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The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as: orthopnea bradypnea apnea tachypnea

orthopnea Dyspneic people can often breathe more easily in an upright position, a condition known as orthopnea, because sitting or standing allows gravity to lower organs from the abdominal cavity away from the diaphragm. Bradypnea is a decrease in respiratory rate. Tachypnea is an increased respiratory rate. Apnea refers to periods during which there is no breathing.

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

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.

While recording the pulse of an infant at 160 beats/min, the parent asks if it is normal for the infant's pulse rate to be so high. Which statement by the nurse best answers the parent's question? "A heart rate of 160 beats/min is normal for a healthy infant." "A heart rate of 160 beats/min is a little too fast for an infant, so I will take it again in 5 minutes." "A heart rate of 160 beats/min is actually slow for an infant, so I will ask the health care provider to reassess." "Every infant's heart rate is different, so you will need to discuss that with the health care provider."

"A heart rate of 160 beats/min is normal for a healthy infant." The average pulse rate of an infant ranges from 100 to 160 beats/min. There is no need to refer the parent to the health care provider for an answer.

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

"Dizziness when you change position can occur when fluid volume in the body is decreased." Dehydration is a cause for orthostatic hypotension, which causes a temporary drop in BP when the client rises from a reclining position. Dizziness is not associated with environmental changes. Dizziness or changes in orthostatic BP occurs when baroreceptors do not respond quickly enough to restore adequate circulation to the brain. Dizziness may be caused by low blood pressure. However, the client is dizzy with ambulation not when lying down.

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? 224 mmHg 132 mmHg 112 mmHg 40 mmHg

40 mmHg 132-94=40

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? Assess the apical pulse. Assess the carotid pulse. Get another nurse for validation. Document the findings.

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. .

Which statement describes diastolic blood pressure? During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. To assess diastolic pressure, the blood pressure measured during ventricular contraction. The pressure is highest when the ventricles of the heart eject blood into the aorta and pulmonary arteries. The flow of blood is produced by contractions of the heart and by the resistance to blood flow through the vessels.

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.

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? Bradypnea is uncommon in a client with IICP. IICP most commonly results in tachypnea. Bradypnea is a response to IICP. This is a normal respiratory rate.

Bradypnea is a response to IICP.

The client is to have a measurement for a pulse deficit performed. What action does the nurse take? Enlist another nurse to help with this measurement. Measure the apical rate first and then the radial rate. Count the beats simultaneously for 15 seconds. Auscultate the apical rate while feeling for the radial pulse.

Enlist another nurse to help with this measurement. To measure for a pulse deficit, two nurses are required for accuracy. One nurse auscultates the apical rate; a second nurse counts the radial rate. They do this simultaneously for 1 minute. To perform this skill in any other manner will result in an inaccurate reading.

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

Palpation of an irregular radial 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.

The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention? Provide privacy for the client. Position the client on the stomach. Insert the thermometer 0.5 in (1.25 cm) into the rectum. Maintain probe position in rectum for 2 minutes.

Provide privacy for the client. Rectal temperature assessment can be embarrassing for the client, so provision of privacy is a priority. The client should be positioned on the side in Sims position to help facilitate probe insertion. The probe should be inserted 1 to 1.5 in (2.5 to 3.75 cm) in an adult client. The probe should only remain in the rectum until the electronic unit emits an audible sound indicating that the temperature assessment is complete.

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse? pulse is strong, and light pressure causes it to disappear. Pulse is felt with difficulty and disappears with slight pressure. Pulse is felt easily, and moderate pressure causes it to disappear. Pulse is strong and remains strong despite moderate pressure.

Pulse is felt with difficulty and disappears with slight pressure. A thready pulse is felt with difficulty or not easily felt, and slight pressure causes it to disappear. A weak pulse is stronger than a thready pulse, and light pressure causes it to disappear. A normal pulse is felt easily, and moderate pressure causes it to disappear. A bounding pulse is strong and does not disappear with moderate pressure.

The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation? Leave the thermometer in and notify the health care provider. Remove the thermometer and assess the blood pressure and heart rate. Remove the thermometer and assess the temperature via another method. Call for assistance and anticipate the need for CPR.

Remove the thermometer and assess the blood pressure and heart rate. Vagal nerve stimulation may occur when obtaining a rectal temperature. Vagal nerve stimulation can cause the pulse and blood pressure to drop significantly, causing the client to feel lightheaded; therefore, the thermometer should be removed immediately and the pulse and blood pressure assessed. The health care provider can be called after assessing the client. The temperature is not the priority at this time. Assistance for CPR would be determined if the client's condition worsens.

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? Recheck BP level to ensure accuracy Take pulse again to assess for tachycardia Wait 20 minutes and recheck oral temperature. Talk with client to allow them to relax before retaking vital signs.

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.

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 may account for this assessment finding? Select all that apply. The client has reports of pain of 8 on a scale of 0 to 10 The client has a blood pressure of 122/70 mm Hg The client just finished ambulating with physical therapy The client has a temperature of 101.8°F (38.8°C) The client has been drinking water

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.

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? The thermometer is broken. The client is showing initial signs of infection. A rectal thermometer must be used. The client is covered with a couple of thick blankets.

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.

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

The client's pulse rate is below 60 beats per minute.

A nurse is assessing a client's blood pressure manually. The nurse should identify the client's systolic blood pressure (SBP) when which event occurs? The first audible sounds begin to decrease in intensity. The first audible sounds cease to be distinct. The initial Korotkoff sounds peak in intensity. The first faint, but clear, sound appears.

The first faint, but clear, sound appears. The first faint, but clear, sound that appears and slowly increases in intensity constitutes the systolic pressure. Each of the other listed sounds would yield an inaccurate SBP reading.

Which client's blood pressure best describes the condition called hypotension? The systolic reading is above 110 and diastolic reading is above 80. The systolic reading is below 100 and diastolic reading is below 60. The systolic reading is above 102 and diastolic reading is above 60. The systolic reading is below 120 and the diastolic reading is below 80.

The systolic reading is below 100 and diastolic reading is below 60.

Which pulse site is generally used in emergency situations? carotid apical radial temporal

carotid The carotid artery is lightly palpated to obtain a pulse in emergency assessments, such as in a client in shock or cardiac arrest. The brachial pulse site is used for infants who have had a cardiac arrest. The apical pulse is the fifth intercostal space for adults and the fourth intercostal space for a young child or infant. Using a stethoscope at the apex of the heart, a nurse can assess the lub dub of the heart sounds. Radial pulse is too distant to assess a pulse in an emergency assessment. Temporal pulse is difficult to assess.

A nurse is assessing an apical pulse on an older adult client who takes metoprolol daily. The nurse can anticipate that the client's medication will: decrease the blood glucose. decrease the blood volume. decrease the apical pulse. decrease the respiratory rate.

decrease the apical pulse.

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: decrease the blood glucose. decrease the blood volume. decrease the apical pulse. decrease the respiratory rate.

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.

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

The nurse is caring for a client who has smoked for more than 20 years and is now experiencing labored respirations. The nurse documents the client is experiencing: dyspnea. fremitus. stridor. wheezing.

dyspnea Dyspnea describes respirations that require excessive effort, such as is common in clients who smoke, suffer from chronic obstructive pulmonary disease, or have been diagnosed with asthma. Stridor are harsh, loud, high-pitched sounds auscultated on inspiration that signal narrowing of the upper airway or presence of a foreign body in the airway. Wheeze is a continuous, high-pitched squeak or musical sound made as air moves through narrowed or partially obstructed airway passages. Fremitus vibration of the chest wall that can be palpated during the physical examination.

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

pumping the blood pressure cuff up to 200 mm Hg routinely 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 mm 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? 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 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.