Chapter 30 Potter & Perry Nursing Skills Related to Vital Signs

For which patients should the nurse pull the ear pinna backward, up and out during temperature assessment at the tympanic membrane site? 1. Adults 2. 3-year-old children 3. Children older than 3 years 4. Children younger than 3 years

1. Adults For adults, the nurse should pull the ear pinna backward, up, and out during temperature assessment at the tympanic membrane site. While assessing 3-year-old children, the covered probe is pointed toward the midpoint between the eyebrow and side burns. When assessing children older than 3 years of age, the nurse should pull the pinna up and back. When assessing children younger than 3 years of age, the covered probe is pointed toward the midpoint between the eyebrow and side burns.

Which action should the nurse avoid while assessing the blood pressure (BP) of a 10-month-old patient? 1. Choosing the cuff based on the name of the cuff 2. Placing the stethoscope flexibly on the antecubital fossa 3. Preparing the child for the unusual sensation of the BP cuff 4. Allowing 15 minutes for the child to recover from recent activity before measuring BP

1. Choosing the cuff based on the name of the cuff The nurse should not use the cuff size on the basis of the name of the cuff; for example, an "infant" cuff may be too small for an infant patient. The stethoscope should be placed flexibly to avoid errors in auscultation. The nurse should understand that the child's cooperation is increased by preparing the child for the unusual sensation of the BP cuff. Readings are difficult to obtain in restless or anxious patients, so the child should be allowed to rest for at least 15 minutes to recover from recent activities and become less apprehensive.

How should the nurse determine the ventilatory rhythm in a patient? 1. Observing the chest or the abdomen 2. Observing the degree of excursion in the chest wall 3. Observing full expiration when counting ventilation 4. Observing full inspiration when counting ventilation

1. Observing the chest or the abdomen The ventilatory rhythm in a patient can be determined by observing the chest or the abdomen. Diaphragmatic breathing results from the contraction and relaxation of the diaphragm. Ventilatory depth can be determined by assessing the depth of respirations by observing the degree of excursion or movement in the chest wall. The respiratory rate can be determined by observing a full expiration and inspiration when counting ventilation or respiration rate.

The nurse is explaining the procedure of measuring oxygen saturation to a patient. This explanation occurs during which step in the nursing process? 1. Planning 2. Evaluation 3. Assessment 4. Implementation

1. Planning Planning is the step in the nursing process that involves explaining the purpose of a procedure to the patient. In this case, the nurse is explaining the measurement of oxygen saturation. Evaluation would involve comparing the oxygen saturation readings with the previous baseline values. Assessment would involve determining signs and symptoms, as well as other factors related to the condition. Implementation involves the nurse performing the planned task.

Which pulse is used by the nurse to teach athletes to monitor their heart rate? 1. Radial pulse 2. Carotid pulse 3. Brachial pulse 4. Temporal pulse

1. Radial pulse Radial pulse is used to teach patients about monitoring their heart rate, mainly for athletes and people taking heart medications. When the radial pulse is abnormal or intermittent due to dysrhythmias, or if it is inaccessible because of a dressing or cast, the apical pulse can be assessed in the patient. The carotid site is recommended for quickly finding and assessing the pulse. The brachial pulse is the best site for assessing pulse in an infant or a young child. Temporal pulse is used to assess pulse in children because it is easily accessible.

The nurse is assessing the rectal temperature of a patient with an electronic thermometer. Which patient position would promote comfort? 1. Sims' position 2. Sitting position 3. Supine position 4. High-Fowler's position While measuring rectal temperature with an electronic thermometer, patients are positioned in Sims' position with the upper leg flexed to promote comfort. The sitting and supine positions are recommended for measuring blood pressure in patients with orthostatic hypertension, not for assessing rectal temperature. A patient with oxygen saturation (SpO2) less than 90% should be placed in a high-Fowler's position to improve ventilation.

1. Sims' position While measuring rectal temperature with an electronic thermometer, patients are positioned in Sims' position with the upper leg flexed to promote comfort. The sitting and supine positions are recommended for measuring blood pressure in patients with orthostatic hypertension, not for assessing rectal temperature. A patient with oxygen saturation (SpO2) less than 90% should be placed in a high-Fowler's position to improve ventilation.

While assessing the apical pulse in a patient, the nurse places the diaphragm of the stethoscope in her palm for 10 seconds. What is the rationale for placing the stethoscope in the palm? 1. To ensure that the diaphragm is warm 2. To reduce anxiety in the patient 3. To prevent the transmission of germs 4. To increase the sensitivity of the stethoscope

1. To ensure that the diaphragm is warm Placing the diaphragm in the palm for 10 seconds ensures warming of the diaphragm and prevents the patient from becoming startled. It also brings comfort to the patient. It does not reduce anxiety or prevent the transmission of germs. It also does not increase the sensitivity of the stethoscope. Explaining the procedure to the patient prevents anxiety. Cleaning the diaphragm with a disinfectant prevents the transmission of germs.

The nurse locates different anatomical landmarks to identify the point of the apical impulse. What is the rationale behind this nursing action? 1. To hear heart sounds correctly 2. To determine apical rate accurately 3. To evaluate for change in contractions 4. To expose chest wall for selection of auscultatory site

1. To hear heart sounds correctly Using anatomical marks allows correct placement of stethoscope over the apex of the heart, which enhances the ability to hear heart sounds clearly. The apical rate can be determined accurately only when the nurse auscultates sounds clearly. The nurse can evaluate the change in contractions by comparing readings and previous baseline or acceptable range of heart rate.The nurse helps the patient to a supine or sitting position to expose the portion of the chest wall for selection of an auscultatory site.

After assessing the blood pressure of four different patients, the primary health care provider recommends follow-up visits. For which patient would the primary health care provider recommend a recheck after 1 year? 1. Patient A (Normal) 2. Patient B (Prehypertension) 3. Patient C (Stage 1 hypertension) 4. Patient D (Stage 2 hypertension)

2. Patient B (Prehypertension) Patient B's blood pressure reports show prehypertension; therefore, patient B should be recommended for a follow-up visit and a recheck in 1 year to minimize the chances of hypertension. Patient A's blood pressure reports are normal, so patient A should be recommended for recheck in 2 years. Patient C's blood pressure reports are showing stage 1 hypertension, so patient C should be recommended for recheck within 1 month to control the severity of hypertension. Patient D's blood pressure reports show stage 2 hypertension; therefore, patient D should be recommended for recheck within one week based on the severity of the condition.

The nurse determines the appropriate site for measuring a patient's temperature. Which nursing process is involved in this step? 1. Planning 2. Evaluation 3. Assessment 4. Implementation

3. Assessment In the assessment step, the nurse should determine the appropriate site for measuring temperature. In the planning step, the nurse should plan the patient's assessment procedures. In the evaluation step, the nurse should compare the patient's current values with the previous baseline values. In the implementation step, the nurse should implement appropriate treatment strategies.

When assessing the patient's respiration, the nurse elevates the bed to 60 degrees in a sitting position. What is the rationale behind this intervention? 1. To reveal a specific disease state 2. To determine respiratory cycle 3. To promote ventilatory movement 4. To minimize discomfort due to shortness of breath

3. To promote ventilatory movement Sitting erect promotes full ventilatory movement and ensures a clear view of the chest wall and abdominal movements.The character of ventilatory movement reveals specific disease states that restrict air from moving into and out of the lungs. The nurse observes the complete respiratory cycle to determine respiratory rate. The nurse should observe for any increased effort of the patient to inhale and exhale because patients with lung disease may experience difficulty breathing all the time and can best describe their discomfort related to shortness of breath.

The nurse is teaching a patient to monitor his/her heart rate. This action occurs during which step in the nursing process? 1. Planning 2. Evaluation 3. Assessment 4. Implementation

4. Implementation Teaching patients how to monitor their own heart rate occurs during the implementation step of the nursing process. When the nurse is monitoring the heart rate of the patient, it is considered an assessment. Planning involves preparing for the assessment of vital signs and monitoring of the patient. Evaluation involves analyzing the values obtained during the assessment tests and determining whether outcomes were met.

While assessing the rectal temperature of a patient, the nurse slides a plastic disposable probe cover over the thermometer probe stem until the cover locks in place. What is the reason behind this intervention? 1. Lubricating rectal mucosa during insertion 2. Maintaining standard precautions when exposed 3. Ensuring adequate exposure against blood vessels 4. Preventing transmission of microorganisms between patients

4. Preventing transmission of microorganisms between patients Sliding a disposable plastic probe cover over the thermometer probe stem will prevent the transmission of microorganisms between patients. Squeezing a liberal portion of lubricant on the tissue helps lubricate the rectal mucosa and minimizes trauma. Application of clean gloves between cleaning the anal region and measuring rectal temperature is important to maintain standard precautions. Inserting the thermometer probe gently into the anus in a direction of umbilicus 2.5 to 3.5 cm helps ensure adequate exposure against blood vessels in the rectal wall.

Which site should be used by the nurse to determine pulse in children? 1. Apical 2. Carotid 3. Brachial 4. Temporal

4. Temporal The temporal site, which is present over the temporal bone of the head, above and lateral to the eye, should be assessed in children to determine pulse. The apical site is used to auscultate for the apical pulse. The carotid site can be accessible during physiological shock or cardiac arrest when other sites are not palpable. The brachial site is used to assess the status of circulation to the lower arm and to auscultate blood pressure.