Fundamentals:Skills Nursing Application: Vital Signs
One possible goal related to Jason's nursing diagnosis is to identify risk factors for fluid deficit and relate the need for increased fluid intake as indicated. Jason asks the nurse why he needs the extra fluid in the form of an IV and to drink more liquids. What should the nurse explain to Jason? Select all that apply.
"Your fever is making you sweat, which is causing you to lose extra fluid." "Your fever is causing you to lose extra fluid and your urine output needs to increase."
Which statements are true related to manual versus automatic blood pressure (BP) measurements? Select all that apply.
-Automatic BP devices should not be used with clients whose BP result is in question in relation to the client's condition. -A manual BP is more accurate than an automatic BP. -Manual BP auscultation will yield assessment cues.
The nurse continues to monitor Jason's response to priority nursing actions. The nurse is responsible for evaluating if more frequent assessments are necessary. Based on which indicators will the nurse monitor Jason's vital signs more often? Select all that apply.
-The client's condition worsens -The healthcare provider's orders
The nurse is caring for a client named Jason (preferred pronouns: he, him, his) who has been hospitalized for treatment of an infection. While waiting for report, the nurse reviews the client's electronic health record (EHR). In the EHR below, select all the assessment findings that require immediate follow-up by the nurse.
-he did not seek medical help -superficial temporal artery temp of 39.0C -regular RR of 22 -shivering -a serum creatine of 1.5 -WBC level of 6000 -pain in my leg where I cut it -recently started taking a new over-the-counter medication called Kaopectate
The nurse, who is assessing a client for cues that would indicate that nursing action is required, knows which statements are true regarding the relationship of thermoregulation, oxygen requirements, and fluid volume? Select all that apply.
A fever increases metabolism. A fever can lead to fluid volume deficit.
The nurse determines Jason's priority needs based on the data collected. Which nursing diagnosis would be appropriate for the nurse to implement in Jason's case?
Deficient fluid volume related to fever
For each client outcome, click to specify if the interventions were effective, ineffective, or unrelated.
EFFECTIVE: Jason's respiratory rate (RR) is 12 breaths/min. Jason is no longer diaphoretic. Jason's oral temperature is 37.0⁰C (98.6⁰F). Jason's blood pressure (BP) is 124/80. Jason increases his fluid intake. Jason's heart rate (HR) is 80 INEFFECTIVE: Jason's urine output is 30 mL/hour. UNRELATED: Jason is able to identify the need to increase carbohydrates in his diet.
Jason's airway is stable, respirations are now within normal limits, and he denies pain. The nurse auscultates Jason's apical heart rate. Which statements are true regarding the measurement of an apical heart rate? Select all that apply.
In auscultating Jason's apical heart rate, the nurse listens for one full minute. The nurse anticipates that Jason's apical heart rate will be elevated. Jason's radial pulse was previously irregular and difficult to assess. Therefore, the apical heart rate is indicated here.
Earlier, the nurse was unable to obtain Jason's SpO2 measurement using a pulse oximeter. Which statement is true related to the possible causes of interference with arterial pulsations needed for pulse oximeter function?
Jason's hands are cold.
The nurse was able to stabilize Jason's shivering. What nursing interventions were most likely used based on the principles of thermoregulation? Select all that apply.
Limit blankets on Jason's bed. Limit Jason's clothing. Apply a cool, damp towel to Jason's forehead.
Which factors must the nurse consider when measuring vital signs? Select all that apply.
Medications Gender Age
For each nursing action, click to specify if it is a priority or not a priority action for the nurse to take at this time.
PRIORITY: -Ask Jason to describe his pain. -Observe Jason's behavioral pain cues -Obtain an oral temperature. -Observe Jason for airway, breathing, and circulation (ABCs). -Palpate a systolic blood pressure. NOT A PRIORITY: -Alert Jason's healthcare provider of the results. -Decrease the frequency of temperature assessment now that Jason's temperature is normal. -Administer pain medication to Jason and reassess vital signs after 30 minutes.
Based on the assessment findings, the nurse determines that the priority nursing actions will focus on efforts to restore thermoregulation. For each nursing intervention, drag and drop it to the correct category to indicate if it is a priority or not a priority for the care of the client.
PRIORITY: -encourage Jason to increase fluid intake -Administer prescribed medical treatments as ordered -Continue to assess Jason's pain characteristics -Continue to alert Jason's healthcare provider of assessment findings
Considering all assessment findings, which findings are consistent with dehydration? Select all that apply.
Pulse oximeter unable to measure SpO2 BP below Jason's baseline HR elevated above Jason's baseline
Using the information from the electronic health record, select the correct priority hypothesis.
infection, elevated, elevated temperature, shivering
Vital signs are interrelated. The nurse knows that a rise in temperature of
one increase four A rise in temperature of 1 degree Fahrenheit may cause an increase in the pulse rate by 4 beats per minute. Respiratory rates and blood pressure readings also increase with a rise in temperature.