Chapter 30: Vital Signs (Pulse, Respiration, and Blood Pressure)

The nurse understands that patients with dysrhythmias may have a pulse deficit. How should the nurse calculate the pulse deficit?

*A. It is the difference in the pulse rates of the apical and radial pulses.* B. It is the difference in the pulse rates of the left and right radial pulses. C. It is the difference in the pulse rates of the radial and femoral pulses. D. It is the difference in the pulse rates of the left and right femoral pulses. Rationale: A pulse deficit is created when an inefficient contraction of the heart fails to transmit a pulse wave to the peripheral pulse site. A pulse deficit is the difference in the apical and radial pulse rates. There is usually no difference in the left and right radial pulse rates or in the left and right femoral pulse rates. A pulse deficit does not indicate a difference in the radial and femoral pulse rates. Pg. 499

The following blood pressures, taken 6 months apart, were from patients screened by the nurse at the assisted-living facility. Which patient should be referred to the healthcare provider for hypertension evaluation?

A. 120/80, 118/78, 124/82 B. 128/84, 124/86, 128/88 *C. 148/82, 148/78, 134/86* D. 154/78, 118/76, 126/84 Rationale: The definition of hypertension requires two elevated blood pressure measurements in a row (≥140 systolic pressure or ≥90 diastolic pressure). The other answers describe prehypertension. Pg. 504

A patient is advised to get an electrocardiogram to rule out dysrhythmia. Which statement is true about an electrocardiogram?

*A. It records the electrical activity of the heart for a 12-second interval.* B. It records and stores 24 hours of electrical activity. C. It provides continuous monitoring of the heart transmitted to a stationary monitor. D. It allows for immediate treatment if the heart rate becomes unstable. Rationale: An electrocardiogram records the electrical activity of the heart for a 12-second interval. The procedure involves placing electrodes across the patient's chest followed by recording the heart rhythm. A Holter monitor is worn on the patient's body, and it records and stores 24 hours of electrical activity. The recorded information cannot be accessed before the 24 hours of assessment are completed. Cardiac telemetry provides continuous monitoring of the heart transmitted to a stationary monitor. It records the heart activity in relation to the patient's activities. It has the advantage of allowing immediate treatment if the heart rate becomes unstable. Pg. 499-500

On examination, the nurse finds that a patient has an apical rate of 92 and a radial rate of 78. What would be the pulse deficit? Record your answer using a whole number.

14 beats Rationale: A pulse deficit refers to the condition in which the pulse wave is not transmitted to the peripheral pulse sites. The major cause of a pulse deficit is an inefficient contraction of the heart. A pulse deficit can be calculated by determining the difference between the apical rate and the radial pulse rate. In this case, the apical rate is 92 and radial rate is 78, so the pulse deficit is 14 beats. Pulse deficits are often associated with abnormal rhythms. Test-Taking Tip: When taking the NCLEX ® exam, an on-screen calculator will be available for you to determine your response, which you will then type in the provided space. Pg. 499

The nurse has been asked to record the nature of the pulse in a patient. What peripheral pulse is the most common and easiest to assess for pulse rate assessment?

*A. Radial* B. Carotid C. Brachial D. Temporal Rationale: The radial site is commonly used for assessing the nature of the pulse and is also used for assessing circulation to the hands. The carotid site is easily accessible and is used during shock and cardiac arrest when other sites are not palpable. The brachial site is suitable for assessing circulation in the upper limb and auscultating blood pressure. The temporal site is easily accessible and is suitable for assessing the pulse in children. Pg. 497

The registered nurse (RN) is teaching a nursing student about common errors and their effects when assessing blood pressure (BP). Which statements by the nursing student indicate the need for further teaching? Select all that apply.

*A. "Inflating the cuff too slowly may cause false-high systolic readings."* *B. "Inflating the cuff inadequately may cause false-low diastolic readings."* C. "Repeating the assessments too quickly may cause false-high systolic readings." D. "Placing the patient's arm below the heart level may lead to false-high readings." E. "Applying the stethoscope too firmly against the antecubital fossa may lead to false-low diastolic readings." Rationale: A few common errors can occur while measuring blood pressure (BP). An improperly fitted cuff or the rate in which the cuff inflates and deflates can cause inaccurate BP measurements. For instance, inflating the cuff too slowly may cause false-high diastolic readings. Inadequate inflation level may cause false-low systolic readings. Repeating the assessments too quickly may cause false-high systolic readings. Placing the patient's arm below the heart level may lead to false-high readings. Applying the stethoscope too firmly against the antecubital fossa may lead to false-low diastolic readings. Pg. 507

The registered nurse (RN) is teaching a nursing student about the acceptable ranges of respiratory rates. Which responses given by the nursing student indicate the need for further teaching? Select all that apply.

*A. "The acceptable range for adults is 30 to 50 breaths per minute."* *B. "The acceptable range for infants is 20 to 30 breaths per minute."* C. "The acceptable range for toddlers is 25 to 32 breaths per minute." *D. "The acceptable range for newborns is 12 to 20 breaths per minute."* E. "The acceptable range for adolescents is 16 to 20 breaths per minute." Rationale: The acceptable range of respiratory rate for adults is 12 to 20 breaths/minute. The acceptable range of respiratory range for infants is 30 to 50 breaths/minute. In newborns, the acceptable respiratory rate is 30 to 60 breaths/minute. For toddlers who are two years of age, the acceptable respiratory rate is 25 to 32 breaths/minute. The acceptable respiratory rate for adolescents is within the range of 16 to 20 breaths per minute. Pg. 501

The nurse has been asked to measure the arterial oxygen saturation of a patient who has consumed an organic phosphorus poison. While using the pulse oximeter with digital probes, what are the factors that affect the functional ability of the device? Select all that apply.

*A. Nail polish* *B. Artificial nails* C. Hyperthermia D. Fair skin pigment *E. Metal studs in nails* Rationale: Nail polish, artificial nails, and metal studs in the nails interfere with light transmission of the device and yield inaccurate results. The presence of hypothermia at the assessment site interferes with the device functioning properly because it decreases the peripheral blood flow. Dark skin pigmentation results in device malfunction and may yield an overestimation of saturation. Pg. 503

The nurse is reviewing the recorded vital signs of her adult patients. Which respiratory rate (RR) findings would indicate tachypnea? Select all that apply.

*A. RR greater than 20 breaths per minute* *B. RR greater than 30 breaths per minute* C. RR less than 12 breaths per minute D. RR less than 18 breaths per minute E. RR between 12 and 20 breaths per minute Rationale: The nurse should know the definitions of alterations in the patterns of breathing. Tachypnea is present when breathing is regular but abnormally rapid and greater than 20 breaths/minute. A respiratory rate less than 12 breaths per minute is called bradypnea. A respiratory rate less than 18 breaths per minute may be considered normal if it is greater than 12. A respiratory rate between 12 and 20 breaths per minute is the normal respiratory rate. Pg. 502

The nurse records a blood pressure (BP) reading of 166/110 mm Hg in a patient. When she reviews his records, she sees that his previous recording was 159/112. What interventions are appropriate for this patient? Select all that apply.

*A. Refer the patient to the healthcare provider.* *B. Evaluate the patient again in 1 month.* C. Reassess the blood pressure within 2 months. D. Recheck the blood pressure within 3 months. E. Recheck the blood pressure three different times in 6 months. Rationale: A blood pressure of 166/110 mm Hg indicates that the patient is in stage 2 hypertension. Stage 2 hypertension is characterized by an average blood pressure reading of 160/100 mm Hg or above taken at two or more visits. The management of stage 2 hypertension includes referring the patient to the healthcare provider for diagnosis and prompt treatment, and then evaluating the patient within one month to assess the efficacy of treatment. For stage 1 hypertension, a confirmation is required within 2 months. Rechecking within 3 months or three different times in 6 months is not appropriate for stage 2 hypertension. The reevaluation should be done on a monthly basis. Pg. 505

A patient has an apical rate of 96 beats per minute and a radial rate of 78 beats per minute. What is the pulse deficit of this patient? Record your answer using a whole number.

18 beats Rationale: The pulse deficit is the difference between the apical rate and the radial rate. Hence, the pulse deficit in the patient is 96 - 78 = 18. Study Tip: Think of the pulse deficit as the amount that the heart puts out, but that does not reach the radial pulse point. That's why it is the difference between the apical and radial rates. Pg. 499

The nurse is teaching a patient who is taking antihypertensive drugs about the management of hypertension. Which statement would indicate that the patient understands the management of hypertension?

A. "I need to have my blood pressure checked monthly." B. "I can still smoke while taking these drugs as long as I cut down." *C. "These pills will help control my high blood pressure."* D. "When my blood pressure is back to normal, I can stop taking these pills." Rationale: The drug therapy for high blood pressure does not cure the disease; it only helps control the symptoms. Patients should check blood pressure regularly, report significant changes, and avoid the use of tobacco in any form. The blood pressure would return to normal with the drug therapy; however, therapy should not be stopped or hypertension may return. Pg. 505

You observe a nursing student taking a blood pressure (BP) reading on a patient. The patient's BP range over the past 24 hours was 132/64 to 126/72 mm Hg. The student used a BP cuff that was too narrow for the patient. Which BP reading made by the student is most likely caused by the incorrect choice of BP cuff?

A. 96/40 mm Hg B. 110/66 mm Hg C. 130/70 mm Hg *D. 156/82 mm Hg* Rationale: When you use a blood pressure cuff that is too narrow or short, your patient will most likely have a BP reading that is higher than it really is: You will get a false-high reading. If the bladder or cuff were too wide, the reading would be a false-low reading. Pg. 506, 507

Which patient is most at risk for tachycardia?

A. A healthy professional tennis player B. A patient admitted with hypothermia *C. A patient with a fever of 39.4° C (103° F)* D. A 90-year-old male taking beta blockers Rationale: Patients with a fever have a high heart rate. A healthy athlete has a low heart rate because of conditioning. Hypothermia slows the heart. Beta-blockers reduce heart rate. Test-Taking Tip: Because you know tachycardia is an increased heart rate, you need to check each choice and consider whether it would increase or decrease the heart rate. Remember that tachy means fast. Think of the tachometer of your car; when you accelerate quickly, it shows visually what you hear the engine doing, which is racing. Pg. 499

In which patient would a resting heart rate of 55 beats/minute be considered a normal finding?

A. An obese patient *B. An athlete* C. A patient who is taking a diuretic D. A patient who weighs less than 90 lb Rationale: The conditioning of athletes, especially runners, allows a resting rate below 60 beats/minute without interrupting the normal sinus rhythm of the heart. A heart rate below 60 beats/minute is considered bradycardia. Athletes often maintain heart rates consistent with sinus bradycardia because their heart is an effective pump with a greater-than-normal stroke volume. An obese person may experience an increase in resting heart rate secondary to cardiac demand. Bradycardia is not associated with diuretics or weight less than 90 lbs. Pg. 499

A diabetic patient with poor glycemic control has been admitted to the intensive care unit (ICU). The nurse observes that the patient is breathing deeply. The respiration rate is regular and increased. What should the nurse label this type of respiratory pattern?

A. Bradypnea B. Biot's respiration *C. Kussmaul's respiration* D. Cheyne-Stokes respiration Rationale: Kussmaul's respiration is an abnormally deep, regular, and increased rate of respiration seen in conditions associated with metabolic acidosis such as in a diabetic patient. Biot's respiration is shallow and associated with irregular periods of apnea. Bradypnea is regular but the rate of respiration is reduced. Cheyne-Stokes' respiration is an irregular rate and has a depth of respiration associated with periods of apnea and hyperventilation. Pg. 502

While caring for a patient with a respiratory disorder, which abnormality can be most appropriately interpreted by the primary health care provider from the continuous recordings of the capnogram?

A. Changes in heart rate *B. Changes in ventilation* C. Changes in heart rhythm D. Changes in partial pressures of oxygen Rationale: Capnography is the measurement of exhaled carbon dioxide throughout exhalation. Interpretation of a continuous recording, or capnogram, can detect changes in ventilation. The ETCO 2 value can be used to evaluate respiratory and cardiac status. Electrocardiogram interpretation is most appropriate for interpreting changes in heart rate and rhythm. Capnography approximates the partial pressure of carbon dioxide, but may not determine the changes in the partial pressure of oxygen. Pg. 501

The registered nurse (RN) observes a difference between a patient's apical pulse and radial pulse rates. Which parameter abnormality is most likely to be associated with this difference in pulses?

A. Heart rate *B. Heart rhythm* C. Blood Pressure D. Respiratory rate Rationale: The difference between the apical and radial pulse rates is the pulse deficit. An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. Pulse deficits are often associated with abnormal rhythms. Peripheral and apical pulse rate assessment often reveals variations in heart rate, but the difference in these pulses is not associated with abnormalities in heart rate. Blood pressure and respiratory rate abnormality may be associated with pulse rate, not pulse deficit. Pg. 499

As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. How should you respond?

A. Nail polish attracts microorganisms and contaminates the finger sensor. B. Nail polish increases oxygen saturation. *C. Nail polish interferes with sensor function.* D. Nail polish creates excessive heat in the sensor probe. Rationale: Black or brown nail polish interferes with the sensor function and light absorption. Nail polish reduces light transmission and can alter oxygen saturation measurement. Pg. 503

Which site is appropriate for assessing the pulse in children?

A. Radial B. Carotid C. Femoral *D. Temporal* Rationale: The temporal site is easily accessible and is suitable for assessing a pulse in children. The radial site is used to assess the status of circulation to the hands. The carotid site is easily accessible and is used during shock and cardiac arrest when other sites are not palpable. The femoral site is an easily accessible site during shock and cardiac arrest, and this site is suitable for assessing circulation in the legs. The brachial or apical pulse is the best site for assessing the pulse in an infant or young child. Pg. 497, 498

A patient is admitted to the emergency room with dyspnea and chest discomfort. Admission vital signs include: heart rate (HR) 112, blood pressure (BP) 138/82, respiratory rate (RR) 22, and oxygen saturation 90%. The patient is administered oxygen at 2 L via a nasal cannula. Which change in vital signs on re-evaluation reflects a positive outcome of oxygen therapy?

A. Radial pulse: 112 B. Respiratory rate: 24 *C. Oxygen saturation: 96%* D. Blood pressure: 134/78 Rationale: The goal of oxygen therapy is to increase oxygen saturation , so an increase in saturation from 90% to 96% is a positive outcome of therapy. Heart rate remains elevated on re-evaluation, so this is not considered a positive outcome. Administering oxygen should decrease the respiratory rate, not increase it. The decline in blood pressure is unlikely to be caused by oxygen. Pg. 502

A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a very slow radial pulse of 44. What is your priority intervention?

A. Request that the nursing assistant repeat the pulse check. B. Call for a stat electrocardiogram (ECG). *C. Assess the patient's apical pulse and evidence of a pulse deficit.* D. Prepare to administer cardiac-stimulating medications. Rationale: Your priority is to assess the patient first. The nurse cannot delegate vital signs for an unstable patient. Therefore, first you determine if the patient has a pulse deficit. Calling for an ECG and administering cardiac-stimulating medications are interventions that require notification of the healthcare provider and occur after you assess the patient. Test-Taking Tip: If the question asks for an immediate action or response, more than one answer may be correct, so base your selection on identified priorities for action. Pg. 499

The nurse is evaluating the assessment skills of students by asking them to perform an assessment of vital signs. The nurse finds that a student is assessing the pulse in an improper way. Which assessment of the student leads the nurse to conclude this?

A. The student is assessing the radial pulses individually. B. The student is assessing the temporal pulses individually. *C. The student is assessing the carotid pulses simultaneously.* D. The student is assessing the brachial pulses simultaneously. Rationale: Carotid pulses should not be assessed simultaneously, because excessive pressure on both the carotids may occlude blood supply to the brain. Radial and temporal pulses may be assessed simultaneously or individually without causing any harm to the patient. Simultaneous assessment of brachial pulses also has no adverse effects. Study Tip: To remember that you should not assess right and left pulses simultaneously, consider that you would not plan to strangle or choke a patient! Thus, you need to assess the carotid pulses individually. Pg. 500

The nurse is measuring a patient's blood pressure. Where should the nurse locate the pulse to auscultate blood pressure?

A. Thumb side of forearm at wrist B. Ulnar side of forearm at wrist *C. Groove between biceps and triceps muscles at antecubital fossa* D. Fourth to fifth intercostal space at left midclavicular line Rationale: The brachial pulse is used when measuring blood pressure. It can be located in the groove between the biceps and triceps muscles at the antecubital fossa. The radial pulse is located at the thumb side of the forearm at the wrist. This pulse is used to assess the circulation to the hand. The ulnar pulse is located at the ulnar side of the forearm at the wrist. This pulse is used to assess the circulatory status to the hand and to perform Allen's test. The apical pulse can be palpated at the fourth to fifth intercostal space at the left midclavicular line. Pg. 508

A healthcare provider instructs the nurse to palpate the posterior tibial artery. Which site does the nurse use?

A. Top of the foot B. Popliteal fossa *C. Inner aspect of the ankle* D. Outer aspect of the lateral malleolus Rationale: The posterior tibial artery is palpated on the inner aspect of the ankle, below the medial malleolus. The dorsalis pedis artery is palpated along the top of the foot. The popliteal artery is palpated within the popliteal fossa. No artery is palpated along the lateral malleolus. Pg. 498

An older adult patient was brought to the hospital after a cardiac arrest, and is being treated and kept under observation. The nurse finds that the patient's condition is suddenly worsening. Which site should the nurse immediately assess to obtain the patient's pulse?

A. Ulnar site *B. Carotid site* C. Popliteal site D. Temporal site Rationale: The carotid artery is the most suitable site for assessing the patient's pulse, because it can be located quickly and provides a good reading on the pulse, as the heart delivers blood through the carotid artery. The ulnar site is used for assessing the status of circulation to the hands. The popliteal site is used to assess the status of circulation to the lower leg. The temporal site is used to assess pulse in pediatric patients. Pg. 497