Chapter 25 Vital signs

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 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.

Which pathologic condition would result in release of antidiuretic hormone (ADH) by the posterior pituitary?

Hemorrhage ADH is released from the posterior pituitary when stimulated by decreased blood volume and blood pressure (such as with hemorrhage) or increased osmolarity of the blood. Its effect is to retain water to increase circulatory fluid volume and, in turn, increase blood pressure. ADH release is not stimulated by allergies, obesity, or asthma.

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."

Normal respiratory rate for adults

12-20 breaths/min

The nursing student is selecting a blood pressure cuff prior to obtaining a patient's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading?

40% of the circumference of the limb to be used

1700

5:00 pm

A client complains of leg pain shortly after being admitted with a fractured tibia sustained in a fall. When the nurse assesses the pain, the client states, "My pain is a 7 out of 10." What action by the nurse would be most appropriate?

Administer pain medication as ordered.

A parent brings a 3-month-old infant to the clinic, reporting that the infant has a cold, is having trouble breathing, and "just does not seem to be acting right." Which action should the nurse take first?

Assess the infant's oxygen saturation.

Which client should not have a temperature assessed rectally?

Client with diarrhea The rectal route is contraindicated in clients with diarrhea, those who have undergone rectal surgery, those with rectal diseases, and those with cancer who are neutropenic.

A nurse is caring for a client with orthostatic hypotension. Which of the following are symptoms of orthostatic hypotension? Select all that apply.

Dizziness Syncope Weakness

Which of the following conditions will lead to an increase in cardiac output?

Exercise

Upon assessing a patient who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?

Increased pulse rate

A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff?

Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared.

During a busy shift, Nurse R. admitted a postsurgical patient who is obese. Nurse R. used the standard size of blood pressure cuff available on the unit, despite the fact that the patient's upper arms have a high circumference. What are the potential consequences of Nurse R.'s action?

Nurse R. may obtain a blood pressure reading that is higher than actual blood pressure. If a blood pressure cuff is too narrow, the reading could be erroneously high because the pressure is not evenly transmitted to the artery. This occurs when an average-sized cuff is used on an obese person. This mismatched cuff will not, however, make it particularly difficult to inflate the cuff and brachial occlusion is not a significant risk.

neutropenic

Pertaining to an abnormally small number of neutrophils in the blood

A nurse palpates the pulse of a patient and documents the following: 6/6/12 pulse 85 and regular, 3+, and equal in radial, popliteal, and dorsalis pedis. What does the number 3+ represent?

Pulse quality (amplitude)

An 80-year-old client has a body temperature of 97°F. Which condition best accounts for this client's temperature reading?

Temperature drops with age It is not uncommon for elderly persons to have body temperatures less than 97.6° because normal temperature drops as a person ages.

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure?

The ability of the arteries to stretch

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 client is covered with a couple of thick blankets.

The nurse is assessing a new patient's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the patient's systolic blood pressure?

The first appearance of faint but distinctive tapping sounds

The nurse is assessing the blood pressure of a hospitalized client using a Doppler ultrasound device. Which actions are performed correctly? Select all that apply.

The nurse places the client in a comfortable lying or sitting position. The nurse centers the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. The nurse wraps the cuff around the limb smoothly and snugly and fastens it. The nurse checks that the needle on the aneroid gauge is within the zero mark.

A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse?

The radial pulse is difficult to obtain

All of the following patients have a body temperature of 38°C (100.4°F). About which patient would a nurse be most concerned?

a 2-month-old infant

orthopnea

ability to breathe only in an upright position

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?

apical

While assessing vital signs of a patient with a head injury and increased intracranial pressure (IICP), a nurse notes that the patient's respiratory rate is 8 breaths/min. How will the nurse interpret this finding?

bradypnea is a response to IICP

The nurse is instructing a client with cancer who is receiving chemotherapy about reporting signs of infection. Which is the most reliable early indicator of infection in a client who is neutropenic?

fever

sympathetic nervous system

fight or flight

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?

listen with the stethoscope at the fifth intercostal space left mid-clavicular line

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?

listen with the stethoscope at the fifth intercostal space left mid-clavicular line To assess the apical pulse, the nurse places the stethoscope over the left ventricle. The stethoscope is placed at the level of the fifth intercostal space, left mid-clavicular line.

orthostatic hypotension

low blood pressure that occurs upon standing up

A client presents to the Emergency Department with a temperature of 100.6F (38.1°C) and BP of 108/60 mmHg. What intervention does the nurse anticipate providing?

oral fluids

Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"?

palpation of the radial pulse on the thumb side of the inner aspect of the wrist.

Which are considered vital signs

pulse temperature respiratory rate blood pressure

The nurse needs to assess an infant's height to determine if the infant is meeting appropriate growth and development parameters. To obtain the most accurate measurement of an infant's height (length), the nurse measures the:

recumbent height with the infant supine.

The nurse is assessing an adult who has a pulse rate of 180 beats/minute. Which condition would the nurse document?

tachycardia

The client's blood pressure has gradually decreased in the last 2 days. Which condition would cause this change?

the client who has had persistent diarrhea

A toddler has a temperature above 101°F (38.3°C). The healthcare provider orders acetaminophen, 120 mg suppository, to be administered rectally every 4 to 6 hours. The nurse should question an order to administer the medication rectally if the child has a diagnosis of:

thrombocytopenia. A child with thrombocytopenia or neutropenia should not receive rectal medication because of the increased risk of infection and bleeding that may result from tissue trauma. No contraindications exist for administering rectal medication to a child with sepsis, leukocytosis, or anemia.

palpate

to examine by touch

ausculate

to listen

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. 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 nurse is teaching a client how to monitor the radial pulse after discharge from the hospital. Which instruction by the nurse is most appropriate?

Use the fingertips of your second and third fingers. The pulse should be counted for 1 full minute.

The nurse is preparing to measure a client's rectal temperature. Which supplies and equipment should the nurse have available before beginning the procedure? Select all that apply.

an electronic thermometer with a rectal probe disposable probe cover water-soluble lubricating gel Clean examination gloves, not sterile gloves, are required, and a bedpan is unnecessary. The other items listed are all needed.

bilateral

both sides

The nurse is assessing a new client's blood pressure, using a manual sphygmomanometer. Which sound constitutes the client's systolic blood pressure?

the first appearance of faint but distinctive tapping sounds

The nurse instructs a mother of young children how to properly use a nonmercury glass thermometer. Which statement made by the client indicates a need for further instruction?

"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, 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 children must be able to follow directions, placing the thermometer under the tongue, and closing the mouth around it.

Normal respiratory rate for infants

30-60 breaths/min

When assessing an adult client's pulse at 125 beats/min, which step would the nurse take first to determine intervention?

Determine cause Following the assessment of the pulse of 125 beats/min, the nurse would first determine the cause for the high rate. This will lead to determining an appropriate intervention. Anxiety, medications, caffeine, and other stimulants and disorders can cause tachycardia. The nurse will also need to check the quality of the pulse to determine regularity, but this would be included in assessing for causes and interventions. The nurse also will check the client's blood pressure, temperature, and pain level because an increase in any of these can be correlated with increased pulse, but again not what should be done first. While assessing a history of heart disease is important, this is not a first step alone and should be included in a full interview upon client intake and triage.

When creating the teaching plan for a client who will be monitoring his or her pulse at home, which factors should the nurse teach the client that may influence the pulse rate by causing an increase in pulse? Select all that apply.

Fever Exercise Stress

The nurse places a patient experiencing labored breathing in an upright position. The nurse notes that the patient is able to breathe more easily in this upright position and documents this condition on the chart as which of the following?

Orthopnea

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?

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.

A 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client?

To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns.

Which client would the nurse consider at risk for low blood pressure?

a client with low blood volume

It is very important to assess for the quality of someone's respirations as well as describe what is heard with auscultation. Which describes stridor?

a harsh, high-pitched inspiratory sound that may be compared to crowing

Which pulse site is generally used in emergency situations?

carotid

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:

decrease the apical pulse.

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?

deep in the posterior sublingual pocket When the probe rests deep in the posterior sublingual pocket, it is in contact with blood vessels lying close to the surface.

Which is not a characteristic used to describe the pulse?

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.

The body loses heat continually through several different processes. Which process is an example of how heat is lost through evaporation?

diaphoresis

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?

diminished, weaker than expected

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 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.

The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:

increased temperature. Body temperature can fluctuate with exercise, changes in hormone levels, changes in metabolic rate, and extremes of external temperature.

Assessment of the pulse amplitude is accomplished by:

palpating the flow of blood through an artery. The pulse amplitude describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction. It is assessed by the feel of the blood flowing through an artery. Auscultation is hearing the blood flow through an artery. Auscultation cannot be used to assess pulse amplitude. A nurse cannot palpate the area of the left ventricle.

Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"?

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.

Which term indicates a serious client condition

pyrexia Pyrexia means an increase above normal in body temperature. Pulse pressure is an objective term related to the pulse. Eupnea means a normal breathing pattern. Afebrile means that the body temperature is not elevated.

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?

rectum

parasympathetic nervous system

rest and digest

mastectomy

surgical removal of a breast

diaphoretic

sweating

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?

1700 Body temperature fluctuates throughout the day. Temperature is usually lowest around 0300 and highest from 1700 to1900.

0300

3:00 am lowest temp

normal heart rate

60-100 bpm

Upon auscultation of a patient's heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/minute. The nurse notifies the physician because the patient is exhibiting signs of which of the following?

A dysrhythmia An irregular pattern of heartbeats is called a dysrhythmia. Tachycardia is an increased heart rate of 100 to 180 beats/minute. Bradycardia is a pulse rate below 60 beats/minute. The normal pulse rate ranges from 60 to 100 beats per minute. Hypertension is a blood pressure that is above normal for a sustained period.

The nurse is talking to an older adult client who performs home blood pressure monitoring (HBPM) and finds that recently her BP measurements have consistently been low. Which factors may contribute to causing this client's BP to be falsely decreased? Select all that apply.

Applying too wide a cuff Using cracked or kinked tubing Releasing the valve rapidly

The nurse is caring for a 5-year-old child in pain. Which of the following methods should the nurse use to most accurately assess the child's pain?

Ask the child to point to a face drawing that indicates pain intensity.

A client presents to the emergency department with profuse bleeding from a crushing injury while at work. Which set of vital signs does the nurse anticipate finding in such this client?

Blood pressure 80/50 mm Hg, heart rate 120 beats/min, respiratory rate 24 breaths/min Profuse bleeding would cause a drop in blood pressure as the client enters hypovolemic shock, which causes the pulse to increase and become thready and respirations to become quick and shallow. Therefore, of the given options, a blood pressure of 80/50 mm Hg, heart rate of 120 beats/min and respiratory rate of 24 breaths/min should be anticipated.

When assessing a client's respiratory rate, the nurse should take which action?

Do it immediately after the pulse assessment so the client is unaware of it.

The nurse is performing bilateral comparison of pulse sites for strength and quality instead of counting the beats per minute. Which pulse locations will the nurse palpate to gather this assessment data? Select all that apply.

Dorsalis pedis Femoral Posterior tibial Popliteal

The nurse is caring for an adult postoperative client. Which physiologic response is related to pain?

Heart rate of 110 beats/min

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?

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.

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?

No stethoscope is required

The nurse is assessing an adult who has a pulse rate of 150 beats/min. Which action should the nurse take next?

Notify the health care provider of tachycardia An adult has tachycardia when the pulse rate is 100 to 180 beats/min. Blood pressure should always be assessed, but the health care provider should be notified immediately. Anaphylaxis and epinephrine are not specific to high pulse rate thus the provider should be called first.

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?

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 is preparing the client to use the hypothermia blanket. How does the nurse measure the client's temperature while the blanket is in use?

Rectal probe continuously

An adolescent client is admitted with a diagnosis of rheumatic fever and is on bed rest. He has a sore throat. His joints are painful and swollen. He has a red rash on his trunk and is experiencing aimless movements of his extremities. Use the chart above to determine what the nurse should do first.

Report the heart rate to the health care provider (HCP).

A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which of the following actions should the nurse perform in order to obtain the accurate temperature of the client?

Wait for 15 to 20 minutes before measuring the oral temperature

A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs?

immediately Vitals signs should be assessed whenever there is a change in the client condition. Because the client reports feeling "different," this indicates an immediate vital sign assessment. Therefore, it is not appropriate to assess vital signs once per day, according to medical orders, or every 4 hours.

When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a little bit more pressure. The pulse is beating at 80 bpm. Which of these should the nurse document as the character of the client's pulse?

thready pulse A feeble, weak, or thready pulse describes a pulse that is difficult to feel or, once felt, is obliterated easily with slight pressure. A normal pulse is described as strong when it can be felt with mild pressure over the artery. A pulse is considered rapid when the beats exceed 100 bpm, which is not the case here. A bounding or full pulse produces a pronounced pulsation that does not easily disappear with pressure. A strong pulse is felt with a very mild pressure over the artery.

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?

auscultate the client's apical pulse

Which of the following terms describes a heart rate that is below the expected norm?

bradycardia

A nurse is assessing the respiratory rate of a sleeping 28-day-old infant. What would the nurse document as a normal finding?

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.

A nurse has applied a blood pressure cuff to a client's upper arm, positioned the stethoscope over the client's brachial artery, inflated the cuff and is now slowly releasing air from the cuff. The nurse should recognize the client's peak blood pressure when what sound is audible?

A faint, clear tapping sound

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. 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 surgical nurse is caring for four clients. Which tasks can the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply.

Attaining an admission weight for a client using a portable bed scale. Ambulating the client who is third day postoperative from right knee surgery. Documenting the urinary output of the client with a Foley catheter.

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?

Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.

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?

Auscultate the apical pulse for 60 seconds

The nurse is teaching the client about a balanced and nutritious diet. Which dietary choices selected by the client indicate an understanding of dietary needs?

Baked potato, salad with olive oil dressing, and lean steak

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?

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 client is diagnosed with bradycardia. For which symptom should the nurse assess first?

Dizziness Bradycardia is a slow heart rate. In many cases, bradycardia is asymptomatic. However, symptoms may include syncope, dizziness, light-headedness, chest pain, shortness of breath and exercise intolerance. Fever, hypertension and pyrexia are not symptoms of bradycardia.

Which statement describes diastolic blood pressure?

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. Diastolic blood pressure occurs when ventricular relaxation happens, and blood pressure is due to elastic recoil of the vessels. Systolic blood pressure is measured during ventricular contraction. Systolic blood pressure is highest when the ventricles of the heart eject blood into the aorta and pulmonary arteries. Blood pressure in general is measured by taking the flow of blood produced by contractions of the heart and multiplying it by the resistance to blood flow through the vessels (P = F × R).

A nurse is educating a postoperative adult client about taking daily temperatures. What statement by the client best indicates understanding of education?

If my temperature is above 99.6°F( 38.3°C) I should call the health care provider." Normal temperatures for an adult range from 97.6°F and 99.6°F (36.5°C and 37.5°C) and a temperature above this should be reported. Taking a temperature right after eating or drinking may raise or lower the reading depending on what was consumed. The axillary route is considered the least accurate route. While a tympanic thermometer may be more accurate in some cases, it is not an accurate method for self-administration of temperature or for postoperative monitoring.

A nurse is assessing an adult client's blood pressure. How should the nurse estimate the client's systolic blood pressure (SBP)?

Inflate the blood pressure cuff while palpating the client's brachial or radial artery.

The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next?

Inflate the cuff about 30 mm Hg above the auscultatory gap.

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?

Inform the client's primary care provider of this assessment finding.

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?

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.

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 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.

Which statement is true regarding the autonomic nervous system and its effect on the rate of a person's pulse?

Sympathetic nervous system activation occurs in response to a variety of stimuli, including changes in intravascular volume. The sympathetic nervous system activation occurs in response to various stimuli, including pain, anxiety, exercise, fever, and changes in intravascular volume. Stimulation of the parasympathetic nervous system results in a decrease in the pulse rate.

The nurse assesses a client admitted with multiple trauma including basilar skull fracture and rhinorrhea (drainage from nose), bilateral otorrhea (drainage from ear), and multiple fractures requiring a full body cast. The client is on a 40% Venturi oxygen mask. What is the best way to evaluate the client's temperature?

Temporal artery The best way to evaluate the client's temperature is the temporal artery since the area is unobstructed. The oral route is not feasible because the client is mouth breathing because of the rhinorrhea (drainage from the nose). The oral route is not accurate when the client is wearing an oxygen mask, too. The tympanic route should not be used because of the basilar skull fracture and the client has otorrhea, or drainage from the ears. The client has a full body cast so it will be difficult to close the arm close to the body, making the axillary route inaccurate.

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.

The client just finished ambulating with physical therapy The client has a temperature of 101.8°F (38.8°C) The client has reports of pain of 8 on a scale of 0 to 10

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 faint, but clear, sound appears.

A client that is an avid runner has been monitoring her pulse at home. Recently, her pulse has been below the normal range of 60-100 bpm for adults. Today her pulse is 58 bpm. The client asks the nurse at her annual screening if she should be concerned. What is the most appropriate response by the nurse?

Well-conditioned athletes can run lower pulse rates because of the greater efficiency and strength of the heart muscle from regular cardiovascular exercise. Physical exercise can cause an increase in pulse rate but well-conditioned athletes can have lower pulse rates because of the greater efficiency and strength of the heart muscle from regular cardiovascular exercise. There is no need to admit this client. Why questions are nontherapeutic and should be avoided, and there is no need for the client to stop running.

The nurse is assessing a client's blood pressure and is having difficulty hearing Korotkoff sounds. What is the most appropriate nursing action?

ask the client to make a fist after cuff inflation

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?

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 best way for a nurse to assess pain in an 18-month-old client is to

observe for behavioral changes. Behavioral changes are common signs of pain and are especially valuable indicators in an 18-month-old client, who has limited verbal skills. Evaluating pupillary response isn't an appropriate technique for assessing pain. Requesting a caregiver report of a client's pain isn't a reliable assessment technique.

The nurse needs to assess the carotid arteries of the client. Which assessment technique would be appropriate for the nurse to use?

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.

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?

Auscultate the client's apical heart rate. 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.

A nurse attempts to count the respiratory rate for a patient via inspection and finds that the patient is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this patient?

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 in the lungs. Pulse oximeter and arterial blood gas results assess respiratory effectiveness.

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?

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.

An older adult client monitors her BP at home. Lately she has been experiencing dizziness and nausea, followed by a headache when she arises from lying down for a nap. She was worried it was her BP so she began taking it after she arose from her nap and found that her BP would drop shortly after getting up from her nap. She followed up with her health care practitioner and was diagnosed with orthostatic hypotension. What is the most appropriate nursing diagnosis to be included in the teaching plan for this patient at this time?

Risk for falls related to inadequate physiologic response to postural (positional) changes Orthostatic hypotension (postural hypotension) is a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing when compared with blood pressure from the sitting or supine position. It results from an inadequate physiologic response to postural (positional) changes in blood pressure. Orthostatic hypotension may be acute or chronic, as well as symptomatic or asymptomatic. It is associated with dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache. Older adults may experience orthostatic hypotension without associated symptoms, leading to falls.

Assessment of the pulse amplitude is accomplished by:

palpating the flow of blood through an artery.