Prep U Ch 24 Vital signs

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

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

the first appearance of faint but distinctive tapping sounds

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

80/50 mm Hg and 145 bpm

The nurse is performing a telephone follow-up with parents that she taught to monitor their newborn's BP and pulse at home. What results reported by the parents would indicate that the parents are performing the technique correctly and there is no cause for concern?

Wait 30 minutes, then assess oral temperature.

The nurse is preparing to assess the client's vital signs. The client just had their morning coffee. What is the appropriate nursing intervention?

palpating the flow of blood through an artery

Assessment of the pulse amplitude is accomplished by:

Assessment of blood pressure is impeded

A client has had a left-side mastectomy. How does this affect the blood pressure assessment?

Encourage the client to use an alternative thermometer to measure temperature at home

A client informs the nurse that she uses a mercury thermometer to take the temperature of her children when they are sick. What health education is most appropriate?

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.

A client monitoring his BP at home notices that his BP is higher in one arm than the other so he calls his health care provider for guidance. What is the most appropriate information for the nurse to give this client?

oral fluids

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

No action is needed, these are normal assessments.

A nurse documents the following assessment for an infant: temperature 98.9°F (37.2°C), pulse 90 bpm, respirations 35 bpm, and blood pressure 85/73. What is the next appropriate action of the nurse based on these assessments?

a faint, clear tapping sound

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

"It is because of the immature ability to regulate temperature in general."

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?

There is an auscultatory gap.

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?

the ability of the arteries to stretch

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?

30 to 60 bpm

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

a harsh, inspiratory sound that may be compared to crowing

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

The resistance that the client's heart must overcome when pumping blood

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?

Perform the blood pressure last

A nurse is taking the vital signs of a 9-year old child who is anxious about the procedures. Which nursing action would be appropriate when assessing this child?

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

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

applying a blanket

The nurse assesses that a client is shivering. Which intervention is most appropriate to prevent further stress on the body?

diastolic blood pressure

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

respirations

Infants and children's pulses vary most with:

peripheral vascular disease

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?

Diaphoresis

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

Ask the client to demonstrate self-blood pressure assessment.

The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mm Hg. What is the priority nursing intervention?

the client who has had persistent diarrhea

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

97.6 to 99.6

The normal adult temperature obtained through the oral route ranges from:

An electronic thermometer with a rectal probe Disposable probe cover Water-soluble lubricating gel

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.

B,C,D

The nurse is providing discharge education for a client diagnosed with hypertension. Which teaching points about monitoring blood pressure should the nurse include in the plan? Select all that apply. a. Use the blood pressure devices in public places to measure BP whenever possible. b. Recommend taking the blood pressure every day at the same time. c. Recommend a cuff size appropriate for the client's limb size. d. If using a forearm monitor, tell the client to keep wrist at heart level when using it.

Remove the thermometer and assess blood pressure and heart 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?

"I know it seems fast, but normal infant heart rates are 100-160 beats per minute."

The nurse is taking the apical pulse of a 6-month-old infant. Upon completion, the nurse tells the parent the baby's pulse is 140 beats per minute. The parent is concerned, stating, "That seems kind of high!" The nurse responds:

the 65-year old male who just finished drinking coffee

The nurse is taking the client's temperature. The nurse understands that the rectal route is one of the most reliable. Which client can safely handle the rectal route of taking temperature?

"Monitoring your BP at home will assist in controlling your BP, thereby decreasing your risk for heart attack and stroke."

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?

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 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:

elevating the client's arm at heart level

The nurse understands that accurate blood pressure taking is dependent on several factors. Which example will most likely render an accurate blood pressure reading?

40% of the circumference of the limb being used

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?

elevated temperature

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

Increased Pulse Rate

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

Skin

What organ is the primary site of heat loss in the body?

Thready pulse

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

Stress, Fever, Exercise

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

a client with low blood volume

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

being in a warm environment

Which factor is not known to cause false blood pressure readings?

Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery itself.

Which is an accurate guideline to follow when assessing blood pressure using a Doppler ultrasound?

Depth

Which is not a characteristic used to describe the pulse? Frequency Quality Rhythm Depth

hemorrhage

Which of the following pathologic conditions would result in release of ADH by the posterior pituitary?

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

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

Galloping

Which term is not used to describe the quality of a person's pulse?

Bounding pulse

pulse that feels as though your heart is pounding or racing.

false

true or false: inspiration is a passive process.