N400 CH 25 PrepU Vital Signs

39. The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with: a. Increased temperature b. Increased cardiac output c. Decreased heart rate d. Decreased respirations

A.Body temperature can fluctuate with exercise, changes in hormone levels, changes in metabolic rate, and extremes of external temperature.

24. The nurse is talking to an older adult client who performs home blood pressure monitoring (HBPM) and finds that recently her BP measurements have consistently been low. Which factors may contribute to causing this client's BP to be falsely decreased? Select all that apply. a. Releasing the valve rapidly b. Using cracked or kinked tubing c. Assessing the BP immediately after exercise d. Applying too wide a cuff e. Applying a cuff that is too narrow

A, B, D.Some factors that may contribute to a falsely decreased BP include a cuff that is too wide, releasing the valve too rapidly, and using cracked or kinked tubing. A cuff that is too narrow may cause a falsely elevated BP. Assessing the BP immediately after exercise may cause a falsely elevated BP.

30. The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that would explain the tachycardia? Select all that apply. a. The client has a temperature of 101.8°F (38.8°C) b. The client has a blood pressure of 122/70 mm Hg c. The client has been drinking water d. The client has reports of pain of 8 on a scale of 0 to 10 e. The client just finished ambulating with physical therapy

A, D, E. There are several factors that may cause an increase in heart rate due to an increase in metabolic rate. This can occur with pain, exercise, fever, medications, and strong emotions. A blood pressure of 120/70 mm Hg does not indicate an association with tachycardia or that a client has been drinking water. Caffeinated beverages may cause an increase in heart rate but water would not.

60. 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 a. diminished, weaker than expected b. brisk, expected (normal) c. bounding d. absent, unable to palpate

A. A +1 pulse amplitude indicates that the pulse is diminished and weaker than expected. An absent pulse is a 0. A pulse that is brisk is a +2, and a bounding pulse is +3.

3. A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client? a. "Dizziness when you change position can occur when fluid volume in the body is decreased." b. "Dizziness can occur due to changes in the hospital environment." c. "Dizziness can occur when baroreceptors overreact to the changes in BP." d. "Dizziness is caused by very low blood pressure when you lie down."

A. Dehydration is a cause for orthostatic hypotension, which causes a temporary drop in BP when the client rises from a reclining position. Dizziness is not associated with environmental changes. Dizziness or changes in orthostatic BP occurs when baroreceptors do not respond quickly enough to restore adequate circulation to the brain. Dizziness may be caused by low blood pressure. However, the client is dizzy with ambulation not when lying down.

2. A nurse is measuring the apical pulse of a client. Where should she place the diaphragm of her stethoscope in this assessment? a. Over the space between the fifth and sixth ribs on the left midclavicular line b. Over the radial artery on the anterior wrist c. Over the carotid artery in the anterior neck d. In the center of the upper back

A. The apical pulse is measured over the apex of the heart, which is located approximately in the area of the space between the fifth and sixth ribs on the left midclavicular line.

31. A nurse is taking the vital signs of a 9-year old child who is anxious about the procedures. Which nursing action would be appropriate when assessing this child? a. Perform the assessments quickly while maintaining a serious demeanor. b. Make sure the child does not touch the assessment equipment. c. Perform as many tasks as possible with the child lying on the examining table. d. Perform the blood pressure measurement last.

A. The blood pressure reading is the most invasive procedure performed when measuring vital signs. If the nurse were to perform it first it may upset the child further and could prevent obtainment of the remainder of the vital signs. Allowing the child to touch the assessment equipment often helps the child be more relaxed for the remainder of the assessment. Lying on the exam table is not necessary for vital signs and will likely cause more anxiety. Being quick with a serious demeanor does not help decrease the child's anxiety.

1. The nurse takes a client's vital signs and notes a blood pressure of 88/56 mm Hg with a pulse rate of 60 beats/min. Which action should the nurse take first? a. Assess the client for dizziness. b. Retake the client's blood pressure. c. Place the client in a supine position. d. Notify the health care provider.

A. The nurse should first assess the condition of the client and determine if physical signs of hypotension are present. After assessing the client's condition, the nurse should retake the blood pressure for accuracy. The client should remain in bed and not get up since dizziness and further drop in blood pressure could occur. Placing the client in the supine position (or flat on their back) will not assist with improving the blood pressure. Placing the client in the Trendelenburg (flat on the back with the feet higher than the head by 15-30 degrees) is appropriate. The nurse can check the chart to determine the client's normal range of blood pressure and notify the health care provider if there are symptoms associated with the hypotension.

61. Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"? a. palpation of the radial pulse on the thumb side of the inner aspect of the wrist. b. firm palpation of bilateral carotid artery for one minute c. light palpation of the femoral pulse below the inguinal area d. firm placement of thumb on the inner wrist of the opposite arm

A. The radial artery is the site most commonly assessed in the clinical setting. The radial pulse is palpated on the thumb side of the inner aspect of the wrist.

10. Which condition will lead to an increase in cardiac output? a. Exercise b. Sleep c. Decrease in blood pressure d. Dehydration

A.Cardiac output increases during exercise and decreases during sleep. When cardiac output is decreased, blood pressure falls. Hemorrhage and dehydration can result in decreased cardiac output and decreased blood pressure.

16. 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: a. Dyspnea b. Fremitus c. Strider d. Wheezing

A.Dyspnea describes respirations that require excessive effort, such as is common in clients who smoke, suffer from chronic obstructive pulmonary disease, or have been diagnosed with asthma. Stridor are harsh, loud, high-pitched sounds auscultated on inspiration that signal narrowing of the upper airway or presence of a foreign body in the airway. Wheeze is a continuous, high-pitched squeak or musical sound made as air moves through narrowed or partially obstructed airway passages. Fremitus vibration of the chest wall that can be palpated during the physical examination.

27. A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation? a. Auscultate the lung sounds and count respirations. b. Notify the health care provider. c. Administer oxygen. d. Perform a pain assessment.

A.If the respirations are too shallow to count it is easier to count respirations by auscultating the lung sounds. The nurse should auscultate lung sounds and count respirations for 30 seconds, then multiply by 2 to calculate the respiratory rate per minute. If the respiratory rate is irregular, the nurse should count for a full minute. The nurse notifies the health care provider of the respiratory rate and the shallowness of the respirations following assessment. Pain typically causes vital signs to elevate. The nurse cannot administer oxygen without a health care provider's prescriptions.

6. The nurse is caring for an adult postoperative client. Which physiologic response is related to pain? a. Heart rate of 110 beats/min b. 2500 milliliters of urine per 24 hours c. Oxygen saturation of 98% d. Constipation

A.Pain medication can cause decreased bowel motility and cause constipation. However, pain itself can cause an increased heart rate which is indicated by the rate of 110 beats/min. Pain can cause decreased urinary output, 2500 milliliters of urine in 24 hours is an indication of increased output. Pain can increase the consumption of oxygen, an O2 saturation of 98% on room air would be a normal reading.

20. Which pulse site is generally used in emergency situations? a. Carotid b. Apical c. Radial d. Temporal

A.The carotid artery is lightly palpated to obtain a pulse in emergency assessments, such as in a client in shock or cardiac arrest. The brachial pulse site is used for infants who have had a cardiac arrest. The apical pulse is the fifth intercostal space for adults and the fourth intercostal space for a young child or infant. Using a stethoscope at the apex of the heart, a nurse can assess the lub dub of the heart sounds. Radial pulse is too distant to assess a pulse in an emergency assessment. Temporal pulse is difficult to assess.

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

A.The point where the brachial or radial pulse disappears provides an estimate of the systolic pressure. Previous baselines are important to know, but these do not provide an estimate of current SBP. Simultaneous palpation of radial pulses and having the client raise his or her arms does not provide an estimate of SBP.

55. The client's blood pressure has gradually decreased in the last 2 days. Which condition would cause this change? a. the client who has had persistent diarrhea b. the client who has been given 3 units of whole blood c. the client who is to be discharged home on hospice d. the client who has unresolved pain issues

A.Vital signs—body temperature (T), pulse (P), respirations (R), and blood pressure (BP)—indicate the function of some of the body's homeostatic mechanisms. Measurement and interpretation of the vital signs are important components of assessment that can yield information about underlying health status.

8. 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? a. deep in the posterior sublingual pocket b. superior to the tongue, with the tip touching the hard palate c. in the inferior buccal space on either side of the tongue d. along either upper gum line, adjacent to an incisor

A.When the probe rests deep in the posterior sublingual pocket, it is in contact with blood vessels lying close to the surface. None of the other areas provides as much contact with blood vessels and therefore is not an appropriate location to place the thermometer probe.

4. Which client's blood pressure best describes the condition called hypotension? a. The systolic reading is above 110 and diastolic reading is above 80. b. The systolic reading is below 100 and diastolic reading is below 60. c. The systolic reading is above 102 and diastolic reading is above 60. d. The systolic reading is below 120 and the diastolic reading is below 80.

B. Hypotension is defined by a systolic pressure below 100 mm Hg and diastolic pressure less than 60 mm Hg. The top number refers to the amount of pressure in the arteries during the contraction of heart muscle. This is called systolic pressure. The bottom number refers to the blood pressure when the heart muscle is between beats. This is called diastolic pressure. Ideal blood pressure is less than 140/90.

59. The normal adult temperature obtained through the oral route ranges from: a. 98.6°F to 100.4°F (37.0°C to 38.0°C). b. 97.6°F to 99.6°F (36.4°C to 37.6°C). c. 96.6°F to 98.6°F (35.9°C to 37.0°C). d. 98.2°F to 100.2°F (36.8°C to 37.9°C).

B. Normal adult oral temperature ranges from 97.6°F to 99.6°F (36.4°C to 37.6°C).

32. An older adult client monitors her BP at home. Lately she has been experiencing dizziness and nausea, followed by a headache when she arises from lying down for a nap. She was worried it was her BP so she began measuring the BP after she arose from her nap and found that her BP would drop shortly after getting up from her nap. She followed up with her health care practitioner and was diagnosed with orthostatic hypotension. What is the most appropriate nursing diagnosis to be included in the teaching plan for this client at this time? a. Acute confusion related to hypotension b. Risk for falls related to inadequate physiologic response to postural (positional) changes c. Sedentary lifestyle related to frequent afternoon naps d. Knowledge deficit related to the inability to take an accurate BP at home

B. Orthostatic hypotension (postural hypotension) is a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing when compared with blood pressure from the sitting or supine position. It results from an inadequate physiologic response to postural (positional) changes in blood pressure. Orthostatic hypotension may be acute or chronic, as well as symptomatic or asymptomatic. It is associated with dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache. Older adults may experience orthostatic hypotension without associated symptoms, leading to falls.

35. The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next? a. Connect the client to the oxygen saturation monitoring device. b. Use the Doppler ultrasound device. c. Use the Bell side of the stethoscope to listen. d. Ask another student nurse to check it for him.

B. Peripheral pulses that cannot be detected by palpation may be assessed with an ultrasonic Doppler device. A conductive gel is first applied to the skin to reduce resistance to sound transmission. The transmitter of the device is then placed over the artery to be assessed. High-frequency waves directed at the artery from the transmitter are disturbed by the pulsating flow of blood and are reflected back to the ultrasound device. The sound disturbances (Doppler shifts) are amplified and heard through earpieces or a speaker attached to the device. The bell effect is created by light pressure on the stethoscope. Using the bell will not facilitate palpation but an auditory assessment. The nursing student should be familiar with other assessment devices such as the Doppler and not asking another nursing student to assess. Connecting the client to the oxygen saturation device does not assist in the assessment of pedal pulses.

51. It is very important to assess for the quality of someone's respirations as well as describe what is heard with auscultation. Which describes stridor? a. respirations that require excessive effort b. a harsh, high-pitched inspiratory sound that may be compared to crowing c. high-pitched musical sound d. discontinuous popping sounds

B. Stridor is a harsh, high-pitched inspiratory sound that may be compared to crowing. It can indicate an upper-airway obstruction. A high-pitched musical sound describes wheezing. Dyspnea is a term used to describe expirations that require excessive effort. Crackles are discontinuous popping sounds.

47. The nurse teaches a client diagnosed with hypertension to self-measure blood pressure with an automated device. Which client behavior indicates the need for additional teaching? a. The client places the blood pressure cup on the upper arm just above the antecubital space. b. The client sits in the chair with feet flat on the floor and arm below the level of the heart. c. The client sits in the chair with feet flat on the floor and arm supported at the level of the heart. d. The client uses a blood pressure cuff width at least 40% of the circumference of the midpoint of the arm.

B. The client behavior that indicates the need for additional teaching is client sitting in the chair with feet flat on the floor and arm below the level of the heart. Taking a blood pressure with the arm in that position can give a falsely high reading. The client placing the blood pressure on the upper arm just above the antecubital space, the client sitting in the chair with feet flat on the floor and arm supported at the level of the heart, and the client using a blood pressure cuff width at least 40% of the circumference of the midpoint of the arm all indicated correct methodology for self-measuring blood pressure and thus require no need for further teaching.

53. A nurse is assessing a newborn at the health care facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be most appropriate? a. "It is because of the closely woven dark fabric wrapped around the baby." b. "It is because of the immature ability to regulate temperature in general." c. "The baby is showing how it is adapting to the environmental temperature." d. "It is common for newborns to have body temperatures less than 36.4°C (97.6°F)."

B. The nurse should explain to the mother that newborns have unstable body temperatures because their thermoregulatory mechanisms are immature. It is not uncommon for an older adult's body temperature to be less than 36.4°C (97.6°F), because normal temperature drops as a person ages. Newborns and infants lack the ability to decrease heat loss in response to environmental temperatures and cannot usually mount a robust fever response to infection. Changes in environmental temperatures do not affect core body temperature. Covering the body with closely woven dark fabric helps reduce radiant heat loss, but it is not responsible for unstable body temperatures in newborns.

34. The nurse understands that accurate blood pressure taking is dependent on several factors. Which example will most likely render an accurate blood pressure reading? a. the ear tip of the stethoscope pointing backwards while taking blood pressure b. placing the client's arm at heart level c. the client reporting moderate pain for the past 4 hours d. using a medium size cuff for a 10-year-old, average weight client

B. The nurse should measure blood pressure with the arm at heart level. Elevating the arm above heart level results in a falsely low measurement, positioning the arm below heart level results in a falsely high reading. The ear tip or bell can be pointed in any direction when taking a blood pressure. Using a small cuff is recommended for a 10-year-old normal-sized child. Pain can increase the blood pressure causing a false elevated reporting.

40. A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which action should the nurse perform to obtain the accurate temperature of the client? a. Ask the client to drink a glass of cold water before measuring the oral temperature b. Wait for 30 minutes before measuring the oral temperature c. Obtain the client's temperature rectally after liberating the rectum d. Use the axillary site for an alternative measurement site

B. The nurse should wait for 15 to 30 minutes and then measure the oral temperature of the client since hot and cold liquids cause slight variations in temperature. Giving the client a glassful of cold water to drink will not help because the thermometer will still show temperature variation, not the accurate body temperature. The rectal route is contraindicated in clients with diarrhea, because it can cause mucosal tearing or perforation. Hence, the nurse should not lubricate the client's rectum or measure the rectal temperature. The axillary route is the least accurate and least reliable site.

57. Which statement is true regarding the autonomic nervous system and its effect on the rate of a person's pulse? a. Stimulation of the sympathetic nervous system results in a decrease in the pulse rate. b. Sympathetic nervous system activation occurs in response to a variety of stimuli, including changes in intravascular volume. c. The sympathetic nervous system is the dominant activation during resting states. d. Stimulation of the parasympathetic nervous system results in an increase in the pulse rate.

B. The sympathetic nervous system activation occurs in response to various stimuli, including pain, anxiety, exercise, fever, and changes in intravascular volume. Stimulation of the parasympathetic nervous system results in a decrease in the pulse rate.

54. Which factor is not known to cause false blood pressure readings? a. being in a warm environment b. smoking 20 minutes before assessment c. eating 5 minutes before assessment d. crossing the legs at the knee

B. To get an accurate blood pressure assessment, the client should not cross the legs at the knee, smoke tobacco 20 minutes before assessment, nor eat 5 minutes before assessment. The client should sit up straight with both feet on the floor and avoid smoking tobacco, eating, and drinking for 30 minutes before blood pressure assessment. Being in a warm environment does not cause a false reading, however, an increased ambient temperature can causes blood vessels near the skin surface to dilate and decrease blood pressure within the normal fluctuation of 10 mm Hg.

42. A nurse is assessing the respiratory rate of a sleeping 28-day-old infant. What would the nurse document as a normal finding? a. 12 to 20 breaths/min b. 30 to 60 breaths/min c. 60 to 80 breaths/min d. 80 to 100 breaths/min

B. When assessing the respiratory rate of an infant less than 1 month of age, the nurse knows that the normal respiratory rate of an infant at rest is approximately 30 to 60 breaths/min. The normal respiratory rate of an adult is 12 to 20 breaths/min. A respiratory rate of 60 to 80 breaths/min or 80 to 100 breaths/min is abnormal and is not seen in infants or adults when they are at rest.

56. Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs a. increased temperature b. increased pulse rate c. increased respiration rate d. increased blood pressure

B. When the stroke volume decreases, such as when blood volume is decreased because of hemorrhage, the heart rate increases to try to maintain the same cardiac output. Respirations may increase, but the primary response is the increase in the heart rate. The blood pressure would decrease. Temperature is not affect initially in hemorrhage.

49. The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mmHg. What is the priority nursing intervention? a. report readings to primary care provider b. ask the client to demonstrate self-blood pressure assessment c. provide the client with a larger blood pressure cuff d. recommend lower sodium in the client's diet

B. While all of these interventions would be appropriate if the client is hypertensive, it is important to assess whether the client is measuring their BP correctly before assuming that hypertension is present. It would be very rare to have a BP of the exact same measurement with every assessment. Therefore, providing the client with a larger blood pressure cuff, recommending lower sodium in the client's diet, and reporting the readings to the primary care provider are not priority actions at this time.

48. The nurse is assessing an adult who has a pulse rate of 150 beats/min. Which action should the nurse take next? a. Administer epinephrine immediately b. Notify the health care provider of tachycardia c. Obtain the client's blood pressure d. Assess the client for allergic reaction

B.An adult has tachycardia when the pulse rate is 100 to 180 beats/min. Blood pressure should always be assessed, but the health care provider should be notified immediately. Anaphylaxis and epinephrine are not specific to high pulse rate thus the provider should be called first.

26. The nurse has completed an assessment and notes that the client's blood pressure is 132/92 mmHg. What is this client's pulse pressure? a. 132 mmHg b. 40mmHg c. 112mmHg d. 224mmHg

B.The difference between systolic blood pressure and diastolic blood pressure is called the pulse pressure, 132 − 92 = 40.

11. 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? a. Ear b. Rectum c. Axillary d. Mouth

B.The rectal temperature, a core temperature, is considered to be one of the most accurate routes.

41. The nurse needs to assess the carotid arteries of the client. Which assessment technique would be appropriate for the nurse to use? a. Palpate both arteries at the same time b. Palpate one artery at a time c. Measure the rate for 1 full minute d. Measure the rate for 30 seconds and multiply by 2

B.To palpate the carotid arteries, the nurse would lightly press on one side of the neck at a time. Never attempt to palpate both carotid arteries at the same time as bilateral palpation could result in reduced cerebral blood. It is not necessary to count the carotid rate.

15. When taking the client's temperature, the student nurse will require further education when they state: a. "Rectal temperature is contraindicated for cardiac clients." b. "The axillary route is the most accurate of all routes." c. "The use of disposable probes is important when taking temperature." d. "I should avoid using the oral route when taking an infant's temperature."

B.Use judgment when selecting the route to measure temperature. The most commonly used sites are the mouth, rectum, ear (tympanic), forehead (temporal artery), and axilla. The least accurate temperature measurement is the axilla because it can register up to a degree lower than rectal or other methods of taking the internal temperature. Rectal temperature is contraindicated for cardiac clients as it can cause the client to vasovagal and cause a lethal arrhythmia. The use of disposable probes is important when taking temperature as it reduces transmission of pathogens between clients. The oral temperature should be avoided in children as they are mouth breathers and this would affect the temperature.

44. Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem? a. coronary artery disease b. pulmonary embolism c. peripheral vascular disease d. chronic obstructive pulmonary disease (COPD)

C. A pulse deficit indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated, a finding that is congruent with peripheral vascular disease. It does not signal a lack of circulation to the heart muscle (coronary artery disease), a pulmonary embolism, or COPD.

38. Which is not a characteristic used to describe the pulse? a. Frequency b. Quality c. Depth d. Rhythm

C. Rate or frequency refers to the number of pulsations per minute. Rhythm refers to the regularity with which pulsation occurs. Quality refers to the strength of the palpated pulsation.

43. Assessment of the pulse amplitude is accomplished by: a. palpating the area of the left ventricle. b. auscultating the area of the left ventricle. c. palpating the flow of blood through an artery. d. auscultating the flow of blood through an artery.

C. The pulse amplitude describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction. It is assessed by the feel of the blood flowing through an artery. Auscultation is hearing the blood flow through an artery. Auscultation cannot be used to assess pulse amplitude. A nurse cannot palpate the area of the left ventricle.

58. The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next? a. Use the bell of the stethoscope to listen for the diastolic sound. b. Record the reading in the chart. c. Inflate the cuff about 30 mm Hg above the auscultatory gap. d. Inflate the cuff about 10 mm Hg above the auscultatory gap.

C. To find the auscultatory gap, palpate the brachial or radial pulse while inflating the cuff. Inflate the cuff about 30 mm Hg above the number where palpable pulsation disappears. In addition to detecting an auscultatory gap, palpation gives an initial estimate of systolic blood pressure and eliminates the need to inflate the cuff to extremely high pressures in people with normal or low blood pressure. Using the bell of the stethoscope to listen for the systolic and diastolic sound is expected. Recording of the blood pressure should occur after the blood pressure is obtained.

45. 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? a. palpate the client's apical pulse b. auscultate the client's brachial artery c. auscultate the client's apical pulse d. arrange for cardiac monitoring

C. When peripheral pulses are difficult to palpate, it is appropriate to auscultate the apex. This is preferable to auscultating a peripheral site, such as the brachial artery, and more accurate than attempting to palpate the apical pulse. Cardiac monitoring is not necessarily indicated in this case.

18. A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record? a. There is a nonauscultatory gap b. There is a widening in the diameter of the artery c. There is an auscultatory gap d. There is an adult diastolic pressure

C.An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mmHg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff sound technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff sound technique.

23. A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse? a. A baseline pulse rate is needed. b. The carotid pulse is bounding. c. The radial pulse is difficult to obtain. d. The blood pressure is elevated

C.Auscultation of the apical pulse provides the most accurate assessment of the pulse rate and is the preferred site when the peripheral pulses are difficult to assess or the pulse rhythm is irregular. While this is an excellent method to determine baseline pulse, it is not the reason for using the apical pulse method. Elevated blood pressure and bounding carotid pulse are not reasons to obtain an apical pulse.

19. A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff? a. Place cuff 8 cm above the elbow b. Fully inflate cuff for about 1 minute c. Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared d. Elevate arm above heart level before inflating the cuff

C.Inflating the cuff to 30 mm Hg above reading where brachial pulse disappeared ensures accurate assessment of systolic blood pressure. The arm does not need to be elevated above the heart level before inflation as this would give an inaccurate systolic blood pressure. The cuff should be placed in the elbow fold and not 8 cm above the elbow. Inflating the cuff for 1 minute before taking a blood pressure can cause an elevation of the systolic blood pressure.

9. 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? a. Reassess the client's radial pulse in 15 minutes. b. Page the client's primary care provider. c. Auscultate the client's apical heart rate. d. Palpate the radial pulse on the opposite wrist.

C.Palpation of an irregular radial pulse should be followed by assessment of the apical pulse in order to confirm the finding. Informing the health care provider is generally necessary only when this is a new finding.

25. The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next? a. Ask another student nurse to check it for him. b. Use the Bell side of the stethoscope to listen. c. Use the Doppler ultrasound device. d. Connect the client to the oxygen saturation monitoring device.

C.Peripheral pulses that cannot be detected by palpation may be assessed with an ultrasonic Doppler device. A conductive gel is first applied to the skin to reduce resistance to sound transmission. The transmitter of the device is then placed over the artery to be assessed. High-frequency waves directed at the artery from the transmitter are disturbed by the pulsating flow of blood and are reflected back to the ultrasound device. The sound disturbances (Doppler shifts) are amplified and heard through earpieces or a speaker attached to the device. The bell effect is created by light pressure on the stethoscope. Using the bell will not facilitate palpation but an auditory assessment. The nursing student should be familiar with other assessment devices such as the Doppler and not asking another nursing student to assess. Connecting the client to the oxygen saturation device does not assist in the assessment of pedal pulses.

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

C.Rectal temperature assessment can be embarrassing for the client, so provision of privacy is a priority. The client should be positioned on the side in Sims position to help facilitate probe insertion. The probe should be inserted 1 to 1.5 in (2.5 to 3.75 cm) in an adult client. The probe should only remain in the rectum until the electronic unit emits an audible sound indicating that the temperature assessment is complete.

29. When assessing an infant's axillary temperature, it will be: a. 1°F (0.5°C) higher than an oral temperature. b. 1°F (0.5°C) higher than a rectal temperature. c. 1°F (0.5°C) lower than an oral temperature. d. the same as the tympanic temperature.

C.Rectal temperatures may be 1°F (0.5°C) higher than oral temperatures and axillary temperatures are 1°F (0.5°C) lower than oral temperatures.

7. 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: a. decrease the blood glucose. b. decrease the blood volume. c. decrease the apical pulse. d. decrease the respiratory rate

C.Some cardiac medications, such as digoxin, whose action is specific to the work of the heart, slow the heart rate while also strengthening the force of contraction to increase cardiac output.

22. 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? a. Carotid b. Radial c. Apical d. Brachial

C.The apical pulse is assessed when a client is being given medications that alter heart rate and rhythm.

17. 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? a. Ear b. Mouth c. Rectum d. Axillary

C.The rectal temperature, a core temperature, is considered to be one of the most accurate routes. The most practical and convenient sites for temperature measurement are the ear, mouth, and axilla. These areas are anatomically close to superficial arteries containing warm blood, enclosed areas where heat loss is minimal, or both.

13. A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs? a. Once per day b. According to medical orders c. Immediately d. Every 4 hours

C.Vitals signs should be assessed whenever there is a change in the client condition. Because the client reports feeling "different," this indicates an immediate vital sign assessment. Therefore, it is not appropriate to assess vital signs once per day, according to medical orders, or every 4 hours.

36. A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse? a. The blood pressure is elevated. b. A baseline pulse rate is needed. c. The carotid pulse is bounding. d. The radial pulse is difficult to obtain.

D. Auscultation of the apical pulse provides the most accurate assessment of the pulse rate and is the preferred site when the peripheral pulses are difficult to assess or the pulse rhythm is irregular. While this is an excellent method to determine baseline pulse, it is not the reason for using the apical pulse method. Elevated blood pressure and bounding carotid pulse are not reasons to obtain an apical pulse.

46. The nurse is preparing the client to use the hypothermia blanket. How does the nurse measure the client's temperature while the blanket is in use? a. Oral temperature every 2 hours b. Rectal temperature every 2 hours c. Tympanic temperature every hour d. Rectal probe continuously

D. During the client's use of the hypothermia blanket, the temperature is monitored by the use of a rectal probe, so that the temperature can be measured continuously. The probe is attached to the control panel for the blanket so that the blanket temperature is maintained at a safe level. If a client is comatose or anesthetized, an esophageal probe is used to monitor the temperature. The temperature needs to be monitored continuously, not hourly or bihourly. The other placements also would not measure core temperature.

37. Which term indicates a potentially serious client condition? a. Eupnea b. Pulse pressure c. Afebrile d. Pyrexia

D. Pyrexia means an increase above normal in body temperature. Pulse pressure is an objective term related to the pulse. Eupnea means a normal breathing pattern. Afebrile means that the body temperature is not elevated.

50. 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? a. Use your thumb to locate the pulse. b. Measure the pulse at the wrist on the side of the pinky finger. c. Measure the pulse for 45 seconds and multiply by 2. d. Use the fingertips of your second and third fingers.

D. The radial pulse is palpated on the thumb side of the inner aspect of the wrist. The pulse should be palpated with the fingertips of the second and third fingers. Using the thumb may result in an inaccurate reading. The pulse should be counted for 1 full minute.

62. The nurse knows that a client who is being taught to perform home blood pressure monitoring (HBPM) understands the teaching plan when he makes which statement about the size of the BP cuff? The cuff should: a. fit snug around the upper arm with room to slip a fingertip under the cuff and should be touching the crease of the elbow. b. fit snug around the upper arm with room to slip three fingertips under the cuff and should be 1 in (2.5 cm) above the crease of the elbow. c. fit snug around the upper arm with no room to slip a fingertip under the cuff and should be 2 in (5 cm) above the crease of the elbow. d. fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow.

D. When teaching a client to perform home blood pressure monitoring (HBPM), he or she should be taught that the proper fitting cuff should fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow.

33. Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period? a. 0300 b. 1100 c. 1500 d. 1700

D.Body temperature fluctuates throughout the day. Temperature is usually lowest around 0300 and highest from 1700 to1900.

12. A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation? a. Notify the health care provider b. Perform a pain assessment c. Administer oxygen d. Ausculate the lung sounds and count respiration's

D.If the respirations are too shallow to count it is easier to count respirations by auscultating the lung sounds. The nurse should auscultate lung sounds and count respirations for 30 seconds, then multiply by 2 to calculate the respiratory rate per minute. If the respiratory rate is irregular, the nurse should count for a full minute. The nurse notifies the health care provider of the respiratory rate and the shallowness of the respirations following assessment. Pain typically causes vital signs to elevate. The nurse cannot administer oxygen without a health care provider's prescriptions.

52. The nurse is assessing a new client's blood pressure, using a manual sphygmomanometer. Which sound constitutes the client's systolic blood pressure? a. the last sound before there is complete and continuous silence b. the first sound that is audible after the auscultatory gap c. the transition from tapping sounds to muffled sounds d. the first appearance of faint but distinctive tapping sounds

D.Korotkoff sounds (or K-Sounds) are the "tapping" sounds heard with a stethoscope as the cuff is gradually deflated. Traditionally, these sounds have been classified into five different phases (K-1, K-2, K-3, K-4, K-5). The systolic blood pressure reading occurs during phase I, which is characterized by the appearance of faint but clear tapping sounds that gradually increase in intensity (K1). The last sound before there is complete and continuous silence is congruous with the diastolic blood pressure measurement (K5). In some patients, sounds may disappear altogether for a short time between Phase II and III, which is referred to as auscultatory gap. The transition from tapping sounds to muffled sound is K4. K-1 (Phase 1): The appearance of the clear "tapping" sounds as the cuff is gradually deflated. The first clear "tapping" sound is defined as the systolic pressure. K-2 (Phase 2): The sounds in K-2 become softer and longer and are characterized by a swishing sound. since the blood flow in the artery increases. K-3 (Phase 3): The sounds become crisper and louder in K-3, which is similar to the sounds heard in K-1. K-4 (Phase 4): As the blood flow starts to become less turbulent in the artery, the sounds in K-4 are muffled and softer. Some professionals record diastolic during Phase 4 and Phase 5 K-5 (Phase 5): In K-5, the sounds disappear completely, since the blood flow through the artery has returned to normal. The last audible sound is defined as the diastolic pressure.

28. A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure? a. the thickness of circulating blood b. the oxygen levels in the blood c. the volume of air entering the lungs d. the ability of the arteries to stretch

D.Measuring the blood pressure helps to assess the efficiency of the client's circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood. Measuring the blood pressure does not help in assessing the thickness of blood, oxygen level in the blood, or the volume of air entering the lungs.

14. 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? a. Measure the pulse for 45 seconds and multiply by 2. b. Measure the pulse at the wrist on the side of the pinky finger. c. Use your thumb to locate the pulse. d. Use the fingertips of your second and third fingers.

D.The radial pulse is palpated on the thumb side of the inner aspect of the wrist. The pulse should be palpated with the fingertips of the second and third fingers. Using the thumb may result in an inaccurate reading. The pulse should be counted for 1 full minute.