Ch. 24 (Vital Signs)

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

applying a blanket

An ultrasonic Doppler is used for:

auscultating a pulse that is difficult to palpate.

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

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

1700

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

False

A pulse deficit is the difference between:

The apical pulse and the radial pulse rates.

The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this?

The client is covered with a couple of thick blankets.

When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. Which statement explains this order?

The client's pulse rate is below 60 beats per minute.

The nurse is assessing the blood pressure of a hospitalized client using a Doppler ultrasound device. Which actions are performed correctly? Select all that apply. - The nurse places the client in a comfortable lying or sitting position. - The nurse checks to see that the manometer is in the horizontal position. - The nurse wraps the cuff around the limb smoothly and snugly and fastens it. - The nurse checks that the needle on the aneroid gauge is within the zero mark. - The nurse opens the valve to the sphygmomanometer once the pulse if found. - The nurse centers the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery.

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

Which are considered vital signs? Select all that apply.

-Respiratory rate -Blood pressure -Temperature -Pulse

A client is taking medications to treat a heart dysrhythmia. Which site should be used to assess the pulse in this client?

Apical

Which peripheral pulse site is generally used in emergency situations?

Carotid

Which client should not have a temperature assessed rectally?

Client with diarrhea

Which is not a characteristic used to describe the pulse?

Depth

Which describes diastolic blood pressure?

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

A client has smoked most of his life and has labored respirations. He is experiencing:

Dyspnea

Which condition will lead to an increase in cardiac output?

Exercise

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

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

During a routine vital sign assessment, the nurse notes the client's blood pressure is 212/110. Why is this finding particularly significant?

It deviates from normal and is significant.

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?

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.

Which of the following sites results in measuring a client's core body temperature?

Rectal

A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature?

Rectum

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.

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.

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

Wait 30 minutes, then assess the oral 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.

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?

the ability of the arteries to stretch

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."

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:

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

When taking the client's temperature, the student nurse will require further education when he states:

"The axillary route is the most accurate of all routes."

The home care nurse notices that the client only has a glass thermometer. What is the best response by the nurse?

"Would you consider using a digital thermometer?"

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

- Femoral - Posterior tibial - Popliteal - Dorsalis pedis

When assessing an infant's axillary temperature, it will be:

1°F (0.5°C) lower than an oral temperature

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

97.6°F to 99.6°F (36.4°C to 37.6°C)

A nurse attempts to count the respiratory rate for 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.

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.

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.

A nurse is caring for four adult clients. Which client would the nurse assess first? A) Client with a heart rate of 88 bpm B) Client with a blood pressure of 120/60 mm Hg C) Client with a respiratory rate 32/min D) Client with a temperature 98.6°F (37°C)

C) Client with a respiratory rate 32/min

A nurse needs to count a client's apical heart rate. Which assessment site is most suitable for counting the apical heart rate?

Chest

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will do what?

Decrease the apical pulse.

A client has been diagnosed with peripheral vascular disease of the lower extremities. What site would the nurse use to assess circulation of the legs?

Dorsalis pedis artery

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 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.

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

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

A nurse 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.

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

Nurse R. may obtain a blood pressure reading that is higher than the actual blood pressure.

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?

Oral fluids

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

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.

Which term indicates a potentially serious client condition?

Pyrexia

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.

A client that 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.

An 80-year-old client has a body temperature of 97°F (36°C). Which condition best accounts for this client's temperature reading?

Temperature drops with age.

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.

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.

A 70-year-old client is taking his own pulse at home. He is following the instructions provided by the nurse. He counts his pulse 62 times in one minute. What should he do next?

Write it down