Chapter 25 Vital Signs Prep U
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
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
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 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.
A client has been diagnosed with peripheral vascular disease of the lower extremities. What will the nurse assess to accurately chart the circulation status in the client's legs? Select all that apply.
Pitting edema Pedal pulses Skin temperature of feet Capillary refill time
The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention?
Provide privacy for the client.
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.
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?
Remove the thermometer and assess the blood pressure and heart rate.
After taking vital signs of an older adult, the nurse writes down findings as T = 98.9/37.2 oral, P = 104, R = 18, BP = 120/82. Based on the collected data, which step would the nurse take next?
Take pulse again to assess for tachycardia
The nurse is assessing the pulse of a young adult who is training for a triathlon competition. The pulse rate is 48 beats/min. What education should the nurse provide to the client?
The heart rate is within normal limits due to the exercise regimen the client is following.
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
An ultrasonic Doppler is used for:
auscultating a pulse that is difficult to palpate.
Which pulse site is generally used in emergency situations?
carotid
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:
fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow.
When performing hourly checks, a client reports feeling "different" than earlier in the day. On what schedule will the nurse assess the client's vital signs?
immediately
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.
The nurse discovers during assessment that the client has an altered temperature. Radiation-
infrared heat waves
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
When assessing an infant's axillary temperature, it will be:
1°F (0.5°C) lower than an oral temperature.
While recording the pulse of an infant at 160 beats/min, the parent asks if it is normal for the infant's pulse rate to be so high. Which statement by the nurse best answers the parent's question?
A heart rate of 160 beats/min is normal for a healthy infant.
A 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 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.
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.
While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute. How will the nurse interpret this finding?
Bradypnea is a response to IICP.
Which guideline should the nurse follow when assessing a client's blood pressure using a Doppler ultrasound?
Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery.
The nurse is preparing to assess the client's oral temperature using a digital thermometer. Place the steps in the order in which the nurse will perform them. Use all options.
Check the frequency of vital signs assessment in the client record. Review the previous and most recent temperatures recorded. Ask the client if he or she has consumed anything hot or cold within the past 30 minutes. Perform hand hygiene by washing hands or using hand sanitizer. Insert the temperature probe into a disposable cover until it locks into place. Place the covered probe beneath the tongue to the right or left of the frenulum. Maintain the probe in position until an audible sound occurs. Document temperature reading in the client record.
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
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
Which statement describes diastolic blood pressure?
During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.
The nurse notes that the temperature of an ill client is 101°F (38.3°C). Which intervention would the nurse take to regulate the client's body temperature?
Give the client a bath in tepid water.
The nurse is teaching an adult client how to monitor the pulse rate. Which statement by the client demonstrates understanding of a normal pulse rate?
If my pulse is higher than 100 beats/min at rest, that is considered abnormal."
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 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?
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.
The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct?
Lightly compress the client's radial artery using the first, second, and third fingers.
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.
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 experienced nurse teaching a student to measure an apical pulse includes which critical information? Select all that apply.
The diaphragm of the stethoscope is placed at the fifth intercostal space at the midclavicular line. To determine the apical pulse, count the heartbeats for 1 full minute.
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.
A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify?
The client's most recent temperature
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?
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
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.
Which client's blood pressure best describes the condition called hypotension?
The systolic reading is below 100 and diastolic reading is below 60.
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?
There is an auscultatory gap.
The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next?
Use the Doppler ultrasound device.
A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which action should the nurse perform to obtain the accurate temperature of the client?
Wait for 30 minutes before measuring the oral temperature
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 from 124/82 to 102/70. She called the nurse concerned about her BP. What is the most appropriate information for the nurse to give this client?
You may have orthostatic hypotension and should be seen by your health care provider as soon as you can.
Which client would the nurse consider at risk for low blood pressure?
a client with low blood volume
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 sterile gloves a bedpan
an electronic thermometer with a rectal probe disposable probe cover water-soluble lubricating gel
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
The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mmHg. What is the priority nursing intervention?
ask the client to demonstrate self-blood pressure assessment
The nurse walks into the client's room to pick up the dinner tray and notes the client has not eaten. Which action should the nurse prioritize after noting the client appears sleepy, has perspiration on the forehead, and the face appears flushed?
assess temperature
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 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
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
The nurse discovers during assessment that the client has an altered temperature. Convection
exposure to a fan
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 nurse is caring for a 77-year-old client who is recovering from surgery. After notifying the health care provider of the incident recorded in the client's chart (above), what will the nurse anticipate teaching the client?
postural hypotension
Which term indicates a potentially serious client condition?
pyrexia
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
The home care nurse is assessing a 37-year-old client's vital signs at rest. Which finding requires nursing intervention?
temporal temperature 100.8º F (38.2º C)
The nurse discovers during assessment that the client has an altered temperature. Conduction
the air itself
A pulse deficit is the difference between:
the apical and the radial pulse rates.
The nurse discovers during assessment that the client has an altered temperature. Evaporation
through sweating
