Assessment Ch. 25 Vital signs
The nurse is taking the apical pulse of a 6-month-old infant. Upon completion, the nurse tells the parent the baby's pulse is 140 beats per minute. The parent is concerned, stating, "That seems kind of high!" The nurse responds:
"I know it seems fast, but normal infant heart rates are 100-160 beats per minute."
When assessing an infant's axillary temperature, it will be:
1 degree lower (.5 degrees C)than an oral temperature
The nurse is performing a telephone follow-up with parents whom she taught to monitor their newborn's BP and pulse at home. Which results reported by the parents would indicate that the parents are performing the technique correctly and there is no cause for concern?
80/50 mmHg and 145 bpm
The nurse is preparing to administer a medication that the client takes to treat a cardiac dysrhythmia. Which site should the nurse use to assess pulse in this client?
Apical
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
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.
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.
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 SUBMIT ANSWER
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.
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.
Which client should not have a temperature assessed rectally?
Client with diarrhea
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will:
Decrease the apical pulse
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
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 pocket
Which statement describes diastolic blood pressure?
During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.
When creating the teaching plan for a client who will be monitoring his or her pulse at home, which factors should the nurse teach the client that may influence the pulse rate by causing an increase in pulse? Select all that apply.
Exercise Fever Stress
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
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 artery.
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.
A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff?
Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared.
During a routine vital sign assessment, the nurse notes the client's blood pressure is 212/110 mmHg. Why is this finding particularly significant?
It deviates from normal and is significant
A client monitoring his BP at home notices that his BP is higher in one arm than the other. 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.
The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct?
Lightly compress the clients radial artery using the first, second, and third fingers
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
Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?
1700
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
A nurse is assessing the respiratory rate of a sleeping infant. What would the nurse document as a normal finding?
30 to 60 breaths/min
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
An ultrasonic Doppler is used for
Auscultating a pulse that is difficult to palpate
Which peripheral pulse site is generally used in emergency situations?
Carotid
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.
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
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.
A client has smoked most of his life and has labored respirations. He is experiencing:
Dyspnea
A person's core body temperature is highest in the early morning and lowest in the late afternoon.
False
Which client would the nurse consider at risk for low blood pressure?
Low blood volume
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
Which term indicates a potentially serious client condition?
Pyrexia
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?
The client has a temperature of 101.8 degrees Fahrenheit The client has reports of pain of 8 on a scale of 0-10 The client just finished ambulating with physical therapy
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.
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
Which factor is not known to cause false blood pressure readings?
being in a warm environment
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
Clients demonstrating apnea have what?
temporary cessation of breathing
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."
A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?
"Dizziness when you change position can occur when fluid volume in the body is decreased."
The nurse is teaching a newly diagnosed hypertensive client how to take his or her own BP at home. The client asks why it is so important to do this. What is the nurse's best response?
"Monitoring your BP at home will assist in controlling your BP, thereby decreasing your risk for heart attack and stroke."
When taking the client's temperature, the student nurse will require further education when they state:
"The axillary route is the most accurate of all routes."
The nurse has just measured an adult client's oral temperature and obtained a result of 102.4ºF (39.1ºC). The client states, "I just finished my coffee right before you came in. Can I have another cup?" Which response by the nurse is most appropriate?
''I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return."
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
A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature?
Rectum
The nurse is 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.
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.
After taking vital signs of an older adult, the nurse writes down findings as T = 98.9/37.2 oral, P = 104, R = 18, BP = 130/82. Based on the collected data, which step would the nurse take next?
Take pulse again to assess for tachycardia
The nurse assesses a client admitted with multiple trauma including basilar skull fracture and rhinorrhea (drainage from nose), bilateral otorrhea (drainage from ear), and multiple fractures requiring a full body cast. The client is on a 40% Venturi oxygen mask. What is the best way to evaluate the client's temperature?
Temporal artery
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
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 has a temperature of 101.8°F (38.8°C) The client just finished ambulating with physical therapy
The nurse teaches a client diagnosed with hypertension to self-measure blood pressure with an automated device. Which client behaviour 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.
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
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.
A 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client?
To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns.
A 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
Which client's blood pressure best describes the condition called hypotension?
Which client's blood pressure best describes the condition called hypotension?
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
An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?
auscultate the client's apical pulse
A nurse 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 clients thigh
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.
A pulse deficit is the difference between:
the apical pulse and the radial pulse rates
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
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