Nursing 101 Vital Signs

The nurse places a client experiencing labored breathing in an upright position. the nurse notes that the client is able to breath more easily in this upright position and documents this condition on the chart as;

orthopnea

do to circadian rhythm your temperature is 1-2 degrees F lower in the _________?

Morning

the nurse needs to assess the carotid arteries of the client. which assessment technique would be appropriate for the nurse to use?

Palpate one artery at a time

The nurse is caring for a 77-year-old client who is recovering for surgery. After notifying the health care provider the client?

Postural hypotension

The nurse is caring for a 77-year-old client who is recovering from surgery, after notifying the health care provider of the incident recorded in the client's chart, what will the nurse anticipate teaching the client?

Postural hypotension

palpable bounding of blood flow in the peripheral artery.

Pulse

what is the most common site for palpation pulse and you only use 1-2 fingers to check pulse ?

Radial

The nurse discovers during assessment that the client has an altered temperature.

Radiation- infrared heat waves open arteriovenous shunts Conduction- the air itself sympathetic nervous system Evaporation- through sweating Convection- Exposure to a fan by "goose bumps" or Piloerection

a client with newly diagnosed hypertension on BP medication has been taking her own bp at home for 2 weeks. When she calls and reports her BP readings to the nurse, the nurse notes and elevated bp in the morning. The client states that she wakes up, has her daily cup of coffee, and takes her bp before eating as she was instructed. What should the nurse recommend to this client?

Take her BP before drinking her morning cup of coffee.

After taking vital signs of an older adult, the nurse writes down findings as T=98.9, P= 104, R=18, BP =120/82. Based on the collected data, which step would th nurse take next ?

Take pulse Again to assess for tachycardia

35.9 degrees to 38 degrees C ( 96.7 to 100.5 degrees F) is the range for

Temperature

an ultra sonic doppler Is used for:

auscultating a pulse that is difficult to palpate

1 + =

barely

occurs at rest

basal metabolic rate

Average <120/80 mm hg and pulse pressure 30 to 50 mm Hg

blood pressure

3 + =

bounding

you check your patient pulse on the antecubital fossa, this is

brachial pulse

Metabolism, basal metabolic rate and movement are productions of what?

heat

what part of your body regulates your temperature?

hypothalamus

a nurse is assessing an adult client's blood pressure. How should the nurse estimate the client's systolic blood pressure (SBP)

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

rhythm of respirations

labored breathing

what controls the respiration rate ?

medulla oblongata

Primary source of heat

metabolism

0 =

no pulse

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

no stethoscope is required

2 + =

normal

sites to assess temperature ?

oral, axillary, tympanic, rectal, forehead

Which guideline should the nurse follow when assessing a client's blood pressure using a doppler ultrasound?

Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery.

A nurse is educating a postoperative adult about taking daily temperatures. What Statement by the client best indicates understanding of education?

"if my temperature is above 99.6 (38.3 C) I should call the health care provider. "

A nurse is assessing a new born at 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?

"it is because of the immature ability to regulate temperature in general."

A nurse is taking a blood pressure measurement to assess for orthostatic hypotension in a client. which sign(s) and symptoms (s) will the nurse assess related to this condition? Select all that apply

- Report of feeling dizzy when sitting up form a supine position - report feeling palpitations when rising form a supine to a standing position - report of feeling light headed when sitting up - syncope

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

1 degree F (0.5 degree C) Lower than an oral temperature.

when having a fever at what degree will it start to be harmful ?

104 degrees F

when pulse is rhythm is regular you check pulse for _________ and multiply by 2

30 sec

a nurse is assessing the respiratory rate of a sleeping 28-day-old infant. What would the nurse document as a normal finding?

30-60 breaths/min

if your patients pulse is irregular how long should you check patients pulse for ?

60 sec

what is the normal pulse rate for adults ?

60-100 bpm

The nurse is performing a telephone follow up with parents whom she taught to monitor their newborn's BP and pulse at home. Which results reported by the parents would indicate that the parents are performing the technique correctly and there is no cause for concern?

70/40 mm Hg and 145 bpm

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

A faint, clear tapping sound

A nurse attempts to count the respiratory rate of a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. what is an alternative method of determining the respiratory rate for this client?

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

where do you place your stethoscope to hear BP ?

Antecubital space

At this site you check pulse by auscultating with a stethoscope, what is the name of site ?

Apical

you check your patient pulse on 5th intercostal and mid-clavicular, this is

Apical pulse

if your patients pulse is lower than 60 BPM or higher than 101 bpm what should you do ?

Asses for Factors

The nurse walks into the client's room to pick up the dinner tray and notes the client has not eaten. which action should the nurse prioritize after noting the client appears sleepy, has perspiration on the forehead, and the face appears flushed?

Assess temperature

The nurse is attempting to assess a client's radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurses take next?

Assess the apical pulse

when are vitals signs taken ?

At rest

when assessing a client's radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. what intervention should the nurse implement next?

Auscultate the apical for 60 seconds

When assessing a client's radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next?

Auscultate the apical pulse for 60 seconds

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

Auscultate the client's apical pulse

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 ?

Auscultate the lung sounds and count respirations

An Ultrasonic doppler is used for

Auscultating a pulse that is difficult to palpate

amount of force by blood against the walls of artery

Blood pressure

Which pulse site is generally used in emergency situation?

Carotid

you check your patient pulse on side of neck, this is

Carotid pulse

what is a respiratory disease that will cause normal o2 stat for patient lower then normal range

COPD

Volume of blood pumped by the heart each minute is ?

Cardiac Output

When a patient has orthostatic hypotension their blood pressure decrease or increases ?

Decreases

Which statement describes diastolic blood pressure?

During Ventricular relaxation, blood pressure is due to elastic recoil of the vessels

Bacteria and viruses trigger immune response system - hypothalamus reacts - raises "set point"

Fever

the nurse notes that the temperature of an ill client is 101 degrees F. Which intervention would the nurse take to regulate the client's body temperature?

Give the client a bath in tepid water

you should check patient bp on lower extremity when they have or had ?

IV's, Dialysis shunt, mastectomy

The nurse is teaching and adult client how to monitor the pulse rate. which statement by the client demonstrates understanding of a normal pulse rate?

If my pulse is higher than 100 beats/min at rest, that is considered abnormal

when a patient has orthostatic hypotension their heart rate decreases or increases ?

Increases

12 to 20 breaths per minute are range for ?

Respiration

this is a passive process, controlled by medulla oblongata, regulates by levels of carbon dioxide, oxygen and hydrogen ion concentration in arterial blood.

Respiration

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

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

what is the most appropriate nursing response when a client with a BMI of 29 expresses concerns of developing hypertension?

Since weight is one factor that can increase the risk of developing hypertension we will refer you to a nutritionist for weight management

The home care nurse is assessing a 37-year-old client's vital signs at rest. which finding requires nursing intervention?

Temporal temperature 100.8 degrees F

The nurse is obtaining vital signs for a client and assesses a heart rate of 124 bpm. What additional assessment information would be important to obtain that would explain the tachycardia? Select all that apply

The client has reports of pain of 8 on a scale of 0 to 10 the client has a temperature of 101.8 the client has just finished ambulating with physical therapy

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

The client is covered with a couple of thick blankets

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?

The client sits in the chair with feet flat on the floor and arm. Below the level of the heart

A nurse will assess the oral temperature of a postoperative client. prior to performing this assessment, which should the nurse identify?

The client's most recent temperature

The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate?

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

A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse ?

The radial pulse is difficult to obtain

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?

There is an auscultatory gap

Temperature, pulse, respiration, blood pressure, pain, oxygen saturation

Vital Signs

clients demonstrating apnea have what?

a temporary cessation of breathing

What are some factors that can give you false o2 stat results ?

anemia , nail polish, impeding blood flow

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

decrease the apical pulse

Increased metabolism, Increased temperature are important

defense mechanism

shallow, normal, deep

depth of respiration

state where heart muscle relax

diastole

represents the pressure in the arteries during diastole

diastolic pressure

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

diminished, weaker than expected

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 clients is experiencing

dyspnea

Age, gender, circadian rhythm, environmental temperatures are

factors affecting temperature

you check your patient pulse by groin, this is

femoral pulse

Family history, obesity, smoking, heavy alcohol consumption, high sodium intake,, sedentary lifestyle, stress, diabetes, elderly, African-American, High cholesterol are all ?

risk factors for hypertension

a patient c/o lightheadedness, dizziness or fainting spells what should you check for ?

orthostatic hypotension

measures oxygen concentration in the blood percent of hemoglobin bound to oxygen in arteries

oxygen saturation (saO2)

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

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

you check your patient pulse behind knee, this is

popliteal pulse

60 to 100 beats per minute is range for ?

pulse

the difference between systole and diastolic pressure

pulse pressure

number of beats felt/heard in 1 minute is pulse rate.

pulse rate

which term indicates a potentially serious client condition ?

pyrexia

you check your patient pulse on the wrist, this is

radial pulse

normal heat loss through

radiation, conduction, convection, evaporation

A nurse is caring for an adult with fever. The nurse determines that which site is most accurate for obtaining the clients core body temperature?

rectum

when checking a non-invasive BP what equipment do you use ?

stethoscope, sphygmomanometer

state where heart muscle contracts

systole

represents the pressure in the arteries during systole

systolic pressure

you check your patient pulse on side of head, this is

temporal pulse

A pulse deficit is the difference between:

the apical and the radial pulse rates.

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

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

rhythm of respiration

unlabored breathing

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

use the doppler ultrasound device

circadian rhythm is

your body time of day