Chapter 25 Vital Signs THE POINT

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. Explanation: When performing blood pressure assessment via Doppler ultrasound, the nurse will have the client assume a comfortable lying or sitting position with the appropriate limb exposed and center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery. If using a mercury manometer, the nurse will check to see that the manometer is in the vertical position and that the mercury is within the zero level with the gauge at eye level. The nurse then hold the Doppler in the nondominant hand. Using the dominant hand, the nurse places the Doppler tip in the gel, adjusts the volume as needed, and moves the Doppler tip around until hearing the pulse.

When assessing a client's respiratory rate, the nurse should take which action?

Do it immediately after the pulse assessment so the client is unaware of it. Explanation: Move immediately from the pulse assessment to counting the respiratory rate to avoid letting the client know the nurse is counting respirations. Clients should be unaware of the respiratory assessment because, if they are conscious of the procedure, they might alter their breathing patterns or rate. Thus, the nurse should not tell the client to breathe normally or deeply. Using a watch with a second hand, count the number of respirations for 30 seconds. Multiply this number by 2 to calculate the respiratory rate per minute.

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. Explanation: 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.

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.

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) Explanation: 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 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. Explanation: 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.

Which term indicates a potentially serious client condition?

pyrexia Explanation: 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 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 Explanation: 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.

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

1°F (0.5°C) lower than an oral temperature. Explanation: 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 surgical nurse is caring for four clients. Which tasks can the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply.

Attaining an admission weight for a client using a portable bed scale. Ambulating the client who is third day postoperative from right knee surgery. Documenting the urinary output of the client with a Foley catheter. Explanation: Using a portable bed scale for a weight, ambulating a stable client, and documenting urinary output are within the capability and scope of practice of UAP. The nurse should change the dressing, obtain initial vital signs, and teach clients. These tasks are not within the scope of practice of UAP, because they require assessing and educating the clients.

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." Explanation: Dehydration is a cause for orthostatic hypotension, which causes a temporary drop in BP when the client rises from a reclining position. Dizziness is not associated with environmental changes. Dizziness or changes in orthostatic BP occurs when baroreceptors do not respond quickly enough to restore adequate circulation to the brain. Dizziness may be caused by low blood pressure. However, the client is dizzy with ambulation not when lying down.

Which statement describes diastolic blood pressure?

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. Explanation: Diastolic blood pressure occurs when ventricular relaxation happens, and blood pressure is due to elastic recoil of the vessels. Systolic blood pressure is measured during ventricular contraction. Systolic blood pressure is highest when the ventricles of the heart eject blood into the aorta and pulmonary arteries. Blood pressure in general is measured by taking the flow of blood produced by contractions of the heart and multiplying it by the resistance to blood flow through the vessels (P = F × R).

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. Explanation: 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 is using a hypothermia blanket as ordered on an adult client with an uncontrolled fever. Which statement accurately describes the safe and effective use of this type of equipment?

Position the blanket under the client so that the top edge of the pad is aligned with the client's neck. Explanation: The nurse should position the blanket under the client so that the top edge of the pad is aligned with the client's neck; use an esophageal probe for clients who are comatose or anesthetized; cover the hypothermia blanket with a thin sheet or bath blanket; and apply lanolin or a mixture of lanolin and cold cream to the client's skin where it will be in contact with the blanket.

During the time a client is on a hypothermia blanket, the nurse turns and positions the client every 30 to 60 minutes. What assessments will the nurse complete on each turn? Select all that apply.

Skin color change Lip and nail bed changes Sensory impairment Explanation: On each client turn, the nurse assesses the client's skin, looking for any color changes to the skin, lips, and nail beds, as well as any areas where there is sensory deficit. A neurological assessment is completed every 15 minutes until the body temperature is stabilized. Additional assessments would include evaluating for shivering and facial muscle twitching, but these are not part of a skin assessment.

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. Explanation: 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.

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. Explanation: 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 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. Explanation: 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 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 15 to 20 minutes before measuring the oral temperature Explanation: The nurse should wait for 15 to 20 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.

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

a client with low blood volume Explanation: 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.

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

advanced age Explanation: It is common for older adults to have body temperatures less than 97°F (36°C), because normal temperature drops as a person ages.

The nurse is assessing a client's blood pressure and is having difficulty hearing Korotkoff sounds. What is the most appropriate nursing action?

ask the client to make a fist after cuff inflation Explanation: 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 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 Explanation: 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.

An ultrasonic Doppler is used for:

auscultating a pulse that is difficult to palpate. Explanation: A Doppler device can be used to detect a pulse that is not easily palpable.

Which pulse site is generally used in emergency situations?

carotid Explanation: 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.

Which is not a characteristic used to describe the pulse?

depth Explanation: 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.

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?

orthostatic hypotension Explanation: 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.

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?

peripheral vascular disease Explanation: 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.

A pulse deficit is the difference between:

the apical pulse and the radial pulse rates. Explanation: When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate.

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." Explanation: The normal pulse rate for an adult is 60 to 100 beats/min. The statement, "If my pulse is above 100 beats/min at rest, that is considered abnormal" demonstrates understanding of the normal pulse rate. The normal respiratory rate is 12 to 20 breaths/min. Calling the health care provider for a pulse rate lower than 80 beats/min is incorrect, as a pulse of 60 beats/min is within normal range. The pulse often lowers at night during sleep; however, a rate of 40 beats/min should be investigated.

The nurse has requested the unlicensed assistive personnel (UAP) check the temperature of a 19-month-old client who has been admitted for pneumonia. Which reading should the nurse question if noted in the record?

102.4°F/39.1°C (T) Explanation: There are several ways to assess the temperature of a client: oral (O), rectal (R), axillary (AX), tympanic (T), and temporal artery (TA). The nurse should question the use of the tympanic thermometer. It is contraindicated for children younger than 2 years due to the smaller size of the ear canal. It is too small for the probe and an accurate reading cannot be obtained. In normal healthy adults the shell temperature generally ranges from 96.6°F to 99.3°F (35.8°C to 37.4°C); core body temperatures ranges from 97.0°F to 99.5°F (36.0°C to 37.5°C). Rectal and arterial temperatures are generally 1°F (0.5°C) higher than oral and 2°F (1°C) higher than axillary. The baseline temperatures for each method are: oral 98.5°F (37.0°C), rectal 99.5°F (37.5°C), axillary 97.5°F (36.4°C), tympanic 99.5°F (37.4°C), and temporal artery 99.4°F (37.4°C). Each of these temperatures would need to be assessed further for the possibility of a fever; however, the one assessed via the tympanic membrane would need to be assessed for accuracy and ensure the UAP does not need further training.

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

1700 Explanation: 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 28-day-old infant. What would the nurse document as a normal finding?

30 to 60 breaths/min Explanation: When assessing the respiratory rate of an infant less than 1 month of age, 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.

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?

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

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?

Assess the apical pulse. Explanation: 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.

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?

Assess the client's ability to stand or sit. Explanation: 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.

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. Explanation: 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.

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 Explanation: 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

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. Explanation: 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?

Auscultate the lung sounds and count respirations. Explanation: 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 health care provider 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 health care provider's prescriptions.

The nurse must assess a client's systolic blood pressure using a Doppler ultrasound. Place the following steps to this procedure in the correct order. Use all options.

Center the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. Wrap the cuff around the limb smoothly and snugly, and fasten it. Place a small amount of conducting gel over the artery. Place the Doppler tip in the gel and move it around until hearing the pulse. Inflate the cuff while continuing to use the Doppler device on the artery. Note the point on the gauge where the pulse disappears. Explanation: To assess a client's systolic blood pressure using a Doppler ultrasound, the nurse would perform the following steps: 1) Center the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. 2) Wrap the cuff around the limb smoothly and snugly, and fasten it. 3) Place a small amount of conducting gel over the artery. 4) Place the Doppler tip in the gel and move it around until hearing the pulse. 5) Inflate the cuff while continuing to use the Doppler device on the artery. 6) Note the point on the gauge where the pulse disappears.

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. Explanation: Orthostatic hypotension is assessed in three positions, with the client resting in each position 3 minutes before measuring the blood pressure and heart rate. The client is positive for orthostatic hypotension when there is a decrease of 20 mm Hg BP or greater and the heart rate increases as the body's means to help compensate for the postural change. In this case, it is part of the assessment to leave the client in the supine position for 3 minutes; the BP and HR are within a normal range and the client is asymptomatic so the nurse would not intervene. The nurse need not intervene while the client is dangling at the bedside and is asymptomatic. After 3 minutes of sitting, there was a positive orthostatic change, but the client is not exhibiting symptoms, so the nurse would finish the assessment by standing the client at the bedside to determine the extent of the postural changes. The nurse would intervene because the client is exhibiting symptoms of low cardiac output: pallor and diaphoresis. The nurse would immediately place the client in a supine position to increase the BP and report the findings to the primary care provider so adjustments in treatment may be made.

Which client should not have a temperature assessed rectally?

Client with diarrhea Explanation: 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 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. Explanation: The body loses heat to the water through conduction during tepid baths. Applying a blanket would reduce radiant heat loss and would raise the client's temperature. Increasing the body's metabolic rate will result in an increase in temperature. Blowing warm air over the client will increase the temperature.

During a routine vital sign assessment, the nurse notes that the client's blood pressure is 212/110 mm Hg. Which is the nurse's next action?

Have the client rest for 5 minutes, then retake the blood pressure. Explanation: Vital sign trends that deviate from normal are much more significant than isolated abnormal values. Hypertension is diagnosed on the basis of serial elevated values rather than a single measurement. Studies have shown that some clients demonstrate higher blood pressure in the health care setting than at home. Before calling the health care provider, the nurse would have the client rest and then retake the blood pressure to see if the blood pressure comes down. A blood pressure cuff that is too large for a client can result in falsely low readings.

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. Explanation: 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?

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. Explanation: 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 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. Explanation: 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 assessing an adult who has a pulse rate of 180 beats/min. Which action should the nurse take next?

Notify the health care provider of tachycardia Explanation: An adult has tachycardia when the pulse rate is 100 to 180 beats/min. The normal adult heart beat range is 60 to 120 beats/min. Blood pressure should always be assessed, but the health care provider should be notified immediately. Anaphylaxis and epinephrine are not specific to high pulse rate thus the provider should be called first.

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 Explanation: 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 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. Explanation: 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 preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention?

Provide privacy for the client. Explanation: Rectal temperature assessment can be embarrassing for the client, so provision of privacy is a priority. The client should be positioned on the side in Sims position to help facilitate probe insertion. The probe should be inserted 1 to 1.5 in (2.5 to 3.75 cm) in an adult client. The probe should only remain in the rectum until the electronic unit emits an audible sound indicating that the temperature assessment is complete.

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. Explanation: 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.

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. Explanation: 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.

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. Explanation: 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.

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 Explanation: 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.

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. Explanation: 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.

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?

The first faint, but clear, sound appears. Explanation: 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 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. Explanation: The client who is young and athletic is exhibiting a training effect where the heart rate is lower than the normal 60 to 100 beats/min. The heart becomes more efficient at supplying body cells with sufficient oxygenated blood with fewer beats. There is no indication that the client should be placed on medications to increase the heart rate since this is most likely a normal state for the client.

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. Explanation: 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 resistance that the client's heart must overcome when pumping blood Explanation: 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. Explanation: 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 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. Explanation: 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.

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. Explanation: 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 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 Explanation: Clean examination gloves, not sterile gloves, are required, and a bedpan is unnecessary. The other items listed are all needed.

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 Explanation: 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 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 Explanation: 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

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

being in a warm environment Explanation: In order for the nurse to get an accurate reading, the client should be in a warm, quiet environment. All the other answers, as well as exercise, would cause a false blood pressure reading.

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. Explanation: Certain cardiac medications, such as digoxin, decrease the heart rate.

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?

deep in the posterior sublingual pocket Explanation: When the probe rests deep in the posterior sublingual pocket, it is in contact with blood vessels lying close to the surface. None of the other areas provides as much contact with blood vessels and therefore is not an appropriate location to place the thermometer probe.

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?

diminished, weaker than expected Explanation: 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.

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. Explanation: 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:

increased temperature. Explanation: Body temperature can fluctuate with exercise, changes in hormone levels, changes in metabolic rate, and extremes of external temperature

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 Explanation: To assess the apical pulse, the nurse places the stethoscope over the left ventricle. The stethoscope is placed at the level of the fifth intercostal space, left mid-clavicular line.

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

placing the client's arm at heart level Explanation: The nurse should 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.

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 Explanation: The drop of blood pressure of more than 20 mm Hg between lying and standing, 1 to 2 hours after eating; the report of dizziness; and almost falling indicate the client has possibly developed postural or postprandial hypotension. The other choices may contribute to the situation, but are not the main concern.

A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing?

prodromal Explanation: Often, the child will experience symptoms prior to the fever surfacing, which is called the prodromal phase and includes the nonspecific symptoms that occur before the body temperature rises. The onset or invasion phase indicates an elevation in body temperature, as well as symptoms related to the fever such as shivering. The stationary phase is when the fever is sustained. The final phase is the resolution or defervescence phase when the temperature abates and returns to the child's baseline temperature.

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 Explanation: The rectal temperature, a core temperature, is considered to be one of the most accurate routes.

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?

rectum Explanation: 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.