Chapter 29 Vital Signs

The RN assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing intervention would be most appropriate for the nurse to use? 1. Ask another nurse to assess the pulses. 2. Document the findings. 3. Obtain a Doppler ultrasound stethoscope. 4. Wait and try again later.

Obtain a Doppler ultrasound stethoscope

The nurse needs to measure the temperature of a client who has a history of heart disease and has eaten a bowl of vegetable soup 45 minutes ago. Which site should the nurse use? 1. Axilla 2. Oral 3. Popliteal 4. Rectal

Oral

Which determinant of blood pressure would explain a client's blood pressure reading of 120/100? 1. Blood viscosity 2. Blood volume 3. Pumping action of the heart 4. Peripheral vascular resistance

Peripheral vascular resistance

Even though a UAP is available to assist with vital sign assessment, the nurse is going to conduct these assessments independently in which situations? Select all that apply: 1. Client who complains of chest pain 2. Client returning from surgery 3. Prior to administering a medication that affects blood pressure 4. Client who complains of dizziness after ambulating. 5. Client being admitted to the care area

-Client who complains of chest pain -Client returning from surgery -Prior to administering a medication that affects blood pressure -Client who complains of dizziness after ambulating.

A client comes to the emergency department with a temperature of 104°F. Which assessment findings should the nurse use to determine if this client is experiencing heat stroke? Select all that apply: 1. Delirious 2. Pale and dizzy 3. Skin warm and flushed 4. No evidence of sweating 5. Had been playing tennis in the sun

-Delirious -Skin warm and flushed -No evidence of sweating -Had been playing tennis in the sun

When assessing a client's respirations, the nurse realizes that the respiratory centers and chemoreceptors respond to changes in which factors? Select all that apply: 1. Oxygen concentration 2. Carbon dioxide concentration 3. Hydrogen ions 4. Potassium level 5. Serum calcium level

-Oxygen concentration -Carbon dioxide concentration -Hydrogen ions

The nurse is planning to assess a client's pulse. What characteristics should the nurse include in this assessment? Select all that apply: 1. Rate 2. Rhythm 3. Volume 4. Tone 5. Viscosity

-Rate -Rhythm -Volume

Prior to assessing a client's blood pressure, the nurse reviews factors that could affect the reading. Which factors could impact blood pressure? Select all that apply: 1. Stress 2. Race 3. Obesity 4. Medications 5. Employment

-Stress -Race -Obesity -Medications

The nurse determines that unlicensed assistive personnel (UAP) are not to be delegated client blood pressure measurements. What did the nurse observe to make this clinical decision? Select all that apply: 1. The valve on the bulb was closed. 2. The client was sitting with the legs crossed. 3. The arm was below the level of the heart. 4. The UAP waited 2 minutes before re-measuring. 5. The cuff bladder was placed over the brachial artery.

-The client was sitting with the legs crossed. -The arm was below the level of the heart.

The nurse assesses phase 1 Korotkoff's sound occurring at 136 and phase 5 Korotkoff's sound occurring at 72. How should the nurse document this client's blood pressure reading? 1. 136/72 2. 72/136 3. 136 - 72 4. 72 - 136

136/72

The nurse is assessing a client's blood pressure. What should the nurse hear during phase 2 of Korotkoff's sounds? 1. A muffled, whooshing, or swishing sound 2. Disappearance of sound 3. Faint, clear tapping sound 4. Increased intensity of sound

A muffled, whooshing, or swishing sound

When documenting a client's axillary temperature on the graphic sheet, how should the nurse identify the method of assessing the temperature? 1. AX 2. O 3. R 4. SL

AX

When assessing a client's oxygen saturation reading, the nurse realizes that what will affect this reading? 1. Activity 2. Environmental conditions 3. Nutrition 4. Skin color

Activity

The nurse is preparing to measure a client's temperature. What is the first thing that the nurse should do to ensure an accurate temperature reading? 1. Assess that the equipment used is working properly. 2. Place the client in a position that is most comfortable for the health care provider. 3. Take the temperature with a chemical disposable thermometer when the client is perspiring. 4. Wait at least 10 minutes before taking the temperature after a client has been smoking.

Assess that the equipment used is working properly.

The nurse is preparing to assess a client's blood pressure. Which artery will the nurse use for this assessment? 1. Brachial 2. Femoral 3. Radial 4. Ulnar

Brachial

The RN needs vital signs assessed for four clients. Which client should the nurse address and not assign to the UAP? 1. Cardiac catheterization client returning to the nursing unit 2. COPD client on 2 Lpm oxygen via nasal cannula 3. Pneumonia client nearing discharge 4. Post-op client of 2 days from gallbladder surgery

Cardiac catheterization client returning to the nursing unit

While waiting for the physician to respond regarding a client's elevated temperature, what can the nurse do to assist the client? 1. Bathe the client with ice water. 2. Give the client an antipyretic. 3. Increase fluid intake. 4. Lower the room temperature.

Increase fluid intake.

A client is unconscious and in respiratory distress after being in a motor vehicle crash. Which should the nurse realize as being a factor that caused a change in this client's respiratory rate? 1. Exercise 2. Increased intracranial pressure 3. Increased environmental temperature 4. Stress

Increased intracranial pressure

An older client has an oral temperature reading of 97.2 degrees F. The nurse realizes that this client's low temperature could be due to which observation? 1. The anxiety level of the client has increased. 2. Hormones have fluctuated in this client. 3. Muscle activity has increased during the client's therapy session. 4. Loss of subcutaneous fat is noted.

Loss of subcutaneous fat is noted.

When assessing a client's peripheral pulse, the health care provider is also assessing which of the following? 1. Depth 2. Rhythm 3. Sound 4. Stress

Rhythm

The nurse needs to assess a client's respiratory status. Which client position would be the best for this assessment? 1. Prone 2. Semi-Fowler's 3. Side-lying 4. Supine

Semi-Fowler's

As the RN is suctioning a client, the pulse oximetry reading drops to 83%. What should the nurse do? 1. Allow the client to take some extra deep breaths. 2. Continue to suction but only intermittently. 3. Keep the catheter in place and wait a few minutes. 4. Stop suctioning and give supplemental oxygen.

Stop suctioning and give supplemental oxygen.

The nurse is going to assess the apical-radial pulse of a client with a cardiovascular disorder. Which rationale did the RN use to make this decision? 1. A forceful radial pulse is much too difficult to count correctly. 2. Both arteriole and venous sounds were heard simultaneously. 3. The pulse was bounding and easily obliterated. 4. The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site.

The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site.

Which condition would lead the RN to choose the dorsalis pedis pulse as the site for further assessing the client's status? 1. Altered level of consciousness 2. Decreased urine output 3. Irregular radial pulse 4. Toes cool to touch

Toes cool to touch

While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds of capillary refilling time. How would the nurse explain these findings? 1. A change in the client's health status has occurred. 2. The client has thrown a blood clot in that extremity. 3. The RN's watch has stopped working. 4. Too much pressure was applied over the pulse site.

Too much pressure was applied over the pulse site.

A client is being treated for congestive heart failure. Which physical finding would lead the RN to believe the client's condition has not improved? 1. Temperature of 98.6°F (37°C) 2. Moderate amount of clear thin mucus 3. Pulse oximetry reading of 96% 4. Wheezing of breath sounds in all lobes

Wheezing of breath sounds in all lobes

In the palpatory method of blood pressure determination, instead of listening for the blood flow sounds, light to moderate pressure is used over the artery as the pressure in the cuff is released. When will the nurse read the pressure from the sphygmomanometer? 1. When the cuff is applied 2. When the cuff is being deflated 3. When the first pulsation is felt 4. When the second pulsation is felt

When the first pulsation is felt