Foundations and Adult Health Nursing - Ch. 11 Vital signs

The nurse is teaching a hypertensive patient about the method for self-assessment of blood pressure (BP). What instruction should the nurse give to the patient?

"Avoid sitting in the cross-legged position while measuring BP."

Which blood pressure reading would be considered hypertension?

148/92

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. _____ beats per minute

14; 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 the radial rate is 78, so the pulse deficit is 14 beats. Pulse deficits are often associated with abnormal rhythms.

The nurse enters a patient's room for a morning assessment. A patient has a radial pulse of 122 and an apical pulse of 75. What is the pulse deficit for this patient? Record your answer using a whole number.

47;At times a difference is found between the apical and radial pulses. This is called a pulse deficit. A pulse deficit is confirmed by having one nurse count the apical pulse and a second nurse count the radial pulse at the same time for 1 full minute using the same watch. A deficit exists when the radial rate is less than the apical pulse. A pulse deficit signifies that the pumping action of the heart is faulty or there is a peripheral vascular issue. This is often seen in atrial fibrillation. The pulse deficit is the difference in the apical and radial pulses. 122 - 75 = 47

A new patient comes into a neighborhood clinic for an appointment. Vital signs are being taken. What is the best method for the nurse to use when assessing the respirations?

Allow fingers to remain on the radial pulse while counting respirations; The best time to assess the respirations is immediately after counting a radial or apical pulse. At this time the patient is unaware it is being done and is less likely to consciously alter respirations. The respiratory rate may not be correct if the nurse is actively talking to the patient. The patient is never informed when the respirations are counted because the respirations may be consciously altered. Having unlicensed assistive personnel count the respirations is not the most appropriate action, because taking the vital signs should require only one person, and it should be the person who takes all of the other vital signs.

A registered nurse needs to determine if a patient has a pulse deficit. The LPN (licensed practical nurse) has been asked to assist. The registered nurse signals and begins counting the apical pulse. What should the LPN do to assist the registered nurse to determine whether a pulse deficit is present?

Begin counting the radial pulse; In assessing the pulse deficit (which can indicate an alteration in cardiac output), the apical pulse should be counted while another nurse counts the radial pulse. The nurse with the watch should begin the count so that the counting is simultaneous. The brachial, femoral, and popliteal pulses are not used in assessment of a pulse deficit if the radial pulse is obtainable.

A patient is four days postoperative after a surgical procedure and has discharge orders on the chart. When the nurse comes to give discharge instructions, the patient states, "I just feel funny." How should the nurse proceed?

Secure supplies needed and assess patient's vital signs; Vital signs should be assessed when the patient reports nonspecific symptoms of physical distress (reports of feeling "funny" or "different"). The patient should be assessed before the primary health care provider is notified. Before discharge instructions are given, the patient must be assessed because the discharge could potentially be postponed pending patient status. Being that the only complaint the patient has is a funny feeling, there are no definite instructions to give to the patient.

A nursing instructor is supervising a student taking an apical pulse. Which action indicates the student is assessing the apical pulse correctly?

The stethoscope is placed at the fifth intercostal space at the left midclavicular line; The apical pulse represents the actual beating of the heart. The point of maximal impulse (PMI) is at the fifth intercostal space at the left midclavicular line. Palpating the area around the wrist is taking a radial pulse. The heart is on the patient's left.

While performing an assessment on a patient, the nurse records a pulse deficit. Which statement best describes a pulse deficit?

There is a difference between the apical and radial pulse rates.

A patient has a prescription for daily weights. What intervention(s) should the nurse implement to ensure that the weight is as accurate as possible? Select all that apply.

Weigh the patient using the same scale & Weigh the patient with the same type of clothing; Patients should be weighed at the same time of the day, on the same scale, and in the same amount of clothing to allow an objective comparison of subsequent weights. The ideal time to weigh a patient is in the morning after voiding and before breakfast. Therefore when the patient has a full bladder and has eaten a meal are not the optimal times to weigh him or her.