Engage Fundamentals RN: Vital Signs

A charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. Identify the order of the steps the nurse should include. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1. Select the site for obtaining the measurement 2. Apply the sensor probe on the chosen site 3. Confirm the pulse rate displayed on the oximeter by palpating the radial pulse 4. Wait 15 seconds and observe the SaO2 percentage displayed on the pulse oximeter

A charge nurse is providing an in-service for a group of nurses about cardiac output. Which of the following statements should the nurse include? A. "Cardiac output is the amount of blood flow through the heart in 1 minute." B. "Cardiac output is the amount of blood ejected from the atria." C. "Cardiac output is the ability of the muscle fibers in the ventricles to stretch." D. "Cardiac output is the resistance of the ventricles to pump blood through the heart."

"Cardiac output is the amount of blood flow through the heart in 1 minute." Rationale: The nurse should identify that cardiac output is the amount of blood pumped by the ventricles through the heart within 1 min.

A nurse is planning care for a client who has hypertension. Which of the following interventions should the nurse include in the plan? (Select all that apply.) A. Provide the client with low-sodium meals and snacks. B. Encourage the client to participate in physical activity each day. C. Instruct the client in the use of relaxation techniques. D. Inform the client of the importance of abstaining from using products that contain nicotine. E. Anticipate a prescription for a 1L IV fluid bolus.

A, B, C, D. A- A diet high in sodium can cause an increase in blood pressure. Therefore, the nurse should provide the client with foods and fluids that are low in sodium. The nurse should also provide information to the client on which foods and fluids are high in sodium and should be avoided. B- Daily physical exercise can decrease blood pressure. The nurse should encourage the client to participate in physical activity each day as they are physically able. C- Relaxation techniques decrease stress, lower the heart rate, and decrease blood pressure. The nurse should instruct the client in the use of relaxation techniques, such as guided imagery, to assist in managing hypertension. D- Nicotine is a stimulant, which increases heart rate and blood pressure. Nicotine also causes vasoconstriction, increasing blood pressure. The nurse should provide information to the client about these effects and encourage the client to avoid products containing nicotine. The nurse should also refer the client to a smoking cessation program if needed.

A nurse is evaluating the effectiveness of interventions used for clients who had alterations in vital signs. Which of the following clients' vital signs indicate that interventions were effective? (Select all that apply.) A. A preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min B. An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min C. A young adult who had hypotension after receiving an opioid analgesic and now has a blood pressure of 98/68 mm Hg D. A toddler who was febrile 2 hr ago due to a viral infection and has a temporal temperature of 38.2° C (100.8° F) E. An adult client who had tachycardia 1 hr ago due to postoperative pain and has an apical pulse rate of 106/min

A, B, C. Rationale: A- The nurse should identify that a respiratory rate of 26/min for a preschooler is within the expected reference range of 22 to 34/min. This finding indicates that interventions were effective. B- The nurse should identify that an apical pulse rate of 66/min is within the expected reference range of 60 to 100/min for an older adult client. This finding indicates that interventions were effective. C- The nurse should identify that hypotension is a blood pressure of less than 90/60 mm Hg. Therefore, a blood pressure of 98/68 mm Hg indicates that the client's blood pressure is no longer hypotensive, so interventions were effective.

A charge nurse is reviewing the expected reference range of blood pressure in adult clients with a newly licensed nurse. Which of the following statements should the charge nurse include? A. "Hypertension is diagnosed with two elevated measurements on two separate occasions." B. "Successive blood pressure measurements of 126 over 78 is classified as stage I hypertension." C. "Stage II hypertension is diagnosed when the blood pressure measurement is 132 over 86." D. "A blood pressure measurement of 176 over 102 is classified as a hypertensive crisis."

A. "Hypertension is diagnosed with two elevated measurements on two separate occasions." Rationale: A diagnosis of hypertension is not usually made based on a single elevated measurement; there are generally at least two elevated readings taken on two or more separate occasions for the provider to determine this diagnosis.

A nurse working on a medical-surgical unit is caring for a group of clients. Which of the following clients' vital signs should the nurse identify is outside the expected reference range and notify the provider? A. A client who has an apical pulse rate of 120/min B. A client who has a blood pressure of 100/74 mm Hg C. A client who has an apical pulse rate of 84/min D. A client who has a blood pressure of 110/68 mm Hg

A. A client who has an apical pulse rate of 120/min Rationale: The nurse should identify the client's apical pulse rate of 120/min is outside the expected reference range of 60 to 100/min and requires notifying the provider.

A nurse is reviewing the vital signs for a group of clients to determine the effectiveness of interventions. Which of the following findings indicates an intervention was effective? A. An adult client who received medication for pain 30 min ago now has a respiratory rate of 18/min. B. A school-age child who received two units of packed red blood cells now has a BP of 76/54 mm Hg. C. A toddler who received an antibiotic injection now has a heart rate of 148/min while sleeping in their parent's arms. D. An older adult client who received an antipyretic medication 1 hr ago now has a temperature of 38.7° C (101.6° F).

A. An adult client who received medication for pain 30 min ago now has a respiratory rate of 18/min. Rationale: An adult client who has a respiratory rate of 18/min is within the expected reference range of 12 to 20/min. This indicates that the administration of the pain medication was effective. Tachypnea, an increased respiratory rate, is an expected finding for clients experiencing pain, anxiety, or increased physical activity.

A nurse is preparing to obtain a young adult client's apical pulse. In which of the following locations should the nurse place their stethoscope to auscultate the client's pulse? A. Apex of the heart. B. Right side of sternum. C. 4th intercostal space. D. Mid-clavicular line below right clavicle

A. Apex of the heart Rationale: The nurse should identify that the apical pulse is auscultated over the apex of the client's heart for a client who is older than 7 years of age. This is located between the 5th intercostal space to the left of the client's sternum.

A nurse is assessing a client who has orthostatic hypotension. Which of the following actions should the nurse take? A. Encourage the client to change positions slowly. B. Restrict the client's oral intake of fluids. C. Encourage the client to take a short walk. D. Discontinue IV fluids.

A. Encourage the client to change positions slowly. Rationale: The nurse should identify that orthostatic hypotension is a drop in systolic pressure of at least 20 mm Hg, or a drop in diastolic pressure of at least 10 mm Hg, within 1 min of moving to a sitting or standing position after lying down.

A nurse is caring for a client who has a heart rate of 118/min. Which of the following actions should the nurse take to improve the client's heart rate? A. Encourage the client to reduce intake of caffeinated soft drinks. B. Inform the client to ambulate in the hallway for 10 min prior to taking vital signs. C. Increase the room temperature and add blankets to warm the client. D. Withhold the client's anti-anxiety medication.

A. Encourage the client to reduce intake of caffeinated soft drinks. Rationale: In an adult client, a heart rate greater than 100/min is known as tachycardia. Tachycardia can be due to exercise, anxiety, certain medications, or use of caffeine or nicotine. It can also be caused by an abnormality in the electrical system of the heart. The nurse should encourage the client to limit their intake of caffeinated soft drinks to decrease the incidence of tachycardia.

A nurse is caring for a client who has an increase in cardiac afterload. Which of the following findings should the nurse expect? A. Increase in blood pressure B. Increase in respiratory rate C. Decrease in cardiac output D. Decrease in preload

A. Increase in blood pressure Rationale: The nurse should identify that a client who has an increase in afterload increases the risk for hypertension. Afterload is the resistance of the ventricle to pump the heart muscle and eject blood into the client's bloodstream during systole.

A nurse is caring for a client who has an increase in cardiac output. Which of the following findings should the nurse expect? A. Increase in blood pressure. B. Decrease in respiratory rate. C. Decrease in heart rate. D. Increase in stroke volume.

A. Increase in blood pressure Rationale: The nurse should identify that an increase in cardiac output causes an increase in the client's blood pressure. Cardiac output is the amount of blood pumped by the ventricles in 1 min.

A nurse is caring for a client who has a heart rate of 120/min. Which of the following action should the nurse take? A. Instruct the client to bear down like they are having a bowel movement. B. Offer the client hot caffeinated tea to drink early in the morning. C. Hold the clients thyroid medication. D. Encourage the client to take a warm shower.

A. Instruct the client to bear down like they are having a bowel movement. Rationale: The Valsalva maneuver can be used to regulate heart rate. To elicit this, the nurse should instruct the client to "bear down" like they're having a bowel movement. This action produces a vasovagal response in the clients body, which lowers the client's heart rate.

A charge nurse is discussing a client's respiratory data with a newly licensed nurse. Which of the following statements should the nurse include? A. "Clients will exhibit an increase in their respiratory rate after using a bronchodilator." B. "Count the respiratory rate for 1 minute for clients who have a respiratory infection." C. "Expect clients who have a brainstem injury to exhibit rapid respirations." D. "Clients who are experiencing acute pain will have slow, deep respirations."

B. "Count the respiratory rate for 1 minute for clients who have a respiratory infection." Rationale: The charge nurse should include that the nurse should count the respiratory rate for 1 min for clients who have a respiratory infection. For clients who are healthy, the nurse can count the rate for 15 seconds and multiply by 4 to determine the rate per minute.

A nurse is planning care for a group of clients and is reviewing the recent vital signs obtained by an assistive personnel. Which of the following clients should the nurse assess and recheck the vital signs prior to notifying the provider? A. 16-year-old female: respiratory rate 18/min, SaO2 98% B. 8-year-old male: respiratory rate 34/min, SaO2 97% C. 11-year-old male: respiratory rate 28/min, SaO2 99% D. 3-year-old female: respiratory rate 32/min, SaO2 96%

B. 8-year-old male: respiratory rate 34/min, SaO2 97% Rationale: The nurse should recognize that this client's respiratory rate is above the expected reference range of 18 to 30/min for a male school-age child and denotes tachypnea. While the SaO2 is within the expected reference range of greater than or equal to 95%, the nurse should assess the client, recheck the respiratory rate, and notify the provider if the child remains tachypneic.

A nurse on a pediatric unit is reviewing the medical records for a group of clients. Which of the following clients has a vital sign outside the expected reference range and requires intervention? A. A 1-month-old infant who has a respiratory rate of 58/min B. A 3-year-old preschooler who has an apical pulse rate of 144/min C. An 8-year-old child who has a respiratory rate of 25/min D. An 18-month-old toddler who has an apical pulse rate of 120/min

B. A 3-year-old preschooler who has an apical pulse rate of 144/min Rationale: The nurse should identify that an apical pulse rate of 144/min is above the expected reference range of 75 to 129/min for a preschooler. This finding requires intervention by the nurse.

A nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings for vital signs. Which of the following findings requires follow up? A. A client that has 8 mm Hg difference in systolic BP when moving from a sitting to a standing position. B. A client has a radial pulse of +4 bilateral. C. An older adult client has a tympanic temperature of 35.9 C (96.6 F). D. A newborn has a respiratory rate of 56/min while sleeping.

B. A client has a radial pulse of +4 bilateral. Rationale: A peripheral pulse strength of +4 is described as bounding and is considered an unexpected finding. The nurse should check further and report the findings to the provider. A pulse strength of +2 is considered an expected finding.

A nurse is reviewing the vital signs for a group of clients obtained by an assistive personnel. The nurse should identify that which of the following clients requires a follow-up assessment due to bradycardia? A. A school-age child who has an apical pulse rate of 78/min B. A young adult who has a radial pulse rate of 56/min C. An adolescent who has a radial pulse rate of 76/min D. An older adult who has an apical pulse rate of 62/min

B. A young adult who has a radial pulse rate of 56/min Rationale: The nurse should identify that a young adult client who has a radial pulse rate of 56/min is exhibiting bradycardia. The nurse should confirm the pulse rate by auscultating the apical pulse for 1 min, as well as assessing the client for manifestations of bradycardia such as fatigue, dizziness, or shortness of breath.

A nurse is discussing the physiology of blood pressure with a group of assistive personnel. Which of the following information should the nurse include? A. Diastolic blood pressure reflects the pressure exerted during contraction of the heart. B. Blood pressure is measured and documented in millimeters of mercury. C. Blood pressure decreases when the blood viscosity increases. D. Systolic blood pressure reflects the pressure when the heart is relaxed.

B. Blood pressure is measured and documented in millimeters of mercury. Rationale: Blood pressure is measured in millimeters of mercury (mm Hg) and is expressed as a fraction. The pressure is measured with a sphygmomanometer.

A nurse is teaching a group of newly licensed nurses about vital sign measurements. Which of the following factors should the nurse include in the teaching? A. Anxiety can cause a decrease in respiratory rate. B. Body temperature is typically lower in older adults. C. Caffeine can cause a temporary decrease in pulse rate in adolescents. D. Blood pressure slightly decreases immediately following the use of nicotine.

B. Body temperature is typically lower in older adults. Rationale: The nurse should identify that body temperature is generally slightly lower in older adults than in younger adults and children.

A nurse is evaluating the effectiveness of interventions provided to a client who has an SaO2 below the expected reference range. Which of the following manifestations requires follow up by the nurse? A. Eupnea B. Dyspnea C. Heart rate of 84/min D. SaO2 of 96%

B. Dyspnea Rationale: A low SaO2 indicates the body's tissues and cells are not receiving enough oxygen and can be related to several causes including hypothermia, decreased cardiac output, or lung disease. Clients who have an SaO2 below the expected reference range of 95% to 100% can exhibit shortness of breath and difficulty breathing, or dyspnea. This indicates the interventions provided by the nurse have not been successful and require further evaluation and notification of the provider.

A nurse is providing care to a client who has an apical pulse rate of 54/min and is experiencing dizziness. Which of the following is the nurse's priority action? A. Teach the client how to take their pulse so they can keep the provider informed of variations. B. Inform the client to ask for assistance with getting out of bed. C. Educate the client on medications, including therapeutic effects and potential adverse effects. D. Ensure the client has been taking medications as prescribed.

B. Inform the client to ask for assistance with getting out of bed. Rationale: Bradycardia associated with dizziness indicates the greatest risk to this client is injury due to a fall; therefore this is the priority action by the nurse.

A nurse is evaluating the effectiveness of interventions provided to a client who was admitted for decreased circulation. Which of the following findings requires further intervention by the nurse? A. Pulse deficit of 0 B. Left radial pulse is nonpalpable C. Peripheral pulse +2 bilateral D. Brachial pulses are symmetrical

B. Left radial pulse is nonpalpable Rationale: Peripheral pulses that are nonpalpable require further intervention by the nurse. The nurse should use a Doppler ultrasound stethoscope to auscultate the pulse. The nurse should also determine if the client has other manifestations of impaired circulation, such as cool, pale skin. The nurse should notify the provider of any unexpected findings.

A nurse is discussing oxygen saturation with a client. Which of the following information should the nurse include? A. Oxygen saturation is determined by the amount of oxygen bound to white blood cells. B. Oxygen saturation reflects the amount of oxygen being delivered to body tissues. C. The expected reference range for oxygen saturation is 90% to 100%. D. A capillary refill time of less than 5 seconds ensures a reliable oxygen saturation measurement.

B. Oxygen saturation reflects the amount of oxygen being delivered to body tissues. Rationale: Oxygen saturation is an indication of the amount of oxygen being transported to body tissues and is a direct reflection of a client's respiratory status.

A nurse is reviewing blood flow through the heart with a group of assistive personnel. The nurse should identify that blood flows to which of the following parts of the heart as it leaves the right ventricle? A. Tricuspid valve B. Pulmonary artery C. Right atrium D. Vena cava

B. Pulmonary artery Rationale: As the right ventricle contracts, blood is forced into the pulmonary artery, where it enters the lungs to become oxygenated. Once oxygenated, the blood is returned to the heart via the pulmonic vein, where it enters the left atrium. It then passes through the mitral valve into the left ventricle. As the ventricle contracts, the blood is forced into the aorta and systemic circulation.

The nurse is reviewing documentation of vital signs by a nearly licensed nurse for an assigned client. Which of the following entries in the chart requires follow up by the nurse? A. BP 130/82 mm Hg left arm, lying. Client reports experiencing postoperative pain as 7 on a scale of 0 to 10. Prescribed analgesic administered and will re-evaluate BP in 30 min. B. Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall. C. saO2 93% left index finger, client, sleeping, nasal O2 dislodged. Nasal O2 readjusted and saO2 increased to 95%. D. Respiratory rate 18/min the observation, client sitting in chair.

B. Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall. Rationale: This client's pulse rate is higher than the expected reference range. While the notation of the client ambulating in the hall can be a factor in the tachycardia, the nurse does not indicate they will re-evaluate the pulse rate after the client has rested. The nurse should use clinical judgment when evaluating vital signs and wait 15 to 30 min following exercise.

A charge nurse is teaching a group of assistive personnel (AP) about the importance of documenting accurate vital signs. Which of the following information should the charge nurse include in the teaching? A. Record vital signs at the end of each shift. B. Recording vital signs provides critical information regarding a client's condition. C. Obtaining and documenting baseline vital signs is the responsibility of the AP. D. It is not necessary to record electronic blood pressure measurements.

B. Recording vital signs provides critical information regarding a client's condition. Rationale: Vital signs, including blood pressure, temperature, pulse, respiratory rate, and SaO2, reflect the client's current health status and will vary according to changes in the client's health condition, such as infection, stress, pain, or bleeding, and should be recorded accurately and in a timely manner.

A nurse is caring for a client who asks about factors that could cause their pulse rate to increase. Which of the following factors should the nurse include in their response? A. Hypothermia B. Smoking C. Sleeping D. Aging

B. Smoking Rationale: Products containing nicotine, such as cigarettes, can increase pulse rate and blood pressure.

A nurse is observing an assistive personnel (AP) obtain vital signs from an adult client. Which of the following actions by the AP requires follow up by the nurse? A. The AP pulls the pinna up and back when obtaining a tympanic temperature. B. The AP informs the client when they are counting the respirations. C. The AP gently presses down with the pads of two to three fingers over the radial pulse site. D. The AP selects a blood pressure cuff width that is 40% the circumference of the client's arm.

B. The AP informs the client when they are counting the respirations. Rationale: According to evidence-based practice, the AP should not inform the client they are going to count their respirations. This action can lead the client to alter their breathing, which can cause inaccurate results. When obtaining vital signs, the AP should count a client's respirations when they are relaxed and at rest.

A nurse is reviewing the vital signs obtained by an assistive personnel at 1200. For which of the following clients should the nurse plan to intervene? A. Adult male who has a respiratory rate of 18/min B. Toddler who has a respiratory rate of 44/min C. Newborn who has a respiratory rate of 56/min D. Adolescent female who has a respiratory rate of 16/min

B. Toddler who has a respiratory rate of 44/min Rationale: The expected reference range for respiratory rate in toddlers is 25 to 30/min, so this client will need to be assessed by the nurse, as they are exhibiting tachypnea. The nurse should reassess the vital signs to ensure previous readings were accurate and evaluate the client to determine a potential cause for the increased respiratory rate, such as anxiety, crying, or physical exertion.

A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. Which of the following statements should the charge nurse make? A. "The first step in checking for orthostatic hypotension is obtaining a client's blood pressure while they are standing." B. "An increase of 5 millimeters of mercury in the diastolic pressure with a position change indicates orthostatic hypotension." C. "A decrease of 20 millimeters of mercury in the systolic pressure with a position change indicates orthostatic hypotension." D. "Wait 5 minutes to check the client's blood pressure after each position change."

C. "A decrease of 20 millimeters of mercury in the systolic pressure with a position change indicates orthostatic hypotension." Rationale: The charge nurse should include that a decrease of at least 20 mm Hg in the systolic pressure with a position change indicates orthostatic hypotension.

A nurse is providing teaching about thermoregulation to a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching? A. "The body increases body temperature through the process known as vasodilation." B. "The body loses heat through shivering." C. "The body lowers body temperature through sweating." D. "The body generates heat through evaporation."

C. "The body lowers body temperature through sweating." Rationale: Sweating, a natural body reaction to increased temperature, helps the body to maintain a consistent temperature by cooling the body through evaporation of the sweat from the skin, thereby lowering the body's temperature.

A nurse is reviewing the recent vital signs of a group of clients. Which of the following clients should the nurse see first? A. A 45-year-old client who is postoperative and has a BP of 130/82 mm Hg B. A 28-year-old client who runs marathons and has a heart rate of 54/min C. A 52-year-old client who has an SaO2 of 92% D. A 78-year-old client who has a temperature of 35.9° C (96.6° F)

C. A 52-year-old client who has an SaO2 of 92% Rationale: Using the airway, breathing, circulation approach to client care, the nurse should identify that the priority finding is the low SaO2. SaO2 is the indicator of the amount of oxygen transported to body tissues and the expected reference range is greater than 95%. Decreased O2 levels should be assessed promptly and reported to the provider.

A nurse is preparing an in-service about peripheral pulses for a group of staff nurses. Which of the following information should the nurse include? A. A pulse strength of +4 indicates that the pulse is of normal strength upon palpation. B. A femoral pulse that is bounding upon palpation is an expected finding in a young adult. C. A pulse strength of +1 indicates that the pulse is weak or diminished upon palpation. D. A pedal pulse that is weak upon palpation is an expected finding in an older adult.

C. A pulse strength of +1 indicates that the pulse is weak or diminished upon palpation. Rationale: The nurse should identify that a pulse strength of +1 indicates that the pulse is weak or diminished upon palpation. This is an expected finding and requires no further evaluation.

A nurse is reviewing the vital signs for a group of clients. Which of the following clients should the nurse identify as exhibiting tachycardia? A. An infant who has an apical pulse rate of 132/min B. A preschooler who has an apical pulse rate of 108/min C. A young adult who has an apical pulse rate of 104/min D. An older adult who has an apical pulse rate of 96/min

C. A young adult who has an apical pulse rate of 104/min Rationale: The nurse should identify that a pulse rate of 104/min is above the expected reference range of 60 to 100/min for a young adult. Therefore, this client is exhibiting tachycardia. The nurse should allow the client to rest in a comfortable position and recheck the apical pulse rate. If it remains elevated, the nurse should notify the provider.

A nurse is evaluating the effectiveness of interventions used to address clients' vital signs that were outside of the expected reference ranges. Which of the following findings indicates the intervention was effective? A. An older adult client who has pneumonia and a respiratory rate of 26/min after a position change B. An adolescent who is postoperative and has an SaO2 of 93% after receiving an opioid analgesic C. A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm Hg after using an inhaler D. An older adult client who has an infection and a pulse rate of 110/min after using relaxation techniques

C. A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm Hg after using an inhaler Rationale: The nurse should identify that a blood pressure of 116/72 mm Hg is within the expected reference range for a young adult. The expected systolic blood pressure should be less than 120 mm Hg and the diastolic blood pressure should be less than 80 mm Hg. Therefore, the intervention of using an inhaler was effective.

A nurse is obtaining vital signs for a group of clients. Which of the following findings requires intervention? A. A 17-year-old who has a respiratory rate of 16/min. B. A young adult who has a pulse rate of 98/min. C. An 11-year-old child who has a respiratory rate of 34/min. D. An older adult who has a pulse rate of 62/min.

C. An 11-year-old child who has a respiratory rate of 34/min Rationale: The nurse should identify that a respiratory rate of 34/min is above the expected reference range of 18 to 30/min for a school-age child. This finding requires intervention by the nurse.

A charge nurse is evaluating a newly licensed nurse's documentation of vital signs for several clients. Which of the following documentation should the charge nurse identify as being incomplete? A. Radial pulse regular at 84/min B. Respirations observed as even, nonlabored at 20/min with client in supine position C. BP 124/82 mm Hg, lying in bed D. Temporal temperature 36.9° C (98.4° F)

C. BP 124/82 mm Hg, lying in bed Rationale: The charge nurse should identify that this documentation is incomplete because it does not include the site from where the blood pressure was obtained.

A nurse is caring for a client who has hypotension. Which of the following factors should the nurse identify as a contributing factor to the client's condition? A. Decrease in contractility B. Increase in blood viscosity C. Decrease in respiratory rate D. Increase in preload

C. Decrease in contractility Rationale: The nurse should identify that a decrease in contractility of the client's heart is a contributing factor to hypotension. Contractility is the ability of the heart muscle to contract effectively.

A nurse is planning care for a client who is experiencing tachycardia. Which of the following interventions should the nurse plan to include? A. Instruct the client to increase exercise. B. Instruct the client to consume no more than four caffeinated beverages per day. C. Encourage the client to practice relaxation techniques each day. D. Encourage the client to engage in pattern paced breathing by panting.

C. Encourage the client to practice relaxation techniques each day. Rationale: Tachycardia can be caused by stress or anxiety. The nurse should encourage the client to participate in relaxation techniques such as guided imagery, meditation, or yoga, because these can decrease heart rate and blood pressure.

A nurse is assessing a 3-month-old infant during a well-child visit. Which of the following actions should the nurse take when assessing the apical pulse? A. Count the number of beats heard in 15 seconds and multiply by 4. B. Notify the provider if the apical pulse rate is greater than 110/min. C. Place the stethoscope over the 4th intercostal space to the left of the sternum. D. Auscultate the apical pulse for an S4 heart sound.

C. Place the stethoscope over the 4th intercostal space to the left of the sternum. Rationale: The nurse should auscultate the apical pulse over the apex of the heart, which is located in the 4th intercostal space to the left of the sternum in infants and children less than 7 years of age.

A charge nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct? A. Pulse 52/min B. Respiratory rate 24 C. SaO2 97% right index finger, room air D. Blood pressure 132/86 mm Hg

C. SaO2 97% right index finger, room air Rationale: The charge nurse should identify that this documentation is thorough and complete and does not require any additional information. The information provided includes the measurement, the site used, and that the client is not on oxygen.

A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart? A. Atrioventricular (AV) node B. Left ventricle C. Sinoatrial (SA) node D. Right ventricle

C. Sinoatrial (SA) node Rationale: The SA node is the pacemaker of the heart. It consists of a small group of special cells in the right atrium which initiates electrical impulses that travel to the AV node and sets the rate of the contraction of the ventricles.

A nurse is preparing an in-service about vital signs for a group of newly hired assistive personnel. Which of the following information should the nurse include about measuring body temperature? A. Tympanic temperature can be affected by environmental temperature. B. Temporal temperature is inaccurate in children under 3 years of age. C. Axillary temperature reflects rapid changes in a client's core body temperature. D. Oral temperature is easily accessible despite a client's position.

D. Oral temperature is easily accessible despite a client's position. Rationale: One advantage of oral temperature is that it is easily accessible despite a client's position. The oral temperature is an accurate measurement of body surface temperature but does not reflect core temperature.

Charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. Which of the following statements should the nurse include? A. "Convection is the loss of body heat when a client is in contact with the cooler surface." B. "Conduction is the loss of body heat when sweat dries from a client's skin." C. "Evaporation is the loss of body heat when a client is near a current of cool air." D. "Radiation is the loss of body heat when a client is in close proximity to a cooler surface."

D. "Radiation is the loss of body heat when a client is in close proximity to a cooler surface." Rationale: The nurse should include that radiation is the loss of body heat that occurs when a client is in close proximity to a cooler surface. For example, radiative heat loss can occur when a client sits near a window when it is cold outside.

A nurse is reviewing the vital signs of four clients. The nurse should identify that which of the following clients has a vital sign outside of the expected reference range? A. A 52-year-old client who has a fever due to a wound infection and a pulse rate of 100/min B. A 76-year-old client who reports moderate pain and has a respiratory rate of 20/min C. A 46-year-old client who is postoperative following a hysterectomy and has an SaO2 of 95% D. A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg

D. A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg Rationale: The nurse should identify that a blood pressure of 82/54 mm Hg indicates hypotension, which is an unexpected finding for a 23-year-old client. With hypotension the client will have systolic BP less than 90 mm Hg or a diastolic BP less than 60 mm Hg. The nurse should expect the client to exhibit bradycardia, or a slow heart rate, due to their high level of physical fitness. However, the nurse should gather more client data for manifestations of hypotension and report the findings to the provider.

A nurse is caring for a client who is experiencing tachypnea due to an exacerbation of asthma. Which of the following medications should the nurse anticipate administering? A. A nicotine product B. An opioid antagonist C. An antihypertensive D. A bronchodilator

D. A bronchodilator Rationale: Tachypnea occurs during an asthma attack due to a constriction in the airways, leading to a decrease in oxygenation. The respiratory rate increases to compensate for the decrease in oxygen to the tissues. A bronchodilator decreases inflammation in the lungs, which opens the airways. This allows for improved oxygenation to the tissues, thereby decreasing the respiratory rate.

A charge nurse in a clinic is preparing an in-service about blood pressure measurements for a group of staff members. Which of the following information should the nurse include? A. A client is diagnosed with an elevated blood pressure when the measurement is greater than 130/80 mm Hg. B. A client is experiencing a hypertensive crisis when their blood pressure is greater than 150/90 mm Hg. C. A client who has a blood pressure of 128/86 mm Hg has stage I hypertension. D. A client who has a blood pressure of 162/102 mm Hg has stage II hypertension.

D. A client who has a blood pressure of 162/102 mm Hg has stage II hypertension. Rationale: The charge nurse should include that a blood pressure of 162/102 mm Hg meets the diagnostic criteria for stage II hypertension. With Stage II hypertension, the systolic BP must be greater than 140 mm Hg and the diastolic BP must be greater than 90 mm Hg.

A nurse is teaching a group of assistive personnel (AP) about techniques used to obtain BP. For which of the following clients should the nurse to instruct the AP to obtain an electronic BP measurement? A. A client who has a BP lower than the expected reference range B. A school-age child C. A client recovering from extensive abdominal surgery D. A client who has stabilized BP measurements

D. A client who has stabilized BP measurements Rationale: Blood pressure can be obtained electronically using a machine that has a blood pressure cuff attached. The machine automatically inflates the bladder of the cuff and displays the blood pressure on a screen. This method is reserved for clients in stable condition with BP measurements within the expected reference range. Manual BP measurements are more accurate than those obtained via an electronic device, so if an abnormal reading is obtained electronically, a manual reading should be obtained.

A nurse is planning care for a group of clients. For which of the following clients should the nurse direct an assistive personnel (AP) to obtain a rectal temperature? A. A toddler who has diarrhea B. A client who is 1 day postoperative following a hemorrhoidectomy and receiving pain medications via PCA pump C. An infant who is receiving intravenous fluids D. A client who is diaphoretic and frequently chewing ice to relieve dry mouth

D. A client who is diaphoretic and frequently chewing ice to relieve dry mouth Rationale: Oral temperatures should not be obtained in clients who have consumed food or liquids or smoked tobacco products within the previous 30 min. The client's diaphoresis will make it difficult to obtain an accurate temperature via the tympanic membrane or temporal artery. Therefore, the nurse should direct the AP to obtain this client's temperature rectally.

A nurse is planning care for a group of clients and is delegating to the assistive personnel (AP) to take the clients' vital signs. For which of the following clients should the nurse obtain the vital signs rather than the AP? A. A client who just received the fourth dose of an antibiotic for an infection. B. A client who has heart failure and is scheduled for discharge later in the day. C. A client who is 24 hr postoperative and is visiting with friends. D. A client who was recently admitted and reports chest pain.

D. A client who was recently admitted and reports chest pain. Rationale: The nurse should identify that a new onset of chest pain is an acute change in condition. The nurse should not delegate this task to the AP. Once the client is stable, the nurse can delegate subsequent measurement of vital signs to an AP.

A nurse is caring for a group of clients. Which of the following clients is experiencing an alteration in their respiratory rate that requires intervention? A. An adolescent who has a respiratory rate of 20/min B. An older adult who has a respiratory rate of 16/min C. An infant who has a respiratory rate of 52/min D. A school-age child who has a respiratory rate of 14/min

D. A school-age child who has a respiratory rate of 14/min Rationale: The nurse should identify that a respiratory rate of 14/min is below the expected reference range of 18 to 30/min for a school-age child. The child is exhibiting bradypnea, which requires further data collection by the nurse.

A nurse is preparing an in-service for a group of newly hired assistive personnel (AP) about body temperature. Which of the following information should the nurse include? A. Wait 5 min after a client has consumed a hot drink to obtain an oral temperature. B. Place a tape or patch thermometer over a client's scapula. C. A tympanic thermometer reflects a client's body surface temperature. D. A temporal probe thermometer uses infrared scanning to determine a client's temperature.

D. A temporal probe thermometer uses infrared scanning to determine a client's temperature. Rationale: The nurse should instruct the AP that a temporal artery thermometer uses infrared scanning to determine the body's core temperature. The thermometer probe is placed in the center of the forehead, swiped laterally toward the hairline, then touched to the skin behind the client's earlobe.

A nurse is preparing an in-service about factors affecting respiratory rate for a group of assistive personnel. Which of the following information should the nurse include? A. Anxiety can decrease a client's respiration rate. B. Opioid analgesics can increase a client's respiratory rate. C. Pain can decrease a client's respiratory rate. D. Fever can increase a client's respiratory rate.

D. Fever can increase a client's respiratory rate. Rationale: The nurse should include that an increased body temperature can cause an increase in a client's respiratory rate. Other factors that can increase respiratory rates include physical exertion, chronic lung disease, and anxiety.

A nurse obtains a client's electronic blood pressure reading of 188/96 mm Hg. Which of the following actions should the nurse take next? A. Provide client teaching regarding medications to control blood pressure. B. Notify the provider of the client's blood pressure reading. C. Provide client education on measures to decrease blood pressure. D. Obtain a manual blood pressure reading from the client.

D. Obtain a manual blood pressure reading from the client. Rationale: Evidence-based practice dictates that if a client's blood pressure is not within the expected reference range when it is taken with an electronic blood pressure machine, then the nurse should recheck the blood pressure by obtaining a manual blood pressure reading to ensure accuracy.

A nurse is caring for a recently admitted client and as part of the plan of care, two nurses obtained simultaneous pulse rates. The client's auscultated apical pulse was 106/min and the palpated radial pulse was 93/min. The nurse should document the findings as which of the following? A. Pulse deficit less than 10 B. Radial pulse irregular C. Apical pulse greater than radial D. Pulse deficit of 13/min

D. Pulse deficit of 13/min Rationale: A pulse deficit is the numerical difference between the apical pulse and a peripheral pulse (usually the radial) for 1 min time. This can be caused by atrial fibrillation, aortic rupture, or coronary artery disease. The nurse should document the findings in the client's medical record and notify the provider if a pulse deficit is present.

A nurse is observing an assistive personnel (AP) who is obtaining a blood pressure reading from a client. Which of the following actions by the AP requires follow up by the nurse? A. The AP uses a cuff width that is 40% of the circumference of the client's arm. B. The AP provides support for the client's arm while taking the BP. C. The AP waits to take the client's BP 45 min after the client ambulates in the hallway. D. The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second.

D. The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second. Rationale: Releasing the pressure at a rate of 5 mm Hg per second is too fast. The recommended rate is 2 mm Hg per second. Releasing the valve too quickly could prevent the AP from noting the correct reading and too slowly can cause additional discomfort to the client.

A nurse is discussing the use of a client's thigh for blood pressure measurements with an assistive personnel (AP). Which of the following information should the nurse include? A. Select a blood pressure cuff width that is 25% of the circumference of the client's thigh. B. Palpate the femoral pulse when obtaining blood pressure in the thigh. C. Expect blood pressure in the thigh to be 10 to 15 mm Hg less than in the arm. D. Use the thigh to obtain blood pressure when a client has severe edema in their arms.

D. Use the thigh to obtain blood pressure when a client has severe edema in their arms. Rationale: The nurse should instruct the AP to obtain blood pressure measurements in the thigh when a client has severe edema in the arms or a shunt in place for dialysis.