Chapter 25 Vital Signs

A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?

"Dizziness when you change position can occur when fluid volume in the body is decreased."

The nurse instructs a mother of young children how to properly use a nonmercury glass thermometer. Which statement made by the client indicates a need for further instruction?

"I will clean the thermometer in the dishwasher."

When taking the client's temperature, the student nurse will require further education when they state:

"The axillary route is the most accurate of all routes."

The nurse is preparing to measure an adult's orthostatic blood pressure. Place the following steps of the procedure in the correct order. Use all options.

-Assist the client into a supine position. -Wait 3 to 10 minutes, then measure the client's blood pressure. -Assist the client to the sitting position with legs dangling. -Wait 1 to 3 minutes, then measure the client's blood pressure. -Assist the client to a standing position. -Wait 2 to 3 minutes, then measure the client's blood pressure.

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?

1700

When assessing an infant's axillary temperature, it will be:

1°F (0.5°C) lower than an oral temperature.

A nurse has applied a blood pressure cuff to a client's upper arm, positioned the stethoscope over the client's brachial artery, inflated the cuff and is now slowly releasing air from the cuff. The nurse should recognize the client's peak blood pressure when what sound is audible?

A faint, clear tapping sound

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?

Apical

The nurse needs to obtain an admission weight for a client diagnosed with end-stage lung cancer. To obtain the client's weight, what should the nurse do first?

Assess the client's ability to stand or sit.

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.

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?

Auscultate the client's apical heart rate.

Which peripheral pulse site is generally used in emergency situations?

Carotid

The nurse is assessing the client's blood pressure (BP) and heart rate (HR) for orthostatic hypotension. In which step should this nurse intervene because of potential danger?

Client stands at bedside, becomes pale, diaphoretic.

T/F A person's core body temperature is highest in the early morning and lowest in the late afternoon.

False

A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs?

Immediately

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 artery.

A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff?

Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared.

During a routine vital sign assessment, the nurse notes the client's blood pressure is 212/110 mmHg. Why is this finding particularly significant?

It deviates from normal and is significant.

A client monitoring his BP at home notices that his BP is higher in one arm than the other. He calls his health care provider for guidance. What is the most appropriate information for the nurse to give this client?

It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results.

The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct?

Lightly compress the client's radial artery using the first, second, and third fingers.

A nurse needs to measure the blood pressure of a client with an electronic manometer. Which of the following advantages does an electronic manometer provide over an aneroid manometer or mercury manometer?

No stethoscope is required.

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

A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?

Over the clients thigh

A nurse is using a hypothermia blanket as ordered on an adult client with an uncontrolled fever. Which statement accurately describes the safe and effective use of this type of equipment?

Position the blanket under the client so that the top edge of the pad is aligned with the client's neck.

The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention?

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 felt with difficulty and disappears with slight pressure.

A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature?

Rectum

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?

Remove the thermometer and assess the blood pressure and heart rate.

A client who has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong?

She should place her three fingers just below the wrist on the outside of the arm with the palm up.

The nurse observes the client's frequent use of the incentive spirometer. The client states "I do not want to have pneumonia while in the hospital." Which vital sign reading demonstrates effectiveness of this intervention?

Temperature of 98.2°F (36.7°C)

The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this?

The client is covered with a couple of thick blankets.

When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. Which statement explains this order?

The client's pulse rate is below 60 beats per minute.

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?

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 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client?

To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns.

t/f During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant.

True

The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next?

Use the Doppler ultrasound device.

An 80-year-old client has a body temperature of 97°F (36°C). Which condition best accounts for this client's temperature reading?

advanced age

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?

auscultate the client's apical pulse

An ultrasonic Doppler is used for:

auscultating a pulse that is difficult to palpate.

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will:

decrease the apical pulse.

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:

decrease the apical pulse.

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

The nurse is assessing the pulse amplitude for a client. Documentation by the nurse states, "Pulses are +1 in the lower left extremity." What amplitude is the nurse assessing?

diminished, weaker than expected

A client has smoked most of his life and has labored respirations. He is experiencing:

dyspnea

The nurse understands that accurate blood pressure taking is dependent on several factors. Which example will most likely render an accurate blood pressure reading?

elevating the client's arm at heart level

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

Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"?

palpation of the radial pulse on the thumb side of the inner aspect of the wrist.

Which term indicates a potentially serious client condition?

pyrexia

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?

rectum