should place her three fingers just below the wrist on the outside of the arm with the palm up. A client is taught to take his or her own pulse before certain medications or after exercise, depending on the individual client's needs. When teaching a client to take his or her own pulse, the nurse should teach the client to sit down and place an arm on a hard surface with the palm upward. Using three fingers, the client should feel just below the wrist on the outer side of the arm for the pulse. The client should be taught not to press too hard or the pulse can be obliterated.

The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this? A. The thermometer is broken. B. The client is showing initial signs of infection. C. A rectal thermometer must be used. D. The client is covered with a couple of thick blankets.

D. The client is covered with a couple of thick blankets. Ordinarily, changes in environmental temperatures do not affect core body temperature, but core body temperature can be altered by exposure to hot or cold extremes such as blankets. The degree of change relates to the temperature, humidity, and length of exposure. The body's thermoregulatory mechanisms are also influential, especially in infants and older adults who have diminished control mechanisms. Using a rectal thermometer or assuming the thermometer is broken is not correct. The client is not exhibiting signs of infection as these may include an elevated temperature, an elevated white blood cell count, general malaise, and body aches.

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? A. The amount of oxygen available to tissues throughout the body B. The volume of the venous system relative to the volume of the arterial system C. The size of the client's heart muscle D. The resistance that the client's heart must overcome when pumping blood

D. 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.

The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next? A. Use the Bell side of the stethoscope to listen. B. Ask another student nurse to check it for him. C. Connect the client to the oxygen saturation monitoring device. D. Use the Doppler ultrasound device.

D. 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.

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? A. brachial B. radial C. carotid D. apical

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

The nurse understands that accurate blood pressure taking is dependent on several factors. Which example will most likely render an accurate blood pressure reading? A. the client reporting moderate pain for the past 4 hours B. using a medium size cuff for a 10-year-old, average weight client C. the ear tip of the stethoscope pointing backwards while taking blood pressure D. placing the client's arm at heart level

D. 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.