Chapter 25 Vital Signs - Coursepoint Quiz

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

A. 97.6°F to 99.6°F (36.4°C to 37.6°C). p. 652 Normal adult oral temperature ranges from 97.6°F to 99.6°F (36.4°C to 37.6°C).

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. p. 645 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 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. Auscultate the lung sounds and count respirations. B. Administer oxygen. C. Perform a pain assessment. D. Notify the primary care provider.

A. Auscultate the lung sound and count respirations p. 656 - 657 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 physician 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 physician's order.

Which peripheral pulse site is generally used in emergency situations? A. Carotid B. Radial C. Apical D. Temporal

A. Carotid p. 652 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.

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

A. Listen for heart sounds. p. 653 The apex of the heart is found after 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 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 client's thigh B. Over the lower arm C. Radial artery D. Brachial artery

A. Over the client's thigh p. 667 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 has assessed a pulse deficit when taking the pulse of a client. What does this assessment indicate for the client? Select all that apply. A. The apical pulse is higher than the radial pulse. B. The health care provider should be notified of any increase in pulse deficit. C. the difference between apical and peripheral pulse rate D. the pulse pressure created when there is friction between the blood and the vessel walls E. the total volume of blood during ventricular contraction

A. The apical pulse is higher than the radial pulse B. The health care provider should be notified of any increase in pulse deficit C. the difference between apical and peripheral pulse rate p. 656 - 657 When some of the ventricular contractions do not perfuse, a difference exists between the apical and peripheral pulses—a pulse deficit. When a pulse deficit is present, the radial pulse rate is always lower than the apical pulse rate. Stroke volume, or the amount of blood, may vary from beat to beat during cardiac contraction, resulting in a pulse wave so weak that it cannot be perceived by palpation at a peripheral site. It is important to recognize this situation because it provides information about the heart's ability to perfuse the body adequately. Document and report to the provider any new finding of a pulse deficit so that evaluation and follow-up can occur.

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 has a temperature of 101.8°F (38.8°C) D. The client just finished ambulating with physical therapy E. The client has been drinking water

A. The client has reports of pain of 8 on a scale of 0 to 10 C. The client has a temperature of 101.8°F (38.8°C) D. The client just finished ambulating with physical therapy p. 653 - 654 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? A. The client is covered with a couple of thick blankets. B. The client is showing initial signs of infection. C. The thermometer is broken. D. A rectal thermometer must be used.

A. The client is covered with a couple of thick blankets. p. 647 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 taking a blood pressure measurement to assess for orthostatic hypotension in a client. Which signs and symptoms will the nurse assess related to this condition? Select all that apply. A. Pallor B. The client states, "I feel lightheaded when sitting up." C. Erythema is present on the bilateral lower extremities D. Client reports feeling palpitations when rising from a supine to a standing position. E. Client reports feeling dizzy when sitting up from a supine position. F. The client has a temperature of 100.4 F

A. The client states, "I feel lightheaded when sitting up." D. Client reports feeling palpitations when rising from a supine to a standing position E. Client reports feeling dizzy when sitting up from a supine position. p. 662 Orthostatic hypotension occurs when the client's blood pressure decreases when moving from a sitting or lying position to a standing position. The systolic pressure drops by at least 20 mm Hg or the diastolic decreases by at least 10 mm Hg within 3 minutes of rising to the standing position. Common signs and symptoms of orthostatic hypotension include dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headaches.

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 Doppler ultrasound device. B. Connect the client to the oxygen saturation monitoring device. C. Use the Bell side of the stethoscope to listen. D. Ask another student nurse to check it for him.

A. Use the Doppler ultrasound device. p. 655 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.

A nurse is assessing the blood pressure of a client who has come to the health care facility for the first time. What is the best site for obtaining the client's blood pressure reading? A. arm B. wrist C. shoulder D. thigh

A. arm p. 666 The first time the blood pressure is measured, it is assessed in each arm. The two blood pressure measurements should not vary more than 5 to 10 mm Hg unless pathology (disease) is present. The blood pressure is not measured in shoulders, wrist, or thighs of clients for the first time. Nurses use the thigh to assess the blood pressure when they cannot obtain readings in either of the client's arms.

Which piece of equipment is no longer used for temperature measurement? A. glass mercury thermometer B. tympanic membrane thermometer C. paper thermometer D. electronic thermometer

A. glass mercury thermometer p. 650 Glass mercury thermometers are no longer used due to the dangers of exposure to mercury.

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: A. orthopnea B. tachypnea C. bradypnea D. apnea

A. orthopnea p. 658 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.

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which health problem should the nurse consider when client falls occur? A. orthostatic hypotension B. primary hypertension C. secondary hypertension D. dyspnea

A. orthostatic hypotension p. 662 Orthostatic hypotension is associated with weakness or fainting when one rises to an erect position. Hypertension and dyspnea do not typically result in loss of balance and/or consciousness. Dyspnea is difficult or labored breathing. Essential or primary hypertension is high blood pressure. Secondary hypertension (secondary high blood pressure) is high blood pressure that's caused by another medical condition.

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

A. palpation of the radial pulse on the thumb side of the inner aspect of the wrist. p. 657 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.

What organ is the primary site of heat loss in the body? A. skin B. lungs C. heart D. kidneys

A. skin p. 646 The skin is the primary site of heat loss in the body. The lungs, heart, and kidneys are located in the body and do not lose heat outwardly like the skin.

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 pulse rate is below 60 beats per minute. B. The client is unable to stay upright when blood pressure is checked. C. The client's systolic blood pressure is less than 100 mm Hg. D. The client's respiratory rate is less than 18 breaths per minute.

A. the pulse rate is below 60 beats per minute p. 653 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 24 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 less than 140 mm Hg. Bradycardia is not associated with a client having to sit upright when the blood pressure is checked.

The nurse is teaching a newly diagnosed hypertensive client how to take his or her own BP at home. The client asks why it is so important to do this. What is the nurse's best response? A. "Your BP measurements at home are more accurate than the ones we do in the health care setting." B. "Monitoring your BP at home will assist in controlling your BP, thereby decreasing your risk for heart attack and stroke." C. "You must do this because the doctor ordered it." D. "Because it is required by your insurance."

B. "Monitoring your BP at home will assist in controlling your BP, thereby decreasing your risk for heart attack and stroke." p. 670 Teaching a client to monitor his or her BP at home has been shown to increase compliance with a treatment plan, thereby assisting in the control of blood pressure and decreasing the risk for stroke and heart attack. The other three answers are not appropriate statements to encourage the client's participation in this activity.

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

B. 1°F (0.5°C) lower than an oral temperature. p. 651-652. 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 is performing a telephone follow-up with parents whom she taught to monitor their newborn's BP and pulse at home. Which results reported by the parents would indicate that the parents are performing the technique correctly and there is no cause for concern? A. 120/80 mm Hg and 60 bpm B. 80/50 mm Hg and 145 bpm C. 102/61 mm Hg and 75 bpm D. 90/50 mm Hg and 85 bpm

B. 80/50 mm Hg and 145 bpm p. 645 Newborns and infants have higher heart rates and lower BP than adults. The heart rate decreases with age and the BP increases with age. The normal range for newborn heart rate is 70-190 bpm and a BP of 80/50 is acceptable. All of the other heart rates in the examples above fall below the normal range for newborns and should cause concern.

The nurse needs to obtain an admission weight for a client diagnosed with end-stage lung cancer. To obtain the client's weight, what should the nurse do first? A. Monitor for the presence of tubes or lines. B. Assess the client's ability to stand or sit. C. Evaluate the client's level of pain. D. Place a cover over the sling of the bed scale.

B. Assess the client's ability to stand or sit p. 738 - 740 The nurse must first assess the client's ability to sit, stand, or lie still to identify the appropriate type of scale to use. Evaluating pain or presence of lines would be done after identifying the type of scale to use. If a portable bed scale is indicated, the nurse would place a cover over the sling of the bed scale.

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. Auscultate the client's apical heart rate. C. Page the client's primary care provider. D. Palpate the radial pulse on the opposite wrist.

B. Auscaltate the client's apical heart rate. p. 657 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 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 primary care provider. B. Auscultate the lung sounds and count respirations. C. Perform a pain assessment. D. Administer oxygen.

B. Auscaltate the lung sounds and count respirations. p. 656 - 657 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 physician 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 physician's order.

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

B. Auscultate the apical pulse for 60 seconds p. 681 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.

Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs? A. increased respiration rate B. increased pulse rate C. increased blood pressure D. increased temperature

B. Increased pulse rate p. 653 When the stroke volume decreases, such as when blood volume is decreased because of hemorrhage, the heart rate increases to try to maintain the same cardiac output. Respirations may increase, but the primary response is the increase in the heart rate. The blood pressure would decrease. Temperature is not affect initially in hemorrhage.

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

B. Lightly compress the client's radial artery using the first, second, and third fingers. p. 678 - 680 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.

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? A. The first audible sounds cease to be distinct. B. The first faint, but clear, sound appears. C. The initial Korotkoff sounds peak in intensity. D. The first audible sounds begin to decrease in intensity.

B. The first faint, but clear, sound appears. p. 681 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.

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 viewed the meniscus from below eye level. B. The nurse misplaced the bell beyond the direct area of the artery. C. The nurse applied a cuff that is too narrow. D. The nurse used a manometer not calibrated at the zero mark. E. The nurse failed to pump the cuff 20 to 30 mm Hg above disappearing pulse. F. The nurse performed the assessment in a noisy environment.

B. The nurse misplaced the bell beyond the direct area of the artery. E. The nurse failed to pump the cuff 20 to 30 mm Hg above disappearing pulse. F. The nurse performed the assessment in a noisy environment p. 667 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.

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? A. To call her health care provider B. 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. C. To take the medication that she missed and retake her BP D. Not to worry and to take double the dose of BP medication

B. 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. p. 669 - 670 HBPM readings are the ideal method for monitoring response to treatment for high BP. This client's average BP after not taking her medication is 138/87 and is not 10 more than what her HBPM reading has been. Clients should be taught when performing HBPM that they should call the health care provider if the averages of HBPM readings increase/decrease by 10, or if she has any concerns. The client should not be told to take double the dose of medication or to take the doses she missed; this is unsafe advice without consulting a health care provider.

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 ear tip of the stethoscope pointing backwards while taking blood pressure B. elevating the client's arm at heart level C. using a medium size cuff for a 10-year-old, average weight client D. the client reporting moderate pain for the past 4 hours

B. elevating the client's arm at heart level p. 669 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.

Assessment of the pulse amplitude is accomplished by: A. auscultating the area of the left ventricle. B. palpating the flow of blood through an artery. C. auscultating the flow of blood through an artery. D. palpating the area of the left ventricle.

B. palpating the flow of blood through an artery. p. 654 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.

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. coronary artery disease B. peripheral vascular disease C. pulmonary embolism D. chronic obstructive pulmonary disease (COPD)

B. peripheral vascular disease p. 659 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.

Which term indicates a potentially serious client condition? A. afebrile B. pyrexia C. eupnea D. pulse pressure

B. pyrexia p. 647 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 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. rectum C. axilla D. mouth

B. rectum p. 652 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 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 volume of air entering the lungs B. the ability of the arteries to stretch C. the oxygen levels in the blood D. the thickness of circulating blood

B. the ability of the arteries to stretch p. 652 - 654 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 client's blood pressure has gradually decreased in the last 2 days. Which condition would cause this change? A. the client who has unresolved pain issues B. the client who has had persistent diarrhea C. the client who is to be discharged home on hospice D. the client who has been given 3 units of whole blood

B. the client who has had persistent diarrhea p. 661 -662 Vital signs—body temperature (T), pulse (P), respirations (R), and blood pressure (BP)—indicate the function of some of the body's homeostatic mechanisms. Measurement and interpretation of the vital signs are important components of assessment that can yield information about underlying health status.

When taking the client's temperature, the student nurse will require further education when they state: A. "Rectal temperature is contraindicated for cardiac clients." B. "The use of disposable probes is important when taking temperature." C. "The axillary route is the most accurate of all routes." D. "I should avoid using the oral route when taking an infant's temperature."

C. "The axillary route is the most accurate of all routes." p. 652 Use judgment when selecting the route to measure temperature. The most commonly used sites are the mouth, rectum, ear (tympanic), forehead (temporal artery), and axilla. The least accurate temperature measurement is the axilla because it can register up to a degree lower than rectal or other methods of taking the internal temperature. Rectal temperature is contraindicated for cardiac clients as it can cause the client to vasovagal and cause a lethal arrhythmia. The use of disposable probes is important when taking temperature as it reduces transmission of pathogens between clients. The oral temperature should be avoided in children as they are mouth breathers and this would affect the temperature.

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

C. 1700 p. 646 Body temperature fluctuates throughout the day. Temperature is usually lowest around 0300 and highest from 1700 to1900.

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

C. 30 to 60 breaths/min p. 645 When assessing the respiratory rate of an infant, 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. Tachypnea is an abnormally fast respiratory rate, usually higher than 20 breaths/min in the adult; bradypnea is an abnormally slow respiratory rate, usually lower than 12 breaths/min in the adult.

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. 112 mmHg B. 132 mmHg C. 40 mmHg D. 224 mmHg

C. 40 mm Hg p. 681 The difference between systolic blood pressure and diastolic blood pressure is called the pulse pressure; 132 − 92 = 40.

The nursing student is selecting a blood pressure cuff prior to obtaining a client's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading? A. 60% of the circumference of the limb to be used B. 50% of the circumference of the limb to be used C. 40% of the circumference of the limb to be used D. 70% of the circumference of the limb to be used

C. 40% of the circumference of the limb to be used p. 663 The width of the cuff should be about 40% of the circumference of the limb to be used. All the other options would cause the cuff to be too small for a client.

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 carotid pulse. B. Get another nurse for validation. C. Assess the apical pulse. D. Document the findings.

C. Assess the apical pulse. p. 678 - 680 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.

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

C. Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2. p. 680 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, not respiratory rate.

Which client should not have a temperature assessed rectally? A. Client with ALS B. Client with cancer C. Client with diarrhea D. Client with a herniated disc

C. Client with diarrhea p. 652 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.

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. Use the bell of the stethoscope to listen for the diastolic sound. C. Inflate the cuff about 30 mm Hg above the auscultatory gap. D. Inflate the cuff about 10 mm Hg above the auscultatory gap.

C. Inflate the cuff about 30 mm Hg above the auscultatory gap. p. 684 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 nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff? A. Elevate arm above heart level before inflating the cuff. B. Fully inflate cuff for about 1 minute. C. Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared. D. Place cuff 8 cm above the elbow.

C. Inflate the cuff to 30 mm Hg above the reading where brachial pulse disappeared. p. 684 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 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. This is unusual and he should be seen by the physician as soon as possible. B. This has no impact on BP readings and he should continue doing what he has been doing. C. 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. D. 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. 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. p. 666 It has been found that most people have differences in BP between arms. For accurate results, the client should use the arm that gives him or her the highest reading.

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? A. Pulse is strong and remains strong despite moderate pressure. B. Pulse is felt easily, and moderate pressure causes it to disappear. C. Pulse is felt with difficulty and disappears with slight pressure. D. Pulse is strong, and light pressure causes it to disappear.

C. Pulse is felt with difficulty and disappears with slight pressure. p. 652-653 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 site results in measuring a client's core body temperature? A. Tympanic B. Oral C. Rectal D. Axillary

C. Rectal p. 651 - 652 Rectal temperature is considered to be the most accurate route for obtaining core body temperature. Surface body temperatures are measured at oral (sublingual), temporal, and axillary sites.

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 take her pulse after her medication so that her pulse is stronger. B. She needs to press harder until she feels a pulse. C. She should place her three fingers just below the wrist on the outside of the arm with the palm up. D. She should stand when taking her pulse to increase blood flow.

C. She should place her three fingers just below the wrist on the outside of the arm with the palm up. p. 669 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 service 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.

Which statement is true regarding the autonomic nervous system and its effect on the rate of a person's pulse? A. Stimulation of the sympathetic nervous system results in a decrease in the pulse rate. B. The sympathetic nervous system is the dominant activation during resting states. C. Sympathetic nervous system activation occurs in response to a variety of stimuli, including changes in intravascular volume. D. Stimulation of the parasympathetic nervous system results in an increase in the pulse rate.

C. Sympathetic nervous system activation occurs in response to a variety of stimuli, including changes in intravascular volume. p. 653 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.

A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify? A. The client's wellness goals B. Preferred site for temperature assessment C. The client's most recent temperature D. The client's nutritional status

C. The client's most recent temperature P. 670 - 677 Prior to assessment, the nurse should note the client's baseline or previous temperature measurements. Assessment results must always be considered in light of client-specific baselines. The client's wellness goals are important, but these are not directly relevant to temperature assessment. Similarly, nutritional status has a minimal bearing on temperature assessment. The client's preferred site for assessment is important, but the nurse ultimately determines the most appropriate site based on nursing knowledge.

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

C. The systolic reading is below 100 and diastolic reading is below 60. p. 661 Hypotension is defined by a systolic pressure below 100 mm Hg and diastolic pressure less than 60 mm Hg. The top number refers to the amount of pressure in the arteries during the contraction of heart muscle. This is called systolic pressure. The bottom number refers to the blood pressure when the heart muscle is between beats. This is called diastolic pressure. Ideal blood pressure is less than 140/90.

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

C. a client with low blood volume p. 661 -662 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 client is self-monitoring blood pressure at home and reports that every reading is 150/90 mmHg. What is the priority nursing intervention? A. report readings to primary care provider B. provide the client with a larger blood pressure cuff C. ask the client to demonstrate self-blood pressure assessment D. recommend lower sodium in the client's diet

C. ask the client to demonstrate self-blood pressure assessment p. 660 - 661 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. aiding palpation of diastolic blood pressure. B. auscultating diastolic blood pressure. C. auscultating a pulse that is difficult to palpate. D. aiding palpation of pulse and rhythm.

C. auscultating a pulse that is difficult to palpate. p. 655 A Doppler device can be used to detect a pulse that is not easily palpable.

Which condition will lead to an increase in cardiac output? A. sleep B. dehydration C. exercise D. decrease in blood pressure

C. exercise p. 653 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 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 no room to slip a fingertip under the cuff and should be 2 in (5 cm) above the crease of the elbow. B. 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. C. 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. D. 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 a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow. p. 669 - 670 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.

The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with: A. increased cardiac output. B. decreased respirations. C. increased temperature. D. decreased heart rate.

C. increased temperature p. 646 Body temperature can fluctuate with exercise, changes in hormone levels, changes in metabolic rate, and extremes of external temperature.

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 transition from tapping sounds to muffled sounds B. the last sound before there is complete and continuous silence C. the first appearance of faint but distinctive tapping sounds D. the first sound that is audible after the auscultatory gap

C. the first appearance of faint but distinctive tapping sounds p. 655 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 patients, 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.

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 closely woven dark fabric wrapped around the baby." D. "It is because of the immature ability to regulate temperature in general."

D. "It is because of the immature ability to regulate temperature in general." p. 649 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 is assessing an adult client's blood pressure. How should the nurse estimate the client's systolic blood pressure (SBP)? A. Note the SBP that was documented during the client's last vital signs assessment. 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. Inflate the blood pressure cuff while palpating the client's brachial artery.

D. Inflate the blood pressure cuff while palpating the client's brachial artery. p. 681 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 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. Need for readjustment is eliminated. B. Ability to read gauge from any direction. C. Inexpensive depending on quality. D. No stethoscope is required.

D. No stethoscope is required. p. 663 - 664 An electronic manometer eliminates the need for a stethoscope. However, an electronic manometer requires a calibration check 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 electronic 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. Measure the rate for 30 seconds and multiply by 2. C. Measure the rate for 1 full minute. D. Palpate one artery at a time.

D. Palpate one artery at a time. p. 678 - 680 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 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? A. Leave the thermometer in and notify the physician. B. Call for assistance and anticipate the need for CPR. C. Remove the thermometer and assess the temperature via another method. D. Remove the thermometer and assess the blood pressure and heart rate.

D. Remove the thermometer and assess the blood pressure and heart rate. p. 652 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 physician 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.

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 measuring the BP 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 client at this time? A. Acute confusion related to hypotension B. Sedentary lifestyle related to frequent afternoon naps C. Knowledge deficit related to the inability to take an accurate BP at home D. Risk for falls related to inadequate physiologic response to postural (positional) changes

D. Risk for falls related to inadequate physiologic response to postural (positional) changes p. 662 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.

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 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. C. The parents should be encouraged to get a neighbor or family member to help them check their infant's pulse. D. 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 have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse. p. 654 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 an adult diastolic pressure. B. There is a nonauscultatory gap. C. There is a widening in the diameter of the artery. D. There is an auscultatory gap.

D. There is an auscultatory gap p. 665 An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mmHg. 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 records a pulse rate of 170 beats/min on a client's electronic health record. For which client would this be considered a normal assessment finding? A. a woman in the third trimester of her pregnancy B. a school-aged child who is visibly anxious C. an older adult with chronic lung disease D. a healthy newborn infant

D. a healthy newborn infant p. 645 For a newborn, a pulse rate of 70 to 190 beats/min is considered normal. A pulse of 170 would constitute tachycardia in each of the other listed clients.

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. carotid B. brachial C. radial D. apical

D. apical p. 657 The apical pulse is assessed when a client is being given medications that alter heart rate and rhythm.

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? A. arrange for cardiac monitoring B. palpate the client's apical pulse C. auscultate the client's brachial artery D. auscultate the client's apical pulse

D. auscaltate the client's apical pulse p. 652 - 655 When peripheral pulses are difficult to palpate, it is appropriate to auscultate the apex. This is preferable to auscultating a peripheral site, such as the brachial artery, and more accurate than attempting to palpate the apical pulse. Cardiac monitoring is not necessarily indicated in this case.

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will: A. decrease the blood glucose. B. decrease the respiratory rate. C. decrease the blood volume. D. decrease the apical pulse.

D. decrease the apical pulse. p. 656 Certain cardiac medications, such as digoxin, decrease the heart rate.

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

D. depth p. 653 - 654 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 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. brisk, expected (normal) B. absent, unable to palpate C. bounding D. diminished, weaker than expected

D. diminished, weaker than expected p. 654 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.

A client has smoked most of his life and has labored respirations. He is experiencing: A. fremitus B. stridor C. wheeze D. dyspnea

D. dyspnea p. 658 Dyspnea describes respirations that require excessive effort.

A person's core body temperature is highest in the early morning and lowest in the late afternoon. True or False

False p. 646 There are individual variations of these temperatures as well as variations related to age, gender, physical activity, state of health, and environmental temperatures. Body temperature also varies during the day, with temperatures being lowest in the early morning and highest in the late afternoon.

During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant. True or False

True p. 675 During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant. Careful insertion is expected during a rectal temperature procedure. Lubrication of the tip of the thermometer probe is necessary.