PrepU Ch.8

The nurse is caring for a client who is having nothing by mouth (NPO) on the first postoperative day. The client's blood pressure was 120/80 mm Hg approximately 4 hours ago, but it is now 140/88 mm Hg. The nurse should ask the client which of the following questions? A) "Are you taking any medications for hypertension?" B) "Do you have enough blankets to stay warm?" C) "Are you having pain from your surgery?" D) "What is your typical blood pressure reading?"

"Are you having pain from your surgery?" Explanation: A client's blood pressure will normally vary throughout the day due to external influences. This includes pain. Ref: (ch.8 pg.133)

A nurse notes that the pulse rate of a client is less than 60 beats per minute. Which question is appropriate for the nurse to ask the client in regards to this finding? A) "How is your stress level today?" B) "What vitamin supplements are you currently taking?" C) "Have you been sitting for a long time?" D) "Are you feeling feverish today?"

"Have you been sitting for a long time?" Ref: (ch.8 pg.132)

The nurse assesses the amplitude of the client's radial pulse and finds it to be weak and diminished. Which of the following scores should the nurse record? a) 0 b) 1+ c) 2+ d) 3+

1+ Ref: (ch.8 pg.122)

A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75 mm Hg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension? A) 160/85 mm Hg B) 130/65 mm Hg C) 120/55 mm Hg D) 140/55 mm Hg

120/55 mm Hg Explanation: A drop in both the systolic and diastolic readings of 20 mm Hg or more from the sitting position to the standing position indicates orthostatic hypotension. A drop of less than 20 mm Hg from the sitting position is considered normal. An elevation is not called hypotension but hypertension.

A nurse has assessed the blood pressure of a recently admitted client and obtained a reading of 128/78 mm Hg. What is this client's pulse pressure? A) 128 mm Hg B) 78 mm Hg C) 50 mm Hg D) 103 mm Hg

50 mm Hg Ref: (ch.8 pg.133)

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client? A) Yellowish B) Ashen gray C) Reddish D) Beige-pink

Ashen gray Explanation: The skin of a dark-skinned client with cyanosis would be ashen gray. The skin tone would appear yellowish in a light-skinned client if the client had jaundice. A beige-pink skin tone would be a normal finding for the light-skinned client. A reddish skin tone could be related to fever, sunburn, or infection.

A client has arrived to the clinic for a routine physical examination. Prior to assessing the client's blood pressure, what should the nurse do? A) Make sure the arm selected is covered with clothing B) Palpate the radial artery to confirm a pulse is present C) Position the arm so that it is below waist level D) Ask the client to sit quietly in a chair for 5 minutes

Ask the client to sit quietly in a chair for 5 minutes Explanation: To ensure an accurate blood pressure measurement, the nurse should ask the client to sit quietly for at least 5 minutes in a chair. The arm selected for measurement should be free of clothing. The nurse should palpate the brachial artery to confirm that it has a viable pulse. The arm should be positioned at heart level.

An 86-year-old male client with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess his temperature using an oral thermometer but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. As well, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with assessment? A) Assess the client's temperature by axilla B) Assess the client's skin tone and the presence or absence of sweating to determine whether the client is febrile C) Use a disposable mercury thermometer to take the client's temperature D) Take the client's temperature rectally

Assess the client's temperature by axilla Explanation: The axillary site is an accurate and acceptable alternative when other sites are impractical or contraindicated. Rectal temperatures are contraindicated in cardiac clients; mercury thermometers are not commonly used. It is unacceptable for the nurse to rely solely on subjective assessments to determine whether the client is febrile.

Ideally, when taking a blood pressure, the client should be instructed to what? A) Avoid smoking for 30 minutes prior to the assessment B) Sit quietly for at least 10 minutes in a chair, rather than on the examining table, with feet flat on the floor and legs uncrossed C) Abstain from drinking caffeine for 45 minutes prior to the assessment D) Take several deep breaths to help relax prior to the assessment

Avoid smoking for 30 minutes prior to the assessment Explanation: Ideally, instruct the client to avoid smoking or drinking caffeinated beverages for 30 minutes before the blood pressure is measured. Ref: (ch.8 pg.133)

A 55-year-old bookkeeper comes to the office for a routine visit. The nurse notes that on a previous visit for treatment of contact dermatitis, the client's blood pressure was elevated. She does not have prior elevated readings, and her family history is negative for hypertension. The nurse measures her blood pressure in the office today. Which of the following factors can result in a false high reading? A) Blood pressure cuff is tightly fitted B) Client is seated quietly for 10 minutes prior to measurement C) Blood pressure is measured on a bare arm D) Client's arm is resting, supported by the nurse's arm at the client's mid-chest level

Blood pressure cuff is tightly fitted Ref: (ch.8 pg.135)

A nurse obtains a pulse rate on an adult client of 56 beats per minute. What is the correct term that the nurse should use to document this finding? A) Normal B) Bradycardia C) Tachycardia D) Hypocardia

Bradycardia Ref: (ch.8 pg.132)

A client's blood pressure is affected by A) cardiac intake, elasticity of the arteries, blood flow, blood cells, and blood thickness B) cardiac intake, elasticity of the veins, blood flow, blood cells, and blood thickness C) cardiac output, distensibility of the veins, blood volume, blood velocity and viscosity D) cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity

Cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity Ref: (ch.8 pg.122)

The nurse should immediately notify the healthcare provider if which assessment finding is obtained on a hospitalized client? A) Temperature 37.5 Celsius B) Cyanotic left lower extremity C) Moderate amount dark blood on dressing D) Heart rate of 105 beats per minute

Cyanotic left lower extremity

An elderly client is seen by the nurse in the neighborhood clinic. The nurse observes that the client is dressed in several layers of clothing, although the temperature is warm outside. The nurse suspects that the client's cold intolerance is a result of A) Decreased body metabolism B) Neurologic deficits C) Recent surgery D) Pancreatic disease

Decreased body mechanism Explanation: Research has shown that for older adults, normal body temperature values for all routes are consistently lower than values reported in younger populations. Ref: (ch.8 pg.128)

The nurse explains to the client that smoking has what effect on the body? Select all that apply. A) Hypertension B) Vasoconstriction C) Peripheral vascular disease D) Vasodilation E) Hypotension

Hypertension Vasoconstriction Peripheral vascular disease Ref: (ch.8 pg.125)

A nurse observes that a young man's arm span appears to be greater than his height. Which condition should the nurse suspect in this client? A) Gigantism B) Marfan syndrome C) Anorexia D) Cushing's syndrome

Marfan syndrome Explanation: Arm span is greater than height and pubis to sole measurement exceeds pubis to crown measurement in Marfan syndrome. In gigantism, there is increased height and weight with delayed sexual development. Extreme weight loss is seen in anorexia nervosa. Central body weight gain with excessive cervical obesity (Buffalos hump), also referred to as endogenous obesity, is seen in Cushing syndrome. Ref: (ch.8 pg. 128)

A client, sipping hot tea, is scheduled for routine vital signs. Which illustration shows the least appropriate method for the nurse to use to obtain an accurate temperature reading? A) oral B) axillary C) tympanic D) temporal

Oral Explanation:The oral temperature would give a falsely elevated reading because the client is sipping hot tea. The axillary temperature will take the longest to register, but would not be affected by the client's tea consumption. Both the tympanic and temporal artery methods are considered safe, reliable, and noninvasive and either would be most appropriate to use. Ref: (ch.8 pg.128)

The current blood pressure measurement on a 24-hour uncomplicated postoperative client while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of: A) Orthostatic hypotension B) Supine hypotension C) Hypertensive crisis D) Postural hypertension

Orthostatic hypotension Ref: (ch.8 pg. 133)

In interviewing a client about his heart rate, the nurse asks whether he has noticed any alteration to his heartbeat. The client responds that he sometimes feels his heart race even when he has not been exerting himself physically. This alteration is known as which of the following? A) Dyspnea B) Pulse pressure C) Apical beats D) Palpitation

Palpitation Explanation: An alteration in heartbeat felt by a client is called a palpitation and can be caused by various circumstances including thyroid dysfunction, medication reaction, or alteration in fluid volume. Dyspnea is difficulty breathing. Pulse pressure is the difference between systolic and diastolic blood pressures. Apical beats are simply the beats of the heart palpated directly over the apex of the heart, on the chest.

When assessing a client's respirations, what is most important to include in the documentation? A) Numerical pain rating B) Position of the client C) Assessment of pedal pulses D) Presence of dyspnea

Presence of dyspnea Explanation: The presence of dyspnea is the most important of the choices listed to include in the documentation. Dyspnea can be an indicator of potential respiratory distress. The presence of pain and position of the client can impact the client's respiratory status, but are not the primary piece of information to include in the documentation. Assessment of pedal pulses is a component of a circulatory assessment.

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? A) Pulse is strong, and light pressure causes it to disappear. B) Pulse is felt with difficulty and disappears with slight pressure. C) Pulse is felt easily, and moderate pressure causes it to disappear. D) Pulse is strong and remains despite moderate pressure.

Pulse is felt with difficulty and disappears with slight pressure Ref: (ch.8 pg.132) Explanation: 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.

When assessing a client's pulse, the nurse should be alert to which of the following characteristics? A) Rate, rhythm, amplitude and contour, and elasticity B) Rate rhythm, temperature, rigidity, color, and elasticity C) Tenderness, moistness, contour, elasticity, pressure D) Pain, temperature, amplitude and contour, and elasticity

Rate, rhythm, amplitude and contour, and elasticity Ref: (ch.8 pg.122)

Since the nurse is unable to obtain an oversized cuff to assess an adult client with a large arm, the nurse uses an average-sized cuff. What blood pressure reading will the nurse most likely obtain for this client? A) Correct reading B) Reading will be low C) Reading will be high D) Reading cannot be obtained

Reading will be high Explanation: If the blood pressure cuff used is too small and the client's arm is large, the blood pressure reading will be high. If the blood pressure cuff is too large and the client's arm is small, the reading will be low. The reading obtained with an inappropriately sized cuff will not be correct. The reading can be obtained; however, the reading will be incorrect. Ref: (ch.8 pg.135)

The nurse assesses the client's vital signs as follows: respirations 20 breaths/minute, tympanic temperature 100.9°F, pulse 88 beats/minute, and blood pressure 104/64 mm Hg. The nurse should A) record the vital signs B) instruct the client to drink more fluids C) refer the client to a primary care provider D) administer Tylenol

Record the vitals Explanation: Validate the assessment data you have collected. This is necessary to verify that the data are reliable and accurate. Document the assessment data following the health care facility or agency policy.

The nurse is having difficulty auscultating Korotkoff sounds. The nurse should (Select all that apply.) A) Reposition the stethoscope B) Consider shock C) Be certain there is full skin contact with the bell D) Keep the cuff inflated for 30 seconds before auscultating E) Request an ECG

Reposition the stethoscope Consider shock Be certain there is full skin contact with the bell Ref: (ch.8 pg.134)

The nurse is taking routine vital signs toward the end of shift. A client's BP reads 204/148. The client's baseline BP has been in the 130's systolic. What should the nurse do first? A) Retake the blood pressure B) Notify the physician immediately C) Give PRN blood pressure medications D) Document the findings

Retake the blood pressure Ref: (ch.8 pg.135)

The nurse assesses the amplitude of the client's radial pulse and finds it to be weak and diminished. Which of the following scores should the nurse record? A) rigid B) resilient C) straight D) springy

Rigid Ref: (ch.8 pg.132)

You are educating your client on taking blood pressure at home. What would be important to include in your client education? A) Monthly replacement of batteries B) Routine recalibration of the device C) Application of a thigh cuff D) Use of a wrist cuff

Routine recalibration of the device Explanation: Follow the guidelines listed, and advise your clients about how to choose the best cuff for home use. Urge them to have their home devices recalibrated routinely. Ref: (ch.8 pg.125)

Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding? A) Systolic pressure 180 mm Hg B) Apical pulse 70 beats/min C) Respirations 12 breaths/min D) Oxygen saturation 95% on room air

Systolic pressure 180 mm Hg Ref: (ch.8 pg.133)

The client has is experiencing hypothermia. What assessment finding would the nurse anticipate? A) Bradycardia B) Tachycardia C) Weakness D) Confusion

Tachycardia Explanation: Assessment findings for clients experiencing hypothermia include tachycardia, and peripheral vasoconstriction. Weakness, confusion and bradycardia are not associated with hypothermia.

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure? A) The ability of the arteries to stretch B) The thickness of the circulating blood C) The oxygen levels in the blood D) The volume of air entering the lungs

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.

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure? A) The blood pressure does not change B) The blood pressure is erratic C) The blood pressure decreases D) The blood pressure increases

The blood pressure increases. Explanation: As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?

A client arrives at the emergency department by ambulance after an accident while playing softball. The client's left leg is swollen and deformed. The client describes the pain as a 9 on a 10-point scale. When the nurse assesses the client's blood pressure, what would the nurse expect to find? A) The blood pressure is lower than normal B) There would be no need to assess the blood pressure C) The blood pressure is elevated D) The blood pressure is within normal limits

The blood pressure is elevated Explanation: Many variables affect vital signs, including pain, stress, anxiety, and activity. Pain and anxiety can contribute to increased blood pressure. The nurse would not expect to find the blood pressure lower than normal or within normal limits with the client's report of pain as a 9 on a 10-point scale. It would be expected that the nurse would assess the blood pressure upon arrival to the emergency department for this client.

A client comes to the cardiovascular intensive care unit (CVICU) directly after a three-vessel coronary artery bypass graft (CABG). The client's orders state "maintain systolic blood pressure greater than 90 but less than 120." How does this order affect the monitoring of the client's blood pressure? A) The nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits B) Monitoring blood pressure once every hour is sufficient for this client C) Monitoring blood pressure every 4 hours is sufficient for this client D) The nurse can delegate monitoring of the client's blood pressure to the client care assistant

The nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits Ref: (ch.8 pg. 122)

A nurse is assessing the blood pressure of a client using the Korotkoff's sounds technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record? A) There is a nonauscultatory gap B) There is a widening in the diameter of the artery C) There is an auscultatory gap D) There is an adult diastolic

There is an auscultatory gap Ref: (ch.8 pg.134)

The nurse is assessing a client's respiratory rate. Which of the following should the nurse do to ensure accuracy of this assessment? A) Watch chest movement before removing the stethoscope after counting the apical beat B) Ask the client to breathe normally C) Observe the client's chest movement before calling the client back to the examination room D) Perform the assessment at the beginning, middle, and end of the examination and average the results

Watch chest movement before removing the stethoscope after counting the apical beat Ref: (ch.8 pg.122)

Which of the following is an average normal temperature in centigrade for a healthy adult? A) oral: 37.0°C B) rectal: 36.5°C C) axillary: 37.5°C D) tympanic: 34.4°C

oral: 37.0°C Ref: (ch.8 pg.129)

The nurse is assessing an elderly postsurgical client in the home. To begin the physical examination, the nurse should first assess the client's A) height and weight B) ability to swallow C) vital signs D) gait

vital signs Ref: (ch.8 pg.122)