Health Assessment - Vital signs

What instruction should be included when educating a patient about home blood pressure measurement?

"Get adequate rest before you take your blood pressure." Rationale: It is important to get adequate rest before measuring blood pressure in order to ensure an accurate reading. The blood pressure should be measured at the same time, and on the same limb, every day in order to effectively compare measurements. Blood pressure should be measured while lying down or sitting in order to avoid false high or low readings.

A patient tells the health care team member that his home blood pressure measurements are always higher in the evening than they are in the morning. What is the best reply for this patient?

"It is normal for the blood pressure to fluctuate throughout the day." Rationale: It is normal for blood pressure to fluctuate throughout the day, and the patient should be instructed that this is normal. The machine does not need to go to the pharmacy to be checked for accuracy. Alterations in blood pressure during the day, unless extreme, do not need to be reported to the doctor immediately. Patients should be instructed to check their blood pressure at the same time every day; but they should check in the morning when the blood pressure tends to be the lowest.

What instruction should be given the patient before using Doppler ultrasound to obtain peripheral pulses?

"You need to remain still for the procedure." Rationale: The patient should remain still throughout the procedure. Movement may result in inaccurate results. Inform the patient that some pressure may be felt as the probe is applied to the skin. An ultrasonic transmission gel enhances the transmission of sound. Using a recommended gel by the manufacturer will improve the accuracy of the test and protect the crystals in the probe.

A 2-month-old infant has a fever when the rectal temperature is higher than which temperature point?

38°C (100.4°F) Rationale: For a child younger than 3 months of age, a rectal temperature higher than 38°C (100.4°F) constitutes fever. For an infant between 3 and 24 months of age, a temperature of 38.3°C (101°F) or higher likely constitutes fever. For a child older than 2 years of age, fever more commonly is defined as a rectal temperature higher than 38°C (100.4°F).

When measuring the blood pressure on a patient's thigh, a systolic pressure of 148 and a diastolic pressure of 74 is recorded. What is the pulse pressure?

74 Rationale: The pulse pressure is the difference between the systolic pressure and the diastolic pressure; in this case 148-74, which equals 74. None of the other answers represent the difference between the systolic pressure and the diastolic pressure.

A nurse is taking the radial pulse of a 26-month-old child who has been crying and holding her breath. The nurse knows that the child's actions can cause which problem?

An irregular heart rhythm, which is not uncommon in young children Rationale: Children commonly have a sinus arrhythmia, which is an irregular heartbeat that speeds up with inspiration and slows down with expiration. The irregular rhythm may not be a cause for excessive concern, but it should be evaluated to ensure that it does not present a problem for the child. Breath holding in a child affects pulse rate. Crying and breath holding do not cause atrial fibrillation.

Which is correct regarding Korotkoff phase 1 sounds?

First sound heard after slow deflation of the cuff begins Rationale: Korotkoff phase I is the first sound heard after deflation of the cuff and reflects the systolic pressure. This sound is clear, repetitive, and tapping in nature. It often coincides with the reappearance of a palpable pulse.

Which is a characteristic of arterial sounds?

Arterial sounds are loud and pulsatile. Rationale: Arterial sounds are loud, pulsatile, pumping sounds that are repeated with each cardiac cycle. Upon expiration, venous sounds are high-pitched and resemble the sound of rushing wind.

During the initial assessment of an older adult who is potentially dehydrated, a colleague comes into the room to assist and offers to start an IV line and draw laboratory samples. Which response is appropriate?

Ask the colleague to first help steady the patient while orthostatic vital signs are obtained. Rationale: Older adults are more likely to be unsteady in the presence of dehydration, so it is helpful to have an assistant available in case the patient becomes syncopal. An assistant does not necessarily speed up the procedure, because the patient must still maintain the positions for the required time intervals; the primary reason for an assistant is to ensure the patient's safety. Painful procedures, such as initiating an IV line, should be deferred until vital signs have been taken. Oral fluids are contraindicated in some cases and should be deferred until a more complete assessment has been completed.

What action is appropriate when evaluating hydration status in an infant?

Ask the family about the number of wet diapers. Rationale: Knowing how often the child is urinating in comparison to normal is helpful in assessing hydration status. Fever may lead to dehydration, but the presence of a fever does not indicate anything about current hydration status. A change in reflexes is not associated with a child's hydration status. Breath sounds do not reflect hydration status in children, except in cases of significant fluid overload, usually from IV fluids.

During assessment of peripheral pulses in the left leg via a Doppler instrument, the dorsalis pedis pulse cannot be located. What is the most appropriate next step?

Attempt to locate the posterior tibial pulse. Rationale: If the most distal pulse of an extremity cannot be located with a Doppler instrument, the next most proximal site should be assessed (posterior tibial in this situation). If no pulse can be detected there, continue moving proximally until blood flow is identified. Reapplying additional transmission gel should not be necessary. Pulse check progression, during evaluation for peripheral pulses, moves from the most distal to the most proximal sites. The popliteal pulse is not the next pulse in the move proximally. Blood flow is being evaluated in the left leg; evaluation of the right leg for comparison is not necessary at this time.

The nurse is about to obtain routine vital signs from a 2-year-old patient. Which statement regarding BP measurement in children is accurate?

BP is not routinely assessed in a 2-year-old child. Rationale: BP is not a routine part of assessment in children younger than 3 years of age. Cuff size must be appropriate for the patient. Korotkoff sounds are difficult to hear in children because of low frequency and amplitude. BP measurement can frighten children, and anxiety can cause unreliable readings.

Which precaution should the nurse take when using pulse oximetry on a neonate in a radiant warmer?

Cover the pulse oximetry sensor. Rationale: Heat and light sources can affect pulse oximetry sensors, so the sensor should be covered before use in a radiant warmer. The baby should not be removed from the warmer because neonates lose heat quickly. An earlobe sensor should not be used on a neonate. Skin protection lotion may be used on neonates before sensor placement to prevent stripping, tears, or blisters.

Which action should be taken before checking a patient for orthostatic vital sign changes?

Evaluate the patient's medication history. Rationale: The patient's medication history should be evaluated. Certain medications can predispose a patient to orthostatic hypotension and produce unreliable results regarding fluid status. IV access is not necessary to obtain orthostatic vital signs. The patient needs to lie in a supine position for at least 5 minutes before the initial measurement. Checking orthostatic vital signs is contraindicated in patients with severe alterations in mental status.

Which of the Korotkoff sounds indicates systolic BP?

First Rationale: BP is recorded with the systolic reading (first Korotkoff sound) before the diastolic (beginning of the fifth Korotkoff sound).

When measuring orthostatic vital signs, which of these is considered a positive result in adults?

Increase in heart rate of 20 bpm or more Rationale: When orthostatic vital signs are measured, one or more of these findings may indicate intravascular volume loss in adults: increase in heart rate of 20 bpm or more, decrease in systolic blood pressure of 20 mm Hg or more, decrease in systolic blood pressure to less than 90 mm Hg, or decrease in diastolic blood pressure of 10 mm Hg or more. A decrease in heart rate of 20 bpm or more is not considered a positive result.

A systolic blood pressure measurement of 100 mm Hg is obtained from a patient with diabetes by using Doppler ultrasound. Which statement is correct regarding this blood pressure measurement?

It may be erroneously elevated. Rationale: Doppler ultrasound blood pressure readings in patients who have diabetes, are obese, or have calcified vessels may be erroneously elevated. Any necessary further treatment will depend upon the patient's baseline blood pressure and other clinical findings. A vasodilator is not warranted in this situation.

Which limb is the most appropriate for blood pressure measurement?

Left arm with multiple tattoos Rationale: The presence of tattoos will not affect blood pressure measurement; so, in this case, the left arm with the tattoos is the most appropriate site. Any limb with IV fluids running, history of mastectomy, or presence of trauma should be avoided for blood pressure measurement because the inflation of the cuff may cause tissue damage.

How should the nurse ensure proper BP cuff size for the upper extremity?

Measure the arm circumference. Rationale: The nurse should measure the arm circumference to ensure that the cuff width is approximately 40% of the arm's circumference and the length is twice the width. Although the cuff should wrap around the arm's diameter at least once, the proper length is twice the width. An oversized cuff width from the antecubital space to the axilla results in falsely low BP readings; an undersized cuff creates falsely high BP readings.

If a patient is at risk for low blood pressure, which sign or symptom should he or she be assessed for?

Mental confusion Rationale: Mental confusion may be associated with low blood pressure and should be assessed if a patient is at risk for low blood pressure. Facial flushing, nosebleed, and headache are associated with high blood pressure and should be assessed if a patient is at risk for high blood pressure.

Which is important to remember when measuring orthostatic vital signs?

Patients taking beta blockers may not have significant changes in heart rate. Rationale: Patients who are taking medications that block beta receptors are unlikely to be able to produce significant changes in heart rate. The patient's arm should be supported at the level of the heart to prevent inaccurate measurements. The high-Fowler position is the alternative to standing for those patients who cannot stand, but the results are less credible. A systolic blood pressure decrease of 20 mm Hg or more is often considered a positive finding.

Orthostatic vital signs have been ordered for a patient in the emergency department. The nurse questions the order for the patient with which of these conditions?

Pelvic injury Rationale: Orthostatic vital signs are contraindicated in patients with supine hypotension, shock, or severely altered mental status, or in those with spinal, pelvic, or lower extremity injuries. Orthostatic vital signs are not contraindicated in the patient with hypertension, dementia, or stroke.

A patient who was rescued from a pond is hypothermic and has been intubated. The patient's blood pressure cannot be auscultated. Which technique using the probe is the best for measuring the patient's blood pressure by Doppler ultrasound?

Place the probe at a 45-degree angle along the length of the vessel. Rationale: The probe should be placed over the artery and tilted to a 45-degree angle along the length of the vessel to optimize frequency shifts and signal amplitude. There are no recommended pounds of pressure to be applied to the probe. Excess pressure on the probe may prevent blood from flowing through the artery and give a false result. Transmission gel, not alcohol, is used to facilitate sound transmission. Alcohol should not be used on the probe. Because a blood pressure cuff cannot be inflated above the femoral pulse, this site is not used in the measurement of blood pressure when using a Doppler ultrasound.

The nurse is measuring a patient's BP in the upper extremity and finds that the patient's BP is lower than normal for the patient. The patient is asymptomatic. What should the nurse check first?

Position of the patient's arm at the time of assessment Rationale: The nurse should first check the position of the patient's forearm, confirming that it is at heart level with the palm facing up. Placement of the arm above the level of the heart causes falsely low readings. Leg crossing can falsely increase systolic and diastolic BP readings. Although sphygmomanometers can go out of calibration, if all other BP measurements obtained for other patients are reasonable, the problem is not likely to be the machine. If the patient's arm and legs are properly positioned, the nurse should verify the position of the stethoscope. Placing the stethoscope directly over the artery provides an accurate BP measurement; however, placement to the side of the artery may cause difficulty auscultating the BP and reduce accuracy.

Which patient position is preferred during BP assessment of the lower extremity?

Prone Rationale: The prone position provides the best access to the popliteal artery and is therefore preferred. However, if the patient is unable to assume the prone position, the supine position with the knee slightly flexed is also acceptable. Neither the side-lying nor the Sims positions are acceptable for measuring BP in the lower extremity.

Which term refers to the difference between systolic pressure and diastolic pressure?

Pulse pressure Rationale: The difference between systolic pressure and diastolic pressure is the pulse pressure. Pulsus paradoxus is a decrease in the strength of the pulse during inspiration. Cardiac output is the amount of blood pumped by the heart in 1 minute. Peripheral resistance is the resistance to blood flow from the heart by the peripheral vasculature.

Which action should be taken after performing the first blood pressure assessment on the patient's right thigh?

Repeat the procedure on the opposite leg. Rationale: After the patient's first blood pressure assessment, the procedure should be repeated on the other leg. Comparing the blood pressure in both legs helps to detect circulatory problems. If the thigh is being used for blood pressure measurement, there is a reason the arms are not being used. Therefore, checking the blood pressure in either arm after the thigh is not effective and may even cause damage. Repeating the procedure on the same leg is not appropriate unless there is reason to believe that the first measurement was not accurate.

During assessment of a patient's brachial pulse, a high-pitched sound is heard. The sound resembles a rushing wind and is cyclic with respirations. What is the best next step?

Reposition the probe until loud, pulsatile sounds are heard. Rationale: High-pitched sounds that resemble a rushing wind and are cyclic with respirations indicate that the probe is over a vein. To assess arterial flow, the probe should be repositioned until loud, pulsatile, pumping sounds are heard. The angle of the probe will improve signal reception but will not change the fact that the probe is over a vein. Cleaning the probe and skin will not change the quality of the sound; it will make the sounds easier to hear. The probe should never be cleaned with alcohol. A 2.25-MHz probe is used to assess fetal heart tones, not peripheral vessels.

A patient's supine vital signs are within normal limits. After moving from a supine to a standing position, the patient complains of feeling weak and dizzy. Which intervention is appropriate?

Returning the patient to a supine position and reporting a positive finding Rationale: Because safety is always a priority, the patient should be returned to a supine position. Also, this patient's symptoms would be considered a positive finding: Weakness, dizziness, visual dimming, and a syncopal episode are all indications of cerebral hypoperfusion, which may be indicative of fluid loss. Once a positive finding has been determined, the orthostatic assessment of vital signs can be halted; continuing to assess vital signs, including blood pressure and heart rate, is not necessary.

Which is the preferred site for measuring blood pressure on a child?

Right arm Rationale: The right arm is the preferred site for blood pressure measurement in children for consistency and comparison with standardized blood pressure measurement tables for age and weight. Blood pressure in the left arm may be low if coarctation of the aorta is suspected. Thigh blood pressure measurement is uncomfortable in children.

An older adult has an order for frequent blood pressure measurements. The health care team member applies the automatic cuff and leaves it on all night in order to obtain every 15 min blood pressure readings. This action places the patient at risk for what complication?

Skin breakdown Rationale: The skin of older adults is more fragile and susceptible to damage from cuff pressure when blood pressure measurements are frequent. More frequent assessment of the skin under the cuff or rotation of blood pressure sites is recommended. Frequent blood pressure measurements do not directly cause infection, falls, or false blood pressure readings.

When educating a patient about blood pressure, which modifiable risk factors for hypertension should be included?

Smoking and sedentary lifestyle Rationale: Modifiable risk factors are those that the patient has the ability to change. These include obesity, high cholesterol, smoking, sedentary lifestyle, and alcohol consumption. Family history of hypertension cannot be changed by the patient. A patient would be able to modify risk factors for lung cancer, but the cancer itself is not a modifiable risk factor.

When assessing blood pressure on a patient's thigh, how should the cuff bladder be positioned?

Snugly, directly over the popliteal artery Rationale: The cuff should always fit snugly, as a loose-fitting cuff causes false-high readings. Positioning the cuff bladder directly over the popliteal artery ensures that proper pressure is applied during inflation. Positioning over the lower half of the calf is appropriate for calf measurement but would not give an accurate thigh measurement.

The emergency department nurse is preparing to obtain orthostatic vital signs on a patient. What position is the patient placed in for the initial readings?

Supine Rationale: Before the initial measurement is taken, the patient should lie in a supine position for at least 5 minutes. The initial reading is not obtained with the patient in the standing, sitting, or high-Fowler position.

The emergency department nurse is obtaining orthostatic vital signs on a patient. Which sequence provides the most accurate results?

Supine-to-standing Rationale: A supine-to-standing measurement is more accurate than a supine-to-sitting measurement. Standing-to-supine is not the most accurate measurement, and the supine position is used for baseline measurement.

Which term refers to the peak pressure that occurs when ventricular contraction forces blood under high pressure into the aorta?

Systolic pressure Rationale: Systole occurs when blood is forced into the aorta during cardiac contraction. Diastolic pressure is the minimal pressure exerted against the arterial wall at all times. Hydrostatic pressure is the pressure of water at equilibrium, not under pressure. Peripheral resistance is the amount of resistance to blood flow applied by the vasculature.

What is a possible explanation for a false-high reading obtained from an obese patient's arm?

The cuff is too small for the extremity. Rationale: A cuff that is too small for a large arm will cause too little compression of the artery at the suitable pressure level. The corrective action is to reapply a larger cuff to the upper arm. Resistance to pressure generated by the heart is a result of an elevated extremity and will cause a false-low reading. A cuff that is not snugly applied can result in a false-high reading due to uneven and slow inflation, resulting in varying tissue compression.

Which is correct regarding size of a pediatric blood pressure cuff?

The length of the cuff bladder should be 80% of arm circumference. Rationale: An appropriate-size blood pressure cuff will result in the most accurate readings. The length of the blood pressure cuff bladder should be 80% of arm circumference, and the width of the bladder should be at least 40% of arm circumference.

What is one limitation of using the oral method of temperature measurement?

The oral temperature method is not used on small children. Rationale: One of the limitations of the oral temperature measurement is that it is not used on infants or small children. Some advantages, not limitations, of using the oral temperature method include: accurate surface temperature reading, accurate reflection of rapid changes in core temperature, and a reliable route for measuring the temperature in intubated patients.

After performing hand hygiene, why does the health care team member turn off the water using a clean, dry paper towel on the faucet handle?

The risk of transferring pathogens is greater when using a wet towel. Rationale: Wet towels and hands allow the transfer of pathogens from the faucet by capillary action. Hands would not be dry if a moist towel were used. Petroleum-based lotions should be avoided. Dry towels do not increase wicking or capillary action.

Vascular sounds are not audible with the Doppler probe over the site where the brachial artery is palpable. What is the best way to assess the sensitivity of the instrument?

Use the probe to check own pulse. Rationale: Sensitivity can be verified by checking own pulse. Hot water should never be used to clean a probe, and many manufacturers do not recommend bleach. The manufacturer's guidelines should be checked before cleaning. Changing probes may ultimately be necessary, but it would not be the first step in troubleshooting this situation. Pressing harder with the probe will not help and may, in fact, obliterate any sounds that are present.

A patient presents to the emergency department with suspected fluid loss of 500 ml before arrival. Which symptom constitutes positive orthostatics in addition to vital sign changes?

Visual dimming Rationale: Orthostatic vital signs alone lack sensitivity to detect volume losses of less than 1000 ml reliably. Therefore, vital signs should be interpreted in the context of the patient's other signs and symptoms, such as dizziness and visual dimming. Noninvasive evaluation of fluid monitoring is used for conditions related to vomiting, diarrhea, bleeding, abdominal pain, and blunt trauma. Mydriasis, hypertension, and hypoglycemia are not symptoms of volume loss.

Which thermometer is the best type to use when measuring an axillary temperature?

An electronic thermometer with an oral probe Rationale: The electronic thermometer includes two separate probes, one for oral use (blue top probe) and one for rectal use (red top probe). The oral probe should be used for measuring axillary temperature; for infection control, the rectal probe should be used only for rectal temperature measurement. Temporal artery thermometers are not used to take axillary temperatures because the instrument is designed to measure a transcutaneous temperature using the temporal artery. Most municipalities have prohibited the sale or use of mercury-containing medical devices because of the potential hazards.

The patient questions the health care team member about washing hands, and the health care team member states, "I was using hand rub as I was entering the room." What process was used for this type of hand hygiene?

Antiseptic hand rub was applied to all surfaces of the hands. Rationale: An antiseptic hand rub is performed by applying an antiseptic hand rub product to all surfaces of the hands to reduce the number of microorganisms present. Hand washing refers to washing hands with plain soap and water. An antiseptic hand wash is defined as washing hands with water and soap or other detergents containing an antiseptic agent. Surgical hand antisepsis is an antiseptic hand wash or antiseptic hand rub performed preoperatively by surgical personnel to eliminate transient and reduce resident hand flora.

A patient is sitting up in bed. The nurse has obtained a radial pulse in the patient's right arm. Which intervention should the nurse perform next?

Assess the pulse in the left arm. Rationale: The nurse should compare radial pulses bilaterally. A marked inequality may indicate that arterial flow is compromised to one extremity, and action should be taken. Assessing the carotid pulse is part of a comprehensive assessment, but not the next step. Having the patient lie down could change the pulse, making a comparative assessment more difficult, and it is not necessary unless other conditions make this an important assessment for the patient. There is no need to contact the practitioner unless the findings are abnormal.

When should the nurse expect the lowest temperature readings?

At 7:00 AM Rationale: Daily fluctuations in temperature are normal. Typically, temperatures are lowest in the early morning and highest in the early evening. The temperature falls gradually during the night. Exercise, surgery, and stress may all cause temperature elevations.

When measuring blood pressure by palpation, how should the patient's arm be positioned for the most accurate blood pressure measurement?

At heart level with palm facing up Rationale: The patient's arm should be positioned at heart level with palm facing up. If below heart level, a higher blood pressure will be recorded. Facing the patient's palm up more easily facilitates palpation of the brachial artery.

When should a child's respiratory rate be assessed?

Before assessment of other parameters Rationale: Assessing respirations first allows a more accurate assessment of rate and rhythm before the child becomes anxious because of fear of strangers or other assessment procedures. Temperature and pulse assessments may evoke anxiety in the child, thereby affecting the respiratory rate.

What characteristics of the pulse would the nurse find if the pulse amplitude is given a 4 rating on a scale of 0 to 4?

Bounding and strong Rationale: The amplitude of a pulse with a 4 rating is bounding and strong. The amplitude of a pulse with a score of 0 on a scale from 0-4 means the pulse is absent or non-palpable. The amplitude of a pulse with a score of 1 means the pulse is diminished, difficult to palpate, thready, or weak. A score of 2 means the pulse is as expected, easy to palpate. A score of 3 indicates the pulse is full, increased.

The nurse who is teaching a patient how to monitor BP at home explains that patients in the home setting usually use which artery?

Brachial Rationale: The brachial artery is most commonly used when patients monitor their own BP. The radial, femoral, and ulnar arteries can be used for self-monitoring but are not as commonly used as the brachial artery. Using the brachial artery ensures better accuracy of readings and allows easier access for those who are monitoring their BP.

How can the nurse keep ambient air from altering a tympanic temperature measurement?

By applying gentle pressure to seal the ear canal Rationale: The shape of the temperature probe allows for gentle pressure to be applied to seal the ear canal from ambient air that could alter a reading. Moving the pinna allows maximum exposure of the tympanic membrane. Movement of the pinna should be backward, up, and out for an adult. For a child younger than 3 years of age, the pinna should be pulled down and back. Taking a tympanic temperature in the ear that the patient has been lying on results in a falsely high temperature reading. A temperature that was not obtained using proper technique may be erroneous.

What is one advantage of using the axillary method of obtaining body temperature?

Can be used on newborns and unconscious patients Rationale: The axillary site can be used to obtain body temperature on unresponsive patients and babies. Easy access to the site and very rapid measurement are two advantages of the temporal artery location. Being comfortable for the patient is an advantage of using the oral method.

What should the nurse do before assessing an adult patient's peripheral oxygen saturation using a finger sensor?

Check for adequate capillary refill time. Rationale: If capillary refill is prolonged, the nurse should select an alternative site. An IV site would be proximal to the finger sensor and would not interfere. The specific age of an adult patient is not relevant to the site choice. Rings can be worn during pulse oximetry assessment if they do not impede blood flow.

A patient is difficult to arouse, and the nurse is unable to obtain a radial pulse. After observing deep and regular breathing, the nurse should take which action?

Check the carotid pulse. Rationale: The nurse checks the carotid pulse to assess core circulation. Carotid pulse assessment is often used during physiologic shock or cardiac arrest when other sites, such as the ulnar or temporal, are not palpable. The practitioner should be called immediately after airway, breathing, and circulation have been assessed.

The nurse is doing an initial assessment on a new patient. The patient is anxious and the patient's pulse, while regular, is higher than expected. What adjustment should the nurse make to obtain a more accurate pulse reading?

Check the patient's pulse at the end of the assessment. Rationale: Anxiety can raise the pulse rate. If the patient's pulse rate is higher than expected, reassess it at the end of the physical assessment when the patient is more relaxed. Moderate pressure on the artery results in more accurate assessment results. If the pulse is irregular, the nurse should count the rate for a full 60 seconds. The count of one is the first beat palpated after timing begins.

The healthcare team member is taking serial BP measurements. Several minutes after obtaining a BP by palpation of the right arm, the patient starts to complain of numbness and tingling in the arm. Which action should be taken first?

Check to make sure the cuff has been completely deflated. Rationale: The first action that should be taken is to make sure the cuff is completely deflated. Keeping the cuff on too long or failing to completely deflate the cuff may cause an arterial occlusion, resulting in numbness and tingling of the affected extremity. The practitioner should be notified only if the numbness and tingling are not resolved by making sure the cuff is completely deflated. Inflating the cuff or obtaining another BP measurement may worsen the numbness and tingling and should be avoided.

A patient was involved in a motor vehicle crash that resulted in major head trauma 2 days ago. The nurse has observed that the patient's breathing pattern has been irregular with cycles of shallow breaths that gradually increase in rate and depth, then slow to periods of apnea, only to start over again. What is this type of breathing called?

Cheyne-Stokes respiration Rationale: Cheyne-Stokes respiration is characterized by a respiratory rate and depth that are irregular with alternating periods of apnea and hyperventilation. The respiratory cycle begins with slow, shallow breaths that gradually increase to an abnormal rate and depth. The pattern reverses, and breathing slows and becomes shallow, climaxing in apnea before respiration resumes. Hyperpnea refers to excessively deep or labored breathing. Kussmaul respirations are abnormally deep and regular and are common in diabetic ketoacidosis. Biot respirations are abnormally shallow for two or three breaths, followed by an irregular period of apnea.

What action should the nurse take upon completion of body temperature measurement?

Compare the temperature results with the patient's previous baseline and with the acceptable temperature range for the patient's age. Rationale: Body temperature fluctuates in a narrow range; a comparison of readings can help identify trends and the presence of an abnormality. At the completion of the procedure, the nurse should remove gloves and perform hand hygiene. Verifying the correct patient using two identifiers, and assessing the patient for factors that affect temperature are steps completed before the procedure.

The practitioner has ordered that a patient have continuous peripheral oxygen saturation monitoring. Which action is the nurse's next step after placing the sensor, turning on the oximeter, and observing the pulse waveform?

Correlating the oximeter pulse rate with the patient's radial pulse Rationale: After placing the sensor and turning on the oximeter, the nurse should observe the pulse waveform or intensity display, listen for the audible beep (if available), and correlate the oximeter pulse rate with the patient's radial pulse. Alarm settings should be verified and adjusted after the patient's baseline reading has been established. Silencing the alarm would only occur after the alarm has been set and only if the alarm sounds. The nurse should monitor skin integrity periodically for breakdown, but this is not the next step.

Which statement describes the correct method of assessing a radial pulse in a patient who has an irregular pulse?

Count the rate for a full 60 seconds. Rationale: If the pulse is irregular, the nurse should count the rate for a full 60 seconds to help ensure an accurate estimate of bpm. If the pulse is regular, the nurse may count the rate for 30 seconds and multiply by 2; however, the pulse was irregular in this patient. An accurate radial pulse cannot be obtained in only 15 seconds, and generally counting the rate for 2 minutes is unnecessary.

The nurse is educating the patient about obtaining body temperature when at home. What action should the nurse take first?

Determine if the patient uses a mercury-containing thermometer. Rationale: The nurse should first determine the type of thermometer the patient uses. After determining if the patient uses a mercury-containing thermometer, the nurse should teach the patient and caregiver about mercury hazards. Education on the proper disposal of mercury-containing devices and recommending alternative devices is also completed after assessing the type of thermometer the patient has at home.

What are some of the signs and symptoms of hyperthermia?

Dry mucous membranes, hypotension, and concentrated urine Rationale: Symptoms of hyperthermia include decreased skin turgor, dry mucous membranes, decreased venous filling, and concentrated urine. Additional signs and symptoms of hyperthermia are hypotension and tachycardia. Heat stroke symptoms include hot, dry skin; tachycardia; hypotension; excessive thirst; muscle cramps; visual disturbances; and confusion or delirium. Pale skin, skin cool or cold to touch, bradycardia and arrhythmias, uncontrollable shivering, reduced level of consciousness, and shallow respirations are signs and symptoms of hypothermia.

A patient has been admitted with a diagnosis of advanced Parkinson's disease. The nurse needs to assess the patient's peripheral oxygen saturation. Which sensor would be the most appropriate to use on this patient?

Earlobe sensor Rationale: Because of its central location, the earlobe is likely the most appropriate site for the patient with Parkinson's disease. The tremors in a patient with advanced Parkinson's disease are likely to be most severe in the extremities, interfering with the pulse oximeter's ability to detect a reading accurately, so a toe or finger sensor would be inappropriate. Disposable sensor pads are more expensive, decrease the ease of assessing skin integrity, can result in skin irritation in sensitive patients, and generally are used only with infants.

The nurse is teaching a patient about modifiable and non-modifiable risk factors for hypertension. Which risk factor cannot be modified by the patient?

Family history of hypertension Rationale: Family history cannot be altered to prevent hypertension. Smoking, hyperlipidemia, and obesity are risk factors that the patient can change to decrease the risk of developing hypertension.

If a young child needs home blood pressure monitoring, the nurse should instruct the parent to do what?

First, perform the procedure on another adult to show the child it is safe. Rationale: Young children are more likely to cooperate if they see the procedure performed on an adult they trust. A child should not be restrained for blood pressure monitoring. Young children do not understand reason, so trying to explain will not help. If home monitoring is necessary, this procedure should be performed. The parent should use play or example to help the child cooperate.

What is the mechanism of action by which dirt and microorganisms on the hands are reduced?

Friction and mechanical rubbing Rationale: Friction and rubbing mechanically combine to form an effective mechanism of action that loosens and removes dirt and transient bacteria. Interlacing of the fingers and thumbs is a technique, not a mechanism of action that removes microorganisms. Interlacing the fingers is also a technique that ensures all surfaces are contacted. Correct hand hygiene requires using plenty of lather and friction for at least 15 seconds or for the length of time stated in the manufacturer's IFU for the product used.

A patient scheduled for discharge in the morning is eager to go home and has been pacing around the medical-surgical unit for the last hour. Which action should the nurse take before assessing patient's pulse?

Have the patient sit and rest for several minutes. Rationale: If the patient has been active, the nurse should wait several minutes before assessing the pulse; to obtain an accurate assessment, the nurse should encourage the patient to relax as much as possible. The patient's temperature and respiratory rate could be falsely elevated after exercise. A patient should not receive medication for the sole purpose of obtaining discharge vital signs.

The nurse knows that an assistant understands the proper technique for measuring the radial pulse when he or she takes which action?

Helps the patient to a supine or sitting position. Rationale: Assisting a patient to a supine or sitting position provides easy access to pulse sites. A relaxed position of the lower arm and extension of the wrist permits full exposure of the artery to palpation. Elevating the patient's arm or counting the pulse for 15 seconds and multiplying by 4 can lead to erroneous results. Applying significant pressure can obliterate the pulse.

When a patient has been ambulating in the hall, what would be the expected response in the respiratory rate?

Higher than normal Rationale: As the body increases its workload (in this case through exercise), it also increases its demand for oxygen, which causes the respiratory rate to increase accordingly. Therefore, the rate would become higher than normal when the patient is ambulating.

When taking an oral temperature, the nurse should place the thermometer in which location?

In the posterior sublingual pocket lateral to the center of the lower jaw Rationale: Heat from superficial blood vessels in the sublingual pocket produces a temperature reading. With an electronic thermometer, temperatures in the right and left posterior sublingual pockets are significantly higher than in the area under the front of the tongue. The thermometer should not be placed between the tongue and the soft palate because an airway injury may result and the temperature reading will not be accurate. Placing a thermometer between the teeth or in the buccal pocket between the gums and the lips would not produce an accurate oral temperature reading.

The nurse is assessing the respiratory rate of a 3-year-old patient and notices an irregular pattern and rate. Which information should the nurse keep in mind?

Infants and young children may have irregular breathing patterns. Rationale: Infants and young children frequently have irregular breathing patterns, so the respiratory rate should be counted for 1 minute for accuracy. Irregular breathing patterns in young children are more often the result of anxiety. Fever would be a more likely indicator of a respiratory infection. Hyperpnea is indicated by excessively deep and shallow breathing.

Which statement is true regarding the oral temperature method?

It is comfortable for the patient. Rationale: The oral method is comfortable for the patient. The tympanic measurement provides the most rapid results. Taking an oral temperature measurement should be delayed if the patient recently ingested hot or cold fluids or foods, chewed gum, or smoked. The oral temperature method should not be used with infants; small children; or confused, unconscious, or uncooperative patients.

Which statement regarding BP measurement of a lower extremity is true?

It may be compared with the patient's baseline lower-extremity BP. Rationale: Ongoing monitoring and care include establishing a baseline and comparing each new BP reading with previous readings to detect changes. However, measurements should be compared only if taken from the same extremity. Systolic BP in the legs is usually higher than in the brachial artery, not lower. The thigh is the least preferred and most uncomfortable site in children.

Which action is an effective intervention by a health care team member to improve hand hygiene?

Keep fingernails natural, trimmed, and free of artificial nails. Rationale: Studies have shown that heath care team members with artificial nails have more bacteria on their fingertips than those without artificial nails. If hands are not visibly soiled, an alcohol-based hand rub should be used for routinely decontaminating hands because consistently using soap and water for hand hygiene can result in dry, cracked skin. Glove use is not a substitute for hand hygiene. Jewelry should be removed every time hands are washed.

A patient admitted with diabetic ketoacidosis has cracked lips and dry mucous membranes. Respirations are deep, regular, and rapid. What is this type of respiratory pattern called?

Kussmaul respiration Rationale: Kussmaul respirations—abnormally deep, regular, and increased in rate—are common in diabetic ketoacidosis. Cheyne-Stokes respiration is characterized by a respiratory rate and depth that are irregular with alternating periods of apnea and hyperventilation. Hyperpnea refers to excessively deep or labored breathing. Biot respirations are abnormally shallow for two or three breaths, followed by an irregular period of apnea.

When taking a blood pressure in a patient's lower extremity, most adults require which cuff size?

Large adult Rationale: A cuff size that is appropriate for the patient should be proportionate to the circumference of the limb being assessed. Most adult patients require a large adult cuff for the lower extremity. Small, medium, and one size fits all are not common sizes for most adult patients.

The nurse should teach the patient that compared with aneroid sphygmomanometers, electronic sphygmomanometers often provide which alterations in blood pressure readings?

Lower systolic readings and higher diastolic readings Rationale: Electronic blood pressure monitors are easier to use, but the nurse should teach the patient that they often provide lower systolic readings and higher diastolic readings than aneroid monitors, which may be used in the doctor's office. This information may spare the patient from undue alarm when different numbers are obtained during home monitoring.

During an assessment at a change of shift, the nurse finds the patient restless, irritable, confused, and with a decreased level of consciousness. After having someone notify the practitioner, what is the nurse's next step while checking the patient's vital signs?

Measure the patient's peripheral oxygen saturation. Rationale: Measuring the patient's peripheral oxygen saturation will help to identify whether the patient has a respiratory issue quickly. Assessing the patient's blood gases would provide important information but would take longer to obtain and wastes valuable time. Reviewing the patient's medication list is important to determine whether the patient has received anything to cause a change in condition but this would not be the first thing to do. The patient's family should be notified after the patient is attended to.

An older adult patient is diagnosed with shortness of breath. The nurse is continuously monitoring the patient's peripheral oxygen saturation using a pulse oximeter with a reusable finger sensor. Which action should the nurse take?

Monitor the patient's skin condition under the sensor. Rationale: During continuous monitoring, the nurse should regularly assess skin integrity underneath the sensor. Older adults require more frequent assessment of skin integrity because of tissue fragility and decreased elasticity. Using alternate sites in older adults is not necessary; more frequent skin assessment is needed. When continuous monitoring is ordered, the sensor may need to be moved to a different location to avoid creating pressure points. Blankets or other opaque coverings may be used to block ambient light from interfering with the sensor.

Which method is the best way to assess the depth of a patient's respirations?

Observe the degree of chest wall movement while counting the respiration rate. Rationale: When assessing the depth of a patient's respirations, the nurse can observe the degree of chest wall movement while counting the respiratory rate. Other methods include palpating chest wall excursion on the anterior chest and auscultating the posterior thorax. Asking the patient to take deep breaths and hold it or to take slow deep breaths does not assess the depth of the patient's normal respirations.

A reusable pulse oximetry sensor on a patient's finger does not pick up a consistent waveform or a pulse. What should the nurse do?

Obtain a new sensor. Rationale: If the finger sensor for pulse oximetry is not functioning properly, the nurse should obtain a new sensor. A finger sensor should not be used on the earlobe or the nose; each sensor is designated for a specific part of the body. Documenting that a pulse oximetry reading is unobtainable is not acceptable; the practitioner's order for pulse oximetry monitoring must be followed.

The nurse is obtaining the core temperature of a resting diaphoretic patient, using a temporal thermometer. The first reading is lower than expected, so the nurse dries the patient's forehead with a towel and repeats the measurement. The temperature is again lower than expected. Which action is the most appropriate?

Obtain a temperature using a tympanic thermometer. Rationale: A temporal thermometer is subject to inaccuracies when the patient's skin is wet. Using a tympanic thermometer is a comfortable and accurate alternative core assessment that is not affected by skin moisture and is less invasive than a rectal temperature. Because the patient continues to sweat, an alternate method is required for accuracy. Diaphoresis has not proven to be resolved after 30 minutes when the patient is at rest. If the patient had been exercising, a 20- to 30-minute rest period may have resolved the issue.

A patient's oral temperature is 38°C (100.4°F). The baseline temperature on admission was 36°C (96.8°F). Which intervention is the most appropriate for this patient?

Obtaining a second measurement soon after the initial one Rationale: Obtaining a repeat temperature after an elevated reading confirms the initial finding. Reassessment in 4 hours may result in delayed diagnosis and treatment. If the patient has a fever, antipyretics should be administered, and the temperature should be remeasured until it stabilizes. Body temperature normally fluctuates within a narrow range. Reporting the change may result in treatment for a normal process.

Which factor may help to prevent an inaccurate blood pressure measurement?

Patient has just voided 350ml clear urine Rationale: The urge to void can significantly increase blood pressure; so, if the patient has just voided, the measurement will be more accurate. Cold room temperature, exercise, and caffeine all have the potential to alter blood pressure.

The health care team member is caring for a patient with C. difficile. What is the recommendation for hand hygiene to be completed by the health care team member?

Perform hand hygiene with soap and water. Rationale: Special hand hygiene precautions using soap and water are required when spore-producing pathogens (such as C. difficile) are suspected or confirmed. Spore-forming pathogens are known to be highly resistant to killing by alcohol. Surgical scrub is not a routine process when caring for a patient with suspected or confirmed C. difficile, and antiseptic hand rub is ineffective at killing the spore-producing pathogens.

Which is an appropriate method of assessing a patient's respirations?

Place the patient's arm or the examiner's hand gently over the patient's upper abdomen. Rationale: One method of assessing a patient's respiratory rate is to place the patient's arm in a relaxed position across the abdomen or lower chest or place the examiner's hand directly over the patient's upper abdomen and count the number of respirations as the abdomen rises and falls. Placing the bed flat or removing supplemental oxygen may create respiratory distress. Assessment of respirations should be inconspicuous, so the nurse should avoid explaining to the patient.

Which technique should be used when measuring the body temperature of an 18-month-old child via the tympanic membrane?

Point the covered probe toward the midpoint between the eyebrow and hairline. Rationale: For a child younger than 2 years of age, the covered probe should be pointed toward the midpoint between the eyebrow and hairline. The pinna of the ear should be pulled backward, up, and out for an adult. Some manufacturers recommend moving the speculum tip in a figure-eight pattern (not a circular pattern), which allows the sensor to detect maximum tympanic membrane heat radiation.

Which statement is generally accepted regarding rectal body temperature measurements?

Rectal body temperature measurements are 0.5°C (0.9°F) higher than oral body temperature measurements. Rationale: Research findings from numerous studies are contradictory; however, it is generally accepted that rectal temperatures are usually 0.5°C (0.9°F) higher than oral temperatures. Axillary and tympanic temperatures are usually 0.5°C (0.9°F) lower than oral temperatures.

What is the advantage of using the rectal body temperature measurement?

Rectal temperature is a reliable measurement when oral temperature cannot be obtained. Rationale: The rectal site is considered reliable when the oral route is not accessible. The axilla site is advantageous for use on newborns and unconscious patients. The temporal membrane site is an easily accessible site and can be obtained without disturbing, waking, or repositioning the patient.

A patient has had a reaction to antibiotic therapy after oral surgery and has a rash over the entire body. How should the nurse assess the patient's temperature?

Rectally Rationale: Sites reflecting core temperature (rectum, tympanic membrane, esophagus, pulmonary artery, and urinary bladder) are more reliable indicators of body temperature than sites reflecting surface temperature (skin, oral cavity, and axilla). In this case, the oral route is not appropriate because oral inflammation may alter temperature readings. The body rash renders the axillary method inaccurate because skin lesions may alter local temperature. Pulmonary artery catheters provide the most accurate way to obtain a core temperature, but the necessary invasive central-line insertion is not warranted in this case.

When teaching BP monitoring in the home, the nurse should instruct the patient to perform which action?

Reduce extraneous noise if a sphygmomanometer and stethoscope are used. Rationale: Extraneous noise, such as television and conversation, should be limited if the patient uses a stethoscope when monitoring BP. A quiet, relaxed environment enhances the accuracy of BP readings. The patient should be instructed to wait 30 minutes after exercising to monitor his or her BP. BP should be monitored at the same time each day for the most accurate comparisons. The patient should be instructed not to monitor BP several times on the same limb because repeated attempts may restrict circulation.

The health care team member notices a health care assistant coming out of one patient's room after obtaining a blood pressure and entering immediately into another patient's room without washing the hands. Which action should the health care team member take?

Remind the health care assistant to wash hands between every patient contact. Rationale: Hand hygiene is not optional. It is a critical responsibility for all health care team members. Hand hygiene should be performed after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient and after contact with every patient. Gloves are not a substitute for hand hygiene.

The health care team member is confident that patient teaching regarding infection risks is effective when the patient takes which action?

Reminds the health care team member to wash hands before providing care Rationale: When patients are educated about the risks of infection in health care facilities, they can play an important role in improving hand hygiene compliance by reminding heath care team members to perform hand hygiene. Not every patient is required to wear a mask or to be placed in a negative-airflow room. It is not necessary for the patient to wash hands every time a health care member enters the room.

Which statement about performing hand hygiene using soap and water is correct?

Remove rings before washing. Rationale: Rings and watches should be avoided. If worn, they must be removed before performing hand hygiene. Rings and watches should be removed when performing hand washing using soap and water as well as when performing any other method of hand hygiene. Clothing or scrub tops with long sleeves should be pushed above the wrists before hand washing. If the hands touch the sink at any time during hand washing, hand washing should be repeated.

When inserting a rectal thermometer, the nurse encounters resistance. Which action is most appropriate?

Remove the thermometer immediately. Rationale: If resistance is felt while inserting a rectal thermometer, the nurse should withdraw it immediately. Pressure or force should never be applied when resistance is encountered because mucosal trauma may result. Deep breaths may allow the patient to relax, but relaxation is not an indication that it is safe to advance the rectal thermometer.

When using the handheld tympanic thermometer in the patient's right ear, the nurse should use which hand?

Right hand Rationale: Accurate temperature measurement with a tympanic thermometer requires the correct probe angle. When holding the handheld unit with the right hand, the nurse should obtain the temperature from the patient's right ear; nurses who are left handed should obtain the temperature from the patient's left ear. Both hands are not needed to hold the thermometer at the correct angle.

When preparing to take an axillary temperature, the nurse should check the patient's axilla for which condition?

Skin lesions and excessive perspiration Rationale: Excessive perspiration may cause an inaccurate reading. Skin lesions may cause patient discomfort. Axillary hair, cyanosis, pallor, and skin dryness are not contraindications for measuring axillary temperature.

What are major risk factors for a patient's alterations in respiration?

Smoking, anemia, and pneumonia Rationale: Smoking, anemia, and pneumonia are major risk factors for alterations in respiration. Osteoporosis would not affect respiration unless the chest ribs were broken. Age is not necessarily a risk factor for respiratory alterations unless combined with other illness or disease.

Which statement is true regarding body temperature for an older adult patient?

Temperatures considered within the normal range often reflect a fever in an older adult. Rationale: The normal physiologic changes associated with the aging process may result in a lower body temperature, which coupled with less temperature variability may result in a blunted fever response. Therefore, temperatures considered within the normal range often reflect a fever in an older adult. A normal temperature for an older adult is at the lower end of the acceptable temperature ranges for adults. Older adults are sensitive to environmental temperature changes because their thermoregulatory systems are not as efficient.

When taking core temperature measurements in preterm neonates, the nurse should use which site?

Temporal Rationale: Core temporal temperature measurements may be obtained in a preterm neonate without unbundling. Axillary temperature measurements may be used for screening purposes but cannot be relied on to detect fevers in an infant and young child. Sites reflecting core temperature (temporal, rectum, tympanic membrane, esophagus, pulmonary artery, urinary bladder) are more reliable indicators of body temperature than sites reflecting surface temperature (skin, oral cavity, axilla).

What is the result of applying too much pressure on the wrist when obtaining a radial pulse?

The artery can be occluded and the nurse may end up counting his or her own pulse. Rationale: Pulse assessment is more accurate when using moderate pressure. Too much pressure occludes the pulse, impairs the blood flow, and can result in the nurse counting his or her own pulse rate. Strength reflects the volume of blood ejected against the arterial wall with each heart contraction. Decreased elasticity and not the amount of pressure placed on an artery can make the vessel feel stiff and knotty. Decreased elasticity is a condition often found in older patients.

What causes an abnormal rise in body temperature?

The body temperature rises when the patient's heat-loss mechanisms do not keep up with heat production. Rationale: An abnormal rise in body temperature is a failure of the patient's heat-loss mechanism's ability to keep pace with excess heat production. Physiologic changes associated with the aging process may result in a lower body temperature, not a higher body temperature. Administering antipyretic medications is a treatment to lower the body temperature, and does not cause a rise in body temperature. Temperature control mechanisms have failed when heat produced by the body is not equal to heat lost to the environment.

Which statement about taking a body temperature measurement for the first time is true?

The first temperature reading provides a baseline for comparison with future temperature measurements. Rationale: Normal body temperatures vary among individuals. A baseline measurement for each patient is needed to assess the patient for clinical changes. A second measurement confirms the initial findings of any abnormal temperature. Precise monitoring is achieved when the same method is used. No single temperature is normal for every person. In clinical practice, personnel providing care to a patient should learn an individual patient's temperature range.

Which action is most important when documenting temperature readings?

The method of temperature measurement Rationale: The method of temperature measurement should always be listed when documenting the intervention. Temperature trends are most accurate when the same method and location are used, as inaccurate measurements may result in improper treatment. Returning the temperature probe to the housing unit is part of the procedure. Verifying the correct patient and informing the patient about the use of antipyretics is part of patient and family education and not related to identifying trends in temperature variations.

An alcohol-based hand rub cannot be used for routinely decontaminating hands under which condition?

When hands are visibly dirty or contaminated with blood or other bodily fluids Rationale: When hands are visibly dirty or contaminated with blood or other bodily fluids, they should be washed with soap and water or antimicrobial soap and water. If the hands are not visibly soiled, an alcohol-based hand rub should be used for routinely decontaminating hands; for example, after contact with a patient's intact skin, after removing gloves, and when moving from a contaminated body site to a clean body site during care.

Before taking the patient's temperature, what information is most important for the nurse to obtain?

The nurse should determine the previous baseline temperature and measurement site from the patient's record. Rationale: Identifying trends in body temperature can help determine proper treatment. Knowledge of previous methods and results of temperature measurement can help determine trends. Comparing the temperature reading with the patient's previous baseline is done after the temperature assessment. Ensuring that the patient is in a comfortable position and moving clothing or the gown away from the site are part of the procedure.

Which situation is a contraindication for obtaining a rectal temperature?

The patient had recent prostate surgery. Rationale: Contraindications for use of the rectal site for body temperature measurement include internal or external hemorrhoids, rectal bleeding or rectal surgery, bleeding tendencies, recent prostate surgery, fecal impaction, diarrhea, or the presence of a colostomy. The rectal site should also not be used on a confused or combative patient. Being in a side-lying position is the preferred position for obtaining a rectal temperature. Sites reflecting core temperature, such as the rectum, tympanic membrane, esophagus, pulmonary artery, and urinary bladder, are not contraindications for use of that site. Core temperature readings are more reliable indicators of body temperature than sites reflecting surface temperature (skin, oral cavity, and axilla)

Which point on the manometer represents the estimated systolic blood pressure when obtaining a blood pressure measurement by palpation?

The point at which the pulse reappears when deflating the cuff Rationale: The point at which the pulse reappears when deflating the cuff represents the estimated systolic blood pressure. It would be difficult to determine when the pulse disappears while inflating the cuff because of the pulsating motion of inflation. The point of strongest pulse reading may be the point at which the pulse reappears with deflation, but may occur later, so is not an accurate measure of systolic blood pressure.

A patient treated for cancer must have a body temperature measurement. Which site should the nurse avoid?

The rectum Rationale: A patient with a low platelet count (e.g., a patient with cancer) should not have anything inserted into the rectum because of the risk of bleeding. The mouth, the axilla, and the temporal region are all acceptable choices for temperature measurement for this patient.

After a shift change, the incoming nurse takes the patient's temperature. Which statement about the nurse's site choice is correct?

The same site should be used when repeated measurements are necessary. Rationale: The same site should be used when repeated measurements are necessary or when temperature measurements are compared over time. The site should be listed with each documented temperature. The safest and most accurate site for the patient should be used.

What should the heath care team member be aware of when assessing the BP of an older adult?

The skin of older adults is more fragile and susceptible to injury from cuff pressure. Rationale: The skin of older adults is more fragile and susceptible to injury caused by cuff pressure, especially when measurements are frequent. Older adults lose upper arm mass, especially in the nondominant arm; thus, special attention to the selection of BP cuff size is needed. This loss of upper arm mass does not determine which arm is used for assessing BP. Older adults have a higher systolic pressure because of decreased vessel elasticity. Older adults often experience a fall in BP after eating, making it more difficult to compare the measurement to a baseline.

Where is the radial artery located in the body?

Thumb side of the forearm at the wrist Rationale: The radial artery is located on the thumb side of the distal forearm at the wrist. The ulnar pulse is best palpated on the ulnar side of the forearm at the wrist. The popliteal artery is located behind the knee in the popliteal fossa. The brachial artery is located in the groove between the biceps and triceps muscles at the antecubital fossa.

Which site is the most reliable for measuring an adult core body temperature?

Tympanic membrane Rationale: Sites reflecting core temperature (rectum, tympanic membrane, esophagus, pulmonary artery, and urinary bladder) are more reliable indicators of body temperature than sites reflecting surface temperature (skin, oral cavity, and axilla). Surface temperatures vary because of external factors, such as ambient temperature.

What is most appropriate intervention when monitoring the peripheral oxygen saturation of an obese patient using a pulse oximeter?

Use a disposable sensor. Rationale: A clip-on sensor may not fit properly on the finger of an obese patient, so a disposable sensor should be used. The sensor should not be placed on an edematous finger because it may alter skin integrity. The sensor is not designed to be placed on the thumb. The sensor should not be placed on a finger of an arm with a blood pressure cuff because cuff inflation may cause an inaccurate reading.

After measuring a blood pressure by palpation on one upper arm, the health care team member assesses blood pressure by palpation on the other upper arm and finds it to be significantly higher. This has happened three times. What should be done next?

Use the arm with the higher pressure Rationale: If there is a consistent difference between the blood pressure in the patient's arms, the arm with the higher pressure should be used. Checking the blood pressure in a leg or in the forearms may not be as accurate and assessment may be more difficult. Since this has been a consistent difference, repeating the pressures will not be of use, and may cause discomfort to the patient.

If unable to palpate an artery because of the patient's low BP, a systolic BP may be obtained by performing which action?

Using a Doppler ultrasonic stethoscope Rationale: A Doppler ultrasonic stethoscope augments the sound of the blood flow in the arteries, making hearing easier. Palpation of lower-extremity BP has limited reliability. Noninvasive BP machines have a limited reliability at extremely low BP readings. Using a double stethoscope and verifying heart sounds with a second nurse do not improve the ability to hear Korotkoff sounds.

The patient asks why his temperature is never 37°C (98.6°F). "Is there something wrong with me?" Which response is the most appropriate?

"Many things affect temperature, and temperature normally varies from person to person." Rationale: No single temperature reading is normal for all people. Although the body usually functions best at 36°C to 38°C (96.8°F to 100.4°F), an acceptable temperature range for a patient depends on age, gender, physical activity, and the state of health.

Under what circumstances are alcohol-based products recommended for hand hygiene?

Before direct contact with patients Rationale: Unless contraindicated, alcohol-based rinses or gels are the gold standard for performing routine patient care. Soap and water or an antimicrobial soap and water are required when hands are visibly dirty or contaminated with blood or other bodily fluids or after exposure to spore-forming pathogens. Use of an alcohol-based gel is not effective in removing visible soil or spores from the hands.

The patient complains of shortness of breath, which has been occurring since admission after activity such as walking. What new assessment should prompt the nurse to notify the practitioner?

New pain during inspiration and expiration Rationale: New pain experienced during both inspiration and expiration may indicate a new finding such as pneumonia or a broken rib. This would be a change in the patient's assessment and would necessitate a call to the practitioner. The patient's dyspnea is not new because it has been occurring with activity since admission. A peripheral oxygen saturation reading of 96% and a respiratory rate of 20 breaths/minute are within normal limits.

A patient calls and states that his BP reading this morning was 80/50 mm Hg and that he is feeling dizzy. Which statement is the most appropriate response by the nurse?

Please have someone bring you in so the nurse can evaluate you. Rationale: Because the patient has low BP and dizziness, he should be evaluated as soon as possible. Waiting until morning puts the patient at risk for harm. Extra BP medication may aggravate the problem by lowering the patient's BP even further. Aspirin has no effect on BP.

If a leg cuff that is too narrow is used to take a patient's BP, how will the results be affected?

The BP will be overestimated. Rationale: Studies show that using a cuff that is too narrow results in an overestimation of BP, and a cuff that is too wide underestimates BP.

Because the pulse waveform or intensity can be changed by ambient conditions, what should the nurse consider?

Whether direct sunlight is hitting the sensor Rationale: Direct sunlight or fluorescent lighting should be avoided when using an oximeter. Factors that affect light transmission (e.g., outside light sources or patient motion) also affect the measurement of peripheral oxygen saturation. The nurse may need to protect the sensor with an opaque covering or washcloth. None of the other answer choices is related to ambient conditions in the room.

Which statement by a patient demonstrates understanding of strategies to prevent hypertension?

"I will exercise every day." Rationale: Exercising every day will help to keep a healthy heart and help to prevent hypertension. Smoking increases the risk of hypertension, whether the patient smokes inside or outside. Pickles are high in sodium content, and therefore will not help to prevent hypertension. Bananas are a healthy source of potassium and do not raise the risk for hypertension.

Which statement by the patient indicates a need for further education about home blood pressure monitoring?

"I will take my blood pressure every 10 minutes when I get home." Rationale: Home blood pressure measurements should not be performed every 10 minutes. Excessive blood pressure monitoring may cause undue anxiety and concern. Taking a blood pressure measurement in the nondominant arm, keeping feet flat on the floor while taking a blood pressure measurement, and seeking medical attention if the blood pressure measurement is low and the patient feels dizzy are all appropriate.

Which statement indicates that the patient understands the nurse's teaching on pulse oximetry?

"If I am short of breath, I will check my pulse oximetry reading." Rationale: The purpose of pulse oximetry is to monitor the oxygen saturation of the blood. Therefore, if a patient is short of breath, the procedure should be implemented. Smoking decreases the oxygen saturation of the blood. Pulse oximetry is a painless procedure, and pain medication is not needed. Restlessness may be caused by a low oxygen saturation, but it is not caused by the monitoring of oxygen saturation.

Which statement indicates that the patient needs further teaching about BP monitoring?

"It is okay to monitor my blood pressure using the same arm the nurse uses for my dialysis." Rationale: A patient should be instructed not to monitor BP in an arm that has an AV graft, an AV shunt, or a fistula used for dialysis. The application of pressure by the inflated bladder can temporarily impair blood flow and compromise circulation in an extremity that already has impaired circulation. A patient should be instructed to notify the practitioner when the BP is low and the BP medication has not been taken because the practitioner may have to alter the patient's BP medications. The patient should be instructed to clean the diaphragm of the stethoscope with alcohol or a damp cloth on a regular basis because the diaphragm can harbor microorganisms. The patient should be instructed to monitor BP when sitting in a comfortable position to obtain the most accurate reading. If the patient is uncomfortable or anxious, the BP may be elevated.

What instruction should the nurse give the patient to obtain the most accurate axillary temperature reading?

"Keep the thermometer securely under your arm until the reading is complete." Rationale: The nurse should educate the patient about the importance of keeping the thermometer securely in the axilla until the reading is complete. Placing the patient's arm across his or her chest keeps the thermometer in the proper position against blood vessels in the axilla. Waiting 1 hour after intense exercise or a hot bath is recommended before measuring body temperature. Wait 20 to 30 minutes after the patient smokes, eats, or drinks a hot or cold liquid before measuring body temperature.

What instruction should the nurse give the patient to obtain the most accurate oral temperature reading?

"Keep the thermometer securely under your tongue until the reading is complete." Rationale: The nurse should educate the patient about the importance of keeping the thermometer securely under the tongue until the reading is complete. The patient should be instructed to hold the temperature probe with lips closed. Waiting 1 hour after intense exercise or a hot bath is recommended before measuring body temperature. Wait 20 to 30 minutes after the patient smokes, eats, or drinks a hot or cold liquid before measuring body temperature.

What instructions does the nurse give the patient to obtain the most accurate tympanic temperature reading?

"Let me help you to a comfortable position and then turn your head away from me." Rationale: Appropriate positioning facilitates the exposure of the auditory canal for accurate temperature measurement. The less acute the angle of approach, the better the probe seal. Heat trapped in the ear facing down will cause an artificially high temperature reading; if the patient has been lying on his or her side, use the upper ear. Waiting 1 hour after intense exercise or a hot bath is recommended before measuring a body temperature. Wait 20 to 30 minutes after the patient smokes, eats, or drinks a hot or cold liquid before measuring body temperature.

What instruction should the nurse give the patient to obtain the most accurate rectal temperature measurement?

"Lie on your side with your upper leg flexed." Rationale: Assisting the patient to a comfortable side-lying position that provides easy access to the rectum helps ensure the patient's comfort and the accuracy of the temperature reading. The thermometer should be held in place until an audible signal indicates completion and the patient's temperature appears on the digital display. Waiting 1 hour after intense exercise or a hot bath is recommended before measuring body temperature. Wait 20 to 30 minutes after the patient smokes, eats, or drinks a hot or cold liquid before measuring body temperature.

The nurse is explaining to a new health care team member how to palpate the patient's BP. Which statement would indicate the new health care team member understands the information?

"Only the systolic BP can be detected via palpation." Rationale: Only the systolic BP can be palpated. The cuff should be inflated above the point at which the pulse can no longer be palpated. In children, the right arm is preferred for BP measurements. The cuff should be deflated slowly, allowing the manometer needle to fall slowly; a decline that is too rapid would result in an inaccurate reading.

When the patient asks which arm should be used for home blood pressure monitoring, how should the nurse reply?

"The first blood pressure reading should be taken in both arms." Rationale: The first home blood pressure reading should be taken in both arms. If the reading in one arm is consistently higher, that arm should be used for future blood pressure monitoring. In general, the nondominant arm is used. The blood pressure should be taken in the same arm each time it is monitored. Usually, blood pressure differs slightly between arms, so the same arm should be used each time.

Selecting the appropriate cuff size when measuring BP is important for which reason?

A cuff that is too small may result in an overestimate of the BP. Rationale: A cuff that is too small for the patient may result in an overestimate of the BP. Thus, choosing the correct cuff size, one in which the bladder completely encircles the arm without overlapping, is important. A cuff that is too large may result in an underestimate of the BP.

A patient is taking a medication that causes peripheral vasoconstriction, resulting in diminished circulation to the hands and feet. The nurse can best assess the patient's peripheral oxygen saturation using which sensor?

A forehead sensor Rationale: For patients with decreased peripheral perfusion to the hands and feet, a forehead sensor is appropriate. A vascular, pulsatile area is needed to detect the change in the transmitted light when taking measurements with a digit sensor. A sensor applied to the finger would give inaccurate readings because of the poor circulation caused by the vasoconstriction.

What factor in the selection of a body temperature site best correlates with accurate core temperature?

A site closest to a major artery Rationale: Measuring core temperature is most accurate if using a site near a major artery. No one site correlates exactly with core temperature. Sites reflecting core temperature (rectum, tympanic membrane, esophagus, pulmonary artery, and urinary bladder) are more reliable indicators of body temperature than sites reflecting surface temperature. Comfort for the patient is not a factor in determining the most accurate core temperature.

At which point in the hospital stay should the nurse begin to educate the patient about home blood pressure monitoring?

A. As soon as the need for home blood pressure monitoring is determined Rationale: Home education should begin as soon as the need for it is determined to allow time for re-enforcement and for the patient to ask questions. At discharge, the patient receives many instructions and may forget some information. The nurse should not wait until the patient asks about the procedure or until a staff educator is available.