CHAPTER 26 ; VITAL SIGNS PREP U

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? - chronic obstructive pulmonary disease (COPD) - peripheral vascular disease - pulmonary embolism - coronary artery disease

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

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? - "Every infant's heart rate is different, so you will need to discuss that with the health care provider." - "A heart rate of 160 beats/min is actually slow for an infant, so I will ask the health care provider to reassess." - "A heart rate of 160 beats/min is a little too fast for an infant, so I will take it again in 5 minutes." - "A heart rate of 160 beats/min is normal for a healthy infant."

"A heart rate of 160 beats/min is normal for a healthy infant." RATIONALE ; 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.

The nurse has palpated the client's radial artery and identified a heart rate of 88 beats per minute with an irregular rate. What is the nurse's most appropriate action? - Reassess the client's radial pulse in 15 minutes. - Auscultate the client's apical heart rate. - Palpate the radial pulse on the opposite wrist. - Page the client's primary care provider.

- Auscultate the client's apical heart rate. RATIONALE ; Palpation of an irregular radial pulse should be followed by assessment of the apical pulse in order to confirm the finding. Informing the health care provider is generally necessary only when this is a new finding.

The nurse is preparing to assess 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.

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. - 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. - This has no impact on BP readings and he should continue doing what he has been doing. - This is unusual and he should be seen by the health care provider as soon as possible.

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

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

- Palpate one artery at a time. RATIONALE ; 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 obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that may account for this assessment finding? Select all that apply. - The client has a temperature of 101.8°F (38.8°C) - The client has a blood pressure of 122/70 mm Hg - The client has been drinking water - The client just finished ambulating with physical therapy - The client has reports of pain of 8 on a scale of 0 to 10

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

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

- The client's most recent temperature RATIONALE ; 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.

he 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? - let the client sleep - assess temperature - assess blood pressure - call the health care provider

- assess temperature RATIONALE ; The client is showing signs of a fever, which can include pinkish, flushed skin that is warm to touch, restlessness or excessive sleepiness, irritability, poor appetite, glassy eyes and sensitivity to light, increased perspiration, headache, above normal pulse and respiratory rate, disorientation and confusion, convulsions in infants and children, and fever blisters. The nurse should first assess the temperature and then take further steps to care for the client, which will include notifying the health care provider. Letting the client continue to sleep after appropriate treatment will be beneficial to the client. It would also be appropriate to assess all the vital signs; however, the temperature would be the priority in this situation.

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

- decrease the apical pulse. RATIONALE ; Metoprolol is a beta-blocker that will decrease the heart rate. Beta blockers do not decrease glucose levels, respiratory rate or blood volume.

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

- temp - pulse - respiratory rate - blood pressure RATIONALE : Vital signs consist of temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation. Pain is considered the sixth vital sign that a nurse should assess.

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

1700

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

1°F (0.5°C) lower than an oral temperature. RATIONALE; 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 has completed an assessment and notes that the client's blood pressure is 132/92 mmHg. What is this client's pulse pressure? - 132 mmHg - 112 mmHg - 40 mmHg - 224 mmHg

40 mmHg RATIONALE The difference between systolic blood pressure and diastolic blood pressure is called the pulse pressure; 132 − 92 = 40.

Which pulse site is generally used in emergency situations

CAROTID RATIONALE ; - 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 educating a client about ways to increase their cardiac output. Which topic does the nurse include in the teaching

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

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

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. RATIONALE ; 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 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? - Ability to read gauge from any direction. - Need for readjustment is eliminated. - No stethoscope is required. - Inexpensive depending on quality.

No stethoscope is required. RATIONALE ; 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 is caring for a client whose recent medical history includes a pulse deficit. In order to assess for a pulse deficit, what is the nurse's most appropriate action?

Obtain help from a colleague to assist with the assessment RATIONALE ; When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate. Two nurses are required to accurately measure a pulse deficit. One nurse auscultates the apical rate; a second nurse counts the radial rate. They do this simultaneously for 1 minute. To perform this skill in any other manner will result in an inaccurate reading. None of the other listed actions will yield data comparing apical and peripheral pulses.

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 RATIONALE ; 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 needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure? - Brachial artery - Over the lower arm - Over the client's thigh - Radial artery

Over the client's thigh RATIONALE : 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 planning the discharge teaching for a client with a dysrhythmia. Which outcome best reflects achievement of the goal, "The client will demonstrate correct technique in taking his own pulse rate"? - Palpation of the radial pulse on the thumb side of the inner aspect of the wrist. - Light palpation of the femoral pulse below the inguinal area - Firm palpation of bilateral carotid artery for one minute - Firm placement of thumb on the inner wrist of the opposite arm

Palpation of the radial pulse on the thumb side of the inner aspect of the wrist RATIONALE ; 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.

The nurse is obtaining and recording vital signs of an adult client in the emergency department. Which finding should be reported first to the health care provider? - Pulse 51 beats/min - Blood pressure 110/50 mm Hg - Respirations 15 breaths/min - Temperature 99.1°F (37.3°C)

Pulse 51 beats/min RATIONALE ; The normal pulse rate of an adult is 60 to 100 beats/min. As such, the client's pulse rate of 51 beats/min should be reported to the health care provider, especially if symptoms of bradycardia are present. A normal blood pressure is below 120/80 mm Hg, and the client's finding is 110/50 mm Hg. The normal respiratory rate for an adult is 12 to 20 breaths/min, and the client's respirations are within normal limits. The normal temperature for an adult is 98.6°F (37.0°C), and a temperature of 99.1°F (37.3°C) is not clinically significant.

The nurse discovers during assessment that the client has an altered temperature. Select one causative factor for each type of heat loss. RADIATION, CONDUCTION, CONVECTION AND EVAPORATION

Radiation ; infrared heat waves Radiation is heat that is lost to infrared heat waves. It can be accelerated by exposing the skin to the heat waves or prevented by covering the skin. Conduction ; the air itself sympathetic nervous system Conduction describes heat that is lost by transferring from one object to the next. For example, heat is lost from the skin to the air or to water. Evaporation ; through sweating Evaporation consists of heat loss that occurs as water is transformed into a gas, such as with sweating. Convection ; exposure to a fan by goose bumps or pilorection Convection facilitates heat loss via passing air, such as with a breeze or a fan. RATIONALE; Arteriovenous shunts may remain open to facilitate the dissipation of heat from the body. A passing breeze facilitates heat loss via convection. In response to the body's temperature the sympathetic nervous system controls the opening and closing of arteriovenous shunts. Shivering is one mechanism for the body to retain heat. Heat can be lost through uncovered body surfaces by the physical process of radiation. Water in the form of a tepid bath or swimming is one way heat loss can occur through conduction. Insensible loss of body fluids is a form of evaporation that takes place on the skin. "Goose bumps" or piloerection is a natural response of the body to retain heat by reducing the surface area of the skin.

Which site results in measuring a client's core body temperature? - temporal - rectal - axillae - sublingual

Rectal RATIONALE ; 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.

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. ? The nurse performed the assessment in a noisy environment. The nurse misplaced the bell beyond the direct area of the artery. The nurse failed to pump the cuff 20 to 30 mm Hg above disappearing pulse. RATIONALE ; 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 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

She should place her three fingers just below the wrist on the outside of the arm with the palm up. RATIONALE ; 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.

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

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

The nurse has been caring for a client for several days and observes that theh client's blood pressure has been gradually decreasing over the past 36 hours. To which aspect of the client's condition would the nurse attribute this change?

The client continues to have persistent diarrhea RATIONALE ; A decrease in circulating volume, either from blood or fluid loss, results in lower blood pressure. Fluid volume deficit can occur with abnormal, unreplaced losses such as diarrhea or diaphoresis. The other listed factors would not normally lead to decreased blood pressure.

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

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

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

The client sits in the chair with feet flat on the floor and arm below the level of the heart. RATIONALE The client behavior that indicates the need for additional teaching is client sitting in the chair with feet flat on the floor and arm below the level of the heart. Taking a blood pressure with the arm in that position can give a falsely high reading. The client placing the blood pressure on the upper arm just above the antecubital space, the client sitting in the chair with feet flat on the floor and arm supported at the level of the heart, and the client using a blood pressure cuff width at least 40% of the circumference of the midpoint of the arm all indicated correct methodology for self-measuring blood pressure and thus require no need for further teaching.

The nurse is 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 should be encouraged to get a neighbor or family member to help them check their infant's pulse. - This infant will need a home cardiac monitor set up. - 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. - 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.

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. RATIONALE ; 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. - The carotid pulse is bounding. - A baseline pulse rate is needed. - The blood pressure is elevated.

The radial pulse is difficult to obtain. RATIONALE ; Auscultation of the apical pulse provides the most accurate assessment of the pulse rate and is the preferred site when the peripheral pulses are difficult to assess or the pulse rhythm is irregular. While this is an excellent method to determine baseline pulse, it is not the reason for using the apical pulse method. Elevated blood pressure and bounding carotid pulse are not reasons to obtain an apical pulse.

A nurse is explaining to a nursing student why blood pressure is a frequently used assessment parameter in a wide variety of care settings. What can be inferred from an assessment of a client's blood pressure? - The amount of oxygen available to tissues throughout the body - The size of the client's heart muscle - The volume of the venous system relative to the volume of the arterial system - The resistance that the client's heart must overcome when pumping blood

The resistance that the client's heart must overcome when pumping blood RATIONALE ; Blood pressure is representative of the amount of resistance that the heart must overcome in order to pump blood; increased BP equates with increased resistance, or afterload. Blood pressure is not necessarily indicative of oxygen supply, the relative volumes of the venous and arterial systems or the size of the heart.

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. RATIONALE ; 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.

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

Wait for 30 minutes before measuring the oral temperature - The nurse should wait for 15 to 30 minutes and then measure the oral temperature of the client since hot and cold liquids cause slight variations in temperature. - Giving the client a glassful of cold water to drink will not help because the thermometer will still show temperature variation, not the accurate body temperature. - The rectal route is contraindicated in clients with diarrhea, because it can cause mucosal tearing or perforation. Hence, the nurse should not lubricate the client's rectum or measure the rectal temperature. The axillary route is the least accurate and least reliable site.

Clients demonstrating apnea have what? -a temporary cessation of breathing -normal respiratory rate of 20 - increased rate and depth of respirations - decreased rate and depth of respirations

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

The nurse is assessing a client's blood pressure and is having difficulty hearing Korotkoff sounds. What is the most appropriate nursing action? - contact the primary care provider for further instruction - wait a few minutes and then try to assess the BP - ask the client to stand while assessing the BP - ask the client to make a fist after cuff inflation

ask the client to make a fist after cuff inflation RATIONALE Korotkoff sounds result from the vibrations of blood within the arterial wall and changes in blood flow. These sounds occur in phases and correlate with blood pressure measurement. They can be increased by asking the client to make a fist after cuff inflation. Standing for BP assessment is not appropriate, as blood volume changes. Waiting to assess the BP could be problematic if the client is experiencing low BP or an acute change. Contacting the PCP is not appropriate, as there is further nursing action that can be taken.

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

exercise RATIONALE ; 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.

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 - mouth - ear - axilla

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

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) RATIONALE ; The nurse should intervene when the client's temperature is 100.5º F (38.2º C) or higher. If the adult's blood pressure is higher than 120/80 mm Hg or respirations more than 20 breaths/min or pulse rate greater than 100 beats/min, then these would also require the nurse to take appropriate action.

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? - thickness of blood - oxygen levels in blood - volume of air entering the lungs - the ability of the arteries to stretch

the ability of the arteries to stretch RATIONALE ; 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