Vital Signs PrepU

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment? - 5,000 mL (5,000 × 109/L) - 5,550 mL (5,500 × 109/L) - 5,850 mL (5,850 × 109/L) - 6,000 mL (6,000 × 109/L)

5,850 mL (5,850 × 109/L)

The nurse is attempting to assess a client's radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurse take next? - Assess the apical pulse. - Assess the carotid pulse. - Get another nurse for validation. - Document the findings.

Assess the apical pulse

A nurse attempts to count the respiratory rate of a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this client? - Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2. - Palpate the posterior thorax excursion, count respirations for 30 seconds, and multiply by 2. - Use a pulse oximeter to count the respirations for 1 minute. - Monitor arterial blood gas results for 1 minute.

Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2

When assessing a client's radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next? - Report the findings to the health care provider - Obtain a bedside electrocardiogram - Compare with previously documented findings - Auscultate the apical pulse for 60 seconds

Auscultate the apical pulse for 60 seconds

The nurse has palpated the client's radial artery and identified a heart rate of 88 beats per minute with an irregular rate. What is the nurse's most appropriate action? - Reassess the client's radial pulse in 15 minutes. - Page the client's primary care provider. - Auscultate the client's apical heart rate. - Palpate the radial pulse on the opposite wrist.

Auscultate the client's apical heart rate

A client presents to the emergency department with profuse bleeding from a crushing injury while at work. Which set of vital signs does the nurse anticipate finding in such this client? - Blood pressure 130/80 mm Hg, heart rate 74 beats/min, respiratory rate 14 breaths/min - Blood pressure 80/50 mm Hg, heart rate 120 beats/min, respiratory rate 24 breaths/min - Blood pressure 124/74 mm Hg, heart rate 90 beats/min, respiratory rate 14 breaths/min - Blood pressure 140/90 mm Hg, heart rate 84 beats/min, respiratory rate 16 breaths/min

Blood pressure 80/50 mm Hg, heart rate 120 beats/min, respiratory rate 24 breaths/min

While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute. How will the nurse interpret this finding? -Bradypnea is uncommon in a client with IICP. - IICP most commonly results in tachypnea. - Bradypnea is a response to IICP. - This is a normal respiratory rate

Bradypnea is a response to IICP

When assessing an adult client's pulse at 125 beats/min, which step would the nurse take first to determine intervention? - Determine cause - Evaluate pulse rate quality - Evaluate blood pressure - Assess for history of heart disease

Determine cause

A nurse is assessing an adult client's blood pressure. How should the nurse estimate the client's systolic blood pressure (SBP)? Inflate the blood pressure cuff while palpating the client's brachial or radial artery. Simultaneously compare the amplitude of the client's left and right radial pulses. Palpate the client's brachial pulse while having the client slowly raise his or her arm. Note the SBP that was documented during the client's last vital signs assessment.

Inflate the blood pressure cuff while palpating the client's brachial or radial artery

A nurse has been unable to palpate a client's dorsalis pedis pulse. The nurse attempted to identify the pulse using Doppler ultrasound and is still unable to identify a pulse. What is the nurse's most appropriate action? - Inform the client's primary care provider of this assessment finding. - Document this finding and reassess within 2 hours. - Reassess after placing the client's leg in a dependent position for 15 minutes. - Have the client perform foot flexion and extension exercises to promote circulation.

Inform the client's primary care provider of this assessment finding

The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention? - Provide privacy for the client. - Position the client on the stomach. - Insert the thermometer 0.5 in (1.25 cm) into the rectum. - Maintain probe position in rectum for 2 minutes.

Provide privacy for the client

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse? Pulse is strong, and light pressure causes it to disappear. Pulse is felt with difficulty and disappears with slight pressure. Pulse is felt easily, and moderate pressure causes it to disappear. Pulse is strong and remains strong despite moderate pressure.

Pulse is felt with difficulty and disappears with slight pressure

The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation? - Leave the thermometer in and notify the physician. - Remove the thermometer and assess the blood pressure and heart rate. - Remove the thermometer and assess the temperature via another method. - Call for assistance and anticipate the need for CPR.

Remove the thermometer and assess the blood pressure and heart rate

The nurse is assessing a client's brachial artery blood pressure. Which nursing actions are performed correctly? Select all that apply. - The nurse centers the bladder of the cuff over the brachial artery about midway on the arm. - The nurse places the cuff over the client's bulky clothing and fastens it snugly. - The nurse notes the point on the gauge at which the first faint but clear sound appears, and increases in intensity as the diastolic pressure. - The nurse repeats any suspicious reading before 1 minute has passed since the last reading. - The nurse has the client lying or sitting down with the forearm supported at the level of the heart and the palm of the hand upward. - The nurse wraps the cuff around the arm smoothly and snugly and fastens it.

The nurse centers the bladder of the cuff over the brachial artery about midway on the arm, The nurse has the client lying or sitting down with the forearm supported at the level of the heart and the palm of the hand upward, The nurse wraps the cuff around the arm smoothly and snugly and fastens it

The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate? - This infant will need a home cardiac monitor set up. - The parents should be encouraged to get a neighbor or family member to help them check their infant's pulse. - The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse. - The parents will not be able to check the pulse accurately; the nurse will need to do home health checks on this infant on a periodic basis.

The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse

A nurse is teaching a client how to monitor the radial pulse after discharge from the hospital. Which instruction by the nurse is most appropriate? - Measure the pulse for 45 seconds and multiply by 2. - Measure the pulse at the wrist on the side of the pinky finger. - Use your thumb to locate the pulse. - Use the fingertips of your second and third fingers.

Use the fingertips of your second and third fingers

The nurse is preparing to administer a medication that the client takes to treat a cardiac dysrhythmia. Which site should the nurse use to assess pulse in this client? - brachial - radial - carotid - apical

apical

The nurse is preparing to administer a medication that the client takes to treat a cardiac dysrhythmia. Which site should the nurse use to assess pulse in this client? brachial radial carotid apical

apical

An ultrasonic Doppler is used for: - auscultating a pulse that is difficult to palpate. - auscultating diastolic blood pressure. - aiding palpation of pulse and rhythm. - aiding palpation of diastolic blood pressure.

auscultating a pulse that is difficult to palpate

Which pulse site is generally used in emergency situations? - carotid - apical - radial - temporal

carotid

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth? - deep in the posterior sublingual pocket - superior to the tongue, with the tip touching the hard palate - in the inferior buccal space on either side of the tongue - along either upper gum line, adjacent to an incisor

deep in the posterior sublingual pocket

The nurse is caring for a client who has smoked for more than 20 years and is now experiencing labored respirations. The nurse documents the client is experiencing: - dyspnea. - fremitus. - stridor. - wheezing.

dyspnea

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods? - listen with the stethoscope at the fifth intercostal space left mid-clavicular line - listen with the stethoscope at the fifth intercostal space at the sternum - listen with a stethoscope at the neck to the right of the coracoid process - listen with a stethoscope at the second intercostal space left sternum

listen with the stethoscope at the fifth intercostal space left mid-clavicular line

The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as: - orthopnea - bradypnea - apnea - tachypnea

orthopnea

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which health problem should the nurse consider when client falls occur? - orthostatic hypotension - dyspnea - primary hypertension - secondary hypertension

orthostatic hypotension

A nurse is caring for an adult with fever. The nurse determines that which site is most accurate for obtaining the client's core body temperature? - ear - rectum - axilla - mouth

rectum

A nurse needs to assess the temperature of a client with high fever. Which site will most closely reflect core body temperature of the client? - ear - mouth - rectum - axilla

rectum