19: Vital Signs

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?

Perform the blood pressure measurement last. The blood pressure reading is the most invasive procedure performed when measuring vital signs. If the nurse were to perform it first it may upset the child further and could prevent obtainment of the remainder of the vital signs. Allowing the child to touch the assessment equipment often helps the child be more relaxed for the remainder of the assessment. Lying on the exam table is not necessary for vital signs and will likely cause more anxiety. Being quick with a serious demeanor does not help decrease the child's anxiety.

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

Provide privacy for the client. 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 client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs?

immediately Vitals signs should be assessed whenever there is a change in the client condition. Because the client reports feeling "different," this indicates an immediate vital sign assessment. Therefore, it is not appropriate to assess vital signs once per day, according to medical orders, or every 4 hours.

The nurse is assessing a female client for orthostatic hypotension. As the nurse assists the client to a standing position, the client states, "I'm feeling really dizzy." What should the nurse do next?

immediately assist the client back to bed If a client becomes severely symptomatic while standing for a blood pressure measurement, the nurse should immediately help the client back to bed without completing the measurement. The client's safety is the priority. Asking the client to explain the term "dizzy," checking the blood pressure, or asking the client whether she wants to sit down are inappropriate. The client's safety is the utmost concern.

The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct?

lightly compress the client's radial artery, using the first, second, and third fingers The radial artery is the most common place to assess a peripheral pulse on an adult. The fingertips are sufficiently sensitive to palpate arterial pulsations; the nurse should use light compression. One hand is used to assess peripheral pulse. The nurse should take care to avoid completely compressing the artery.

Which is the primary source of heat in the body?

metabolism The primary source of heat in the body is metabolism, with heat produced as a byproduct of metabolic activities that generate energy for cellular functions. Various mechanisms increase body metabolism, including hormones and exercise that activates muscles. Blood circulation does not affect the heat of the body.

A student is reading the medical record of an assigned client and notes that the client has been afebrile for the past 12 hours. What does the term "afebrile" indicate?

normal body temperature A person with normal body temperature is referred to as afebrile. A client with a fever or increased body temperature is febrile.

What is an average normal temperature in Celsius for a healthy adult?

oral: 37°C The normal range for an oral temperature is 37°C (98.6°F), rectal temperature is 37.5°C (99.5°F), an axillary temperature is 36.5°C (97.7°F), and a tympanic temperature is 37.5°C (99.5°F).

While recording the pulse of an infant at 160 beats/min, the parent asks if it is normal for the infant's pulse rate to be so high. Which statement by the nurse best answers the parent's question?

"A heart rate of 160 beats/min is normal for a healthy infant." The average pulse rate of an infant ranges from 100 to 160 beats/min. There is no need to refer the parent to the health care provider for an answer.

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." 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.

A nurse is obtaining an oral temperature on a client, using an electronic thermometer. The client notes having an electronic thermometer at home and asks how to care for it. Which response is appropriate?

"When not in use, keep the probe in the storage place within the unit." Return the probe to the storage place within the unit, and return the thermometer to the battery pack. Cleanse according to manufacturer recommendations. Proper storage prevents damage to the sensitive temperature probe and ensures that the unit will be recharged and ready for use. As the unit is electronic, you would not submerge in water as it could corrode the inner workings of the machine. The thermometer is battery charged and does not have to be charging continuously and can be off the charger for short periods of time. Allowing the unit to lose a full charge does not generate full charging capabilities and can yield undue wear on the unit.

The nurse is assessing a client's brachial artery blood pressure. Which nursing actions are performed correctly? Select all that apply.

- The nurse centers the bladder of the cuff over the brachial artery about midway on the arm. - The nurse has the client lying or sitting down with the forearm supported at the level of the heart and the palm of the hand upward. - The nurse wraps the cuff around the arm smoothly and snugly and fastens it. Pressure in the cuff applied directly to the artery provides the most accurate readings. If necessary, thick or bulky clothing is removed to allow for audible sounds of the blood pressure. The cuff should be centered over the site of the brachial artery, midway up the client's upper arm. Blood pressure measured with the arm below the level of the right atrium of the heart may produce a falsely high reading; if above the level of the heart the readings may be falsely low. A smooth cuff and snug wrapping produce equal pressure and help promote an accurate measurement. A cuff wrapped too loosely results in an inaccurate reading. The first faint but clear sound is the systolic (not diastolic) pressure. False readings are likely to occur if there is congestion of blood in the limb while obtaining repeated readings that are less than 1 minute apart.

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 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.

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. 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.

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. 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.

What anatomic site regulates the pulse rate and force?

Cardiac sinoatrial (SA) node The pulse is regulated by the autonomic nervous system through the cardiac sinoatrial (SA) node. The other anatomic sites may affect, but do not regulate, the pulse rate and force. SA node = Pacemaker node

The nurse is preparing to assess the client's oral temperature using a digital thermometer. Place the steps in the order in which the nurse will perform them. Use all options.

Check the frequency of vital signs assessment in the client record. Review the previous and most recent temperatures recorded. Ask the client if he or she has consumed anything hot or cold within the past 30 minutes. Perform hand hygiene by washing hands or using hand sanitizer. Insert the temperature probe into a disposable cover until it locks into place. Place the covered probe beneath the tongue to the right or left of the frenulum. Maintain the probe in position until an audible sound occurs. Document temperature reading in the client record. When preparing to assess the client's temperature, the nurse will first determine the frequency that the assessment is required. This may be the regularly scheduled assessment of vital signs or an assessed need based on a change in the client's status. It is important that the nurse then review the most recent recording of the client's temperature to note any apparent trends. Prior to physical contact with the client or objects that will touch the client, the nurse will perform hand hygiene to prevent the transmission of pathogens. When using a digital thermometer to take an oral temperature, the nurse will begin by inserting the probe into a sheath covering that will be disposed of after it has been contaminated by the client's saliva. The nurse can now place the probe in the correct position in the oral cavity to take an oral temperature. The temperature reading is not complete until an audible sound is heard. The nurse will hold the probe in place to support the client until the audible signal is heard. The nurse will immediately document the temperature reading in the client's record.

A nurse is caring for a middle-age client who looks worried and flares his nostrils when breathing. The client reports difficulty in breathing, even when he walks to the bathroom. Which breathing disorder is most appropriate to describe the client's condition?

Dyspnea Clients with dyspnea usually appear anxious and worried. The nostrils flare as they fight to fill the lungs with air. Dyspnea is almost always accompanied by a rapid respiratory rate because clients work to improve the efficiency of their breathing. The client's condition cannot be termed hyperventilation, hypoventilation, or apnea. Hyperventilation and hypoventilation affect the volume of air entering and leaving the lungs. Apnea is total absence of breathing, which is life-threatening if it lasts more than 4 to 6 minutes.

The client is to have a measurement for a pulse deficit performed. What action does the nurse take?

Enlist another nurse to help with this measurement. To measure for a pulse deficit, two nurses are required for accuracy. One nurse auscultates the apical rate; a second nurse counts the radial rate. They do this simultaneously for 1 minute. To perform this skill in any other manner will result in an inaccurate reading.

The nurse is caring for an adult postoperative client. Which physiologic response is related to pain?

Heart rate of 110 beats/min Pain medication can cause decreased bowel motility and cause constipation. However, pain itself can cause an increased heart rate which is indicated by the rate of 110 beats/min. Pain can cause decreased urinary output; 2500 milliliters of urine in 24 hours is an indication of increased output. Pain can increase the consumption of oxygen; an O2 saturation of 98% on room air would be a normal reading.

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

Inflate the cuff about 30 mm Hg above the auscultatory gap. To find the auscultatory gap, palpate the brachial or radial pulse while inflating the cuff. Inflate the cuff about 30 mm Hg above the number where palpable pulsation disappears. In addition to detecting an auscultatory gap, palpation gives an initial estimate of systolic blood pressure and eliminates the need to inflate the cuff to extremely high pressures in people with normal or low blood pressure. Using the bell of the stethoscope to listen for the systolic and diastolic sound is expected. Recording of the blood pressure should occur after the blood pressure is obtained.

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. 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.

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. The apex of the heart is found by 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 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. 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.

A nurse is preparing to assess a client's temperature and finds the client to be perspiring profusely. Which method would be least appropriate for the nurse to use to assess this client's temperature?

Temporal artery temperature Diaphoresis causes skin cooling which may cause a false low reading with a temporal artery thermometer. Another method, such as oral, tympanic membrane, or rectal, should be used.

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. 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.

When assessing a client's vital signs, a nursing student has explained to the client each of their next actions prior to assessing the client's temperature, pulse, and blood pressure. However, the nursing student did not announce their intention to assess the client's respiratory rate prior to measuring it. What is the rationale for the nursing student's decision to withhold this information?

The client may alter the rate of respirations if the client is aware that his breaths are being Because respiratory rate is under both autonomic and voluntary control, making the client conscious of his respiratory rate prior to assessment has the potential to affect that accuracy of the assessment. It is not possible to simultaneously assess pulse and respirations. Temperature, pulse, and blood pressure are not necessarily more volatile than respiratory rate. Tachypnea is not an expected finding.

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?

The reading will be erroneously high. The bladder of the cuff should enclose at least two-thirds of the adult limb. If the cuff is too narrow, the reading could be erroneously high because the pressure is not being transmitted evenly to the artery. If the cuff is too large, then the reading could be too low. The pressure is not related to the painfulness of the cuff. It will not be difficult to pump up the bladder of the cuff, whether it is too large or too small.

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. 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 hospital unit has a policy that rectal temperatures may not be taken on clients who have had cardiac surgery. What rationale supports this policy?

Thermometer insertion stimulates the vagus nerve. Because inserting the thermometer into the rectum can slow the heart rate by stimulating the vagus nerve, assessing a rectal temperature may not be allowed for clients after cardiac surgery. Taking a rectal temperature cannot perforate the wall of the rectum as the thermometer is only inserted 1/3 inch in the rectum. In addition, a rectal temperature is not cost effective as the thermometers are used for only one client and not shared. For adults, taking a rectal temperature can be embarrassing but it is a very accurate measurement of core temperature.

The nurse discovers during assessment that the client has an altered temperature. Select one caustive factor for each type of heat loss.

Type of Heat Loss Causative Factors Radiation infrared heat waves Conduction the air itself Evaporation through sweating Convection exposure to a fan Radiation is heat that is lost to infrared heat waves. It can be accelerated by exposing the skin to the heat waves or prevented by covering the skin. Conduction describes heat that is lost by transfering from one object to the next. For example, heat is lost from the skin to the air or to water. Evaporation consists of heat loss that occurs as water is transformed into a gas, such as with sweating. Convection facilitates heat loss via passing air, such as with a breeze or a fan. Arterioveous shunts may remain open to facilitate the dissapation of heat from the body. A passing breeze facilitates heat loss via convection. In response to the body's temperature the sympathetic nervous system controls the opening and closing of arteriovenous shunts. Shivering is one mechanism for the body to retain heat. Heat can be lost through uncovered body surfaces by the physical process of radiation. Water in the form of a tepid bath or swimming is one way heat loss can occur through conduction. Insensible loss of body fluids is a form of evaporation that takes place on the skin. "Goose bumps" or piloerection is a natural response of the body to retain heat by reducting the surface area of the skin.

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. 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.

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 30 minutes before measuring the oral temperature The nurse should wait for 15 to 30 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.

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 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.

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

a client with low blood volume 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.

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 bpm. The nurse notifies the health care provider because the client is exhibiting signs of:

a dysrhythmia. An irregular pattern of heartbeats is called a dysrhythmia. Tachycardia is an increased heart rate of 100 to 180 bpm. Bradycardia is a pulse rate below 60 bpm. The normal pulse rate ranges from 60 to 100 bpm. Hypertension is a blood pressure that is above normal for a sustained period.

Which pulse site is generally used in emergency situations?

carotid 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.

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

diaphoresis Evaporation causes heat loss as water is transformed to gas. An example of this is diaphoresis, or sweating.

Before assessing a client's respiratory rate, the nurse should remind the client to breathe normally.

false probably makes patient more anxious and they "forget" how they normally breathe

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 Dyspneic people can often breathe more easily in an upright position, a condition known as orthopnea, because sitting or standing allows gravity to lower organs from the abdominal cavity away from the diaphragm. Bradypnea is a decrease in respiratory rate. Tachypnea is an increased respiratory rate. Apnea refers to periods during which there is no breathing.

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 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 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.

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 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 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 nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, +3, and equal in radial, popliteal, and dorsalis pedis. What does the number +3 represent?

pulse amplitude Pulse amplitude describes the quality of the pulse in terms of its fullness, ranging from absent (0) to bounding (+3). Pulse rates are measured in beats per minute. Pulse rhythm is the pattern of the pulsations and the pauses between them. The pulse deficit is the difference between the apical and radial pulse rates.

A nursing student is assessing blood pressure in an adult client. Which action by the nursing student would require intervention from the nursing instructor?

pumping the blood pressure cuff up to 200 mm Hg routinely The instructor should intervene if the student is routinely inflating the cuff to 200 mm Hg. This may be very uncomfortable for the client, and there is no reason to do so unless the Korotkoff sounds are heard when inflating. All other options are correct and do not require intervention.

A nurse is taking a client's temperature and wants the most accurate measurement, based on core body temperature. What site should be used?

rectal Heat is generated by metabolic processes in the core tissues of the body, transferred to the skin surface by the circulating blood, and then dissipated to the environment. Core body temperatures may be measured at rectal or tympanic sites. Axillary temperatures are considered not accurate but can be used if rectal and tympanic are not available.

A nurse is assessing the apical heart rate of a healthy person. In order to hear the heartbeats loud and clear, where should the nurse place the stethoscope?

slightly below the left nipple in line with middle of clavicle The heartbeats are best heard or felt in a healthy client slightly below the left nipple, in line with the middle of the clavicle. The nurse does not place the stethoscope on the center of the rib cage, between the nipples, or 4 in (10 cm) below the left clavicle with every client to accurately assess the apical heart rate of a healthy person.

The home care nurse is assessing a 37-year-old client's vital signs at rest. Which finding requires nursing intervention?

temporal temperature 100.8º F (38.2º C) The nurse should intervene when the client's temperature is 100.5º F (38.2º C) or higher. If the adult's blood pressure is higher than 120/80 mm Hg or respirations more than 20 breaths/min or pulse rate greater than 100 beats/min, then these would also require the nurse to take appropriate action.

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 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.

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

the first appearance of faint but distinctive tapping sounds Korotkoff sounds (or K-Sounds) are the "tapping" sounds heard with a stethoscope as the cuff is gradually deflated. Traditionally, these sounds have been classified into five different phases (K-1, K-2, K-3, K-4, K-5). The systolic blood pressure reading occurs during phase I, which is characterized by the appearance of faint but clear tapping sounds that gradually increase in intensity (K1). The last sound before there is complete and continuous silence is congruous with the diastolic blood pressure measurement (K5). In some patients, sounds may disappear altogether for a short time between Phase II and III, which is referred to as auscultatory gap. The transition from tapping sounds to muffled sound is K4. K-1 (Phase 1): The appearance of the clear "tapping" sounds as the cuff is gradually deflated. The first clear "tapping" sound is defined as the systolic pressure. K-2 (Phase 2): The sounds in K-2 become softer and longer and are characterized by a swishing sound. since the blood flow in the artery increases. K-3 (Phase 3): The sounds become crisper and louder in K-3, which is similar to the sounds heard in K-1. K-4 (Phase 4): As the blood flow starts to become less turbulent in the artery, the sounds in K-4 are muffled and softer. Some professionals record diastolic during Phase 4 and Phase 5 K-5 (Phase 5): In K-5, the sounds disappear completely, since the blood flow through the artery has returned to normal. The last audible sound is defined as the diastolic pressure.