Nursing 102 Chapter 26 Vital signs

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?

the ability of the arteries to stretch

The nurse is teaching an 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."

The nurse discovers during assessment that the client has an altered temperature. Select one caustive factor for each type of heat loss.

1-Radiationinfrared heat waves 2-Conduction the air itself 3-Evaporation through sweating 4- Convection exposure to a fan

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

1700

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?

40 mmHg

The nursing student is selecting a blood pressure cuff prior to obtaining a client's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading?

40% of the circumference of the limb to be used

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

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 nurse take next?

Assess the apical pulse.

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

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

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

The nurse has palpated the client's radial artery and identified a heart rate of 88 beats per minute with an irregular rate. What is the nurse's most appropriate action?

Auscultate the client's apical heart rate.

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.

The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?

Listen for heart sounds.

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.

The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next?

Inflate the cuff about 30 mm Hg above the auscultatory gap.

The nurse is caring for a client whose recent medical history includes a pulse deficit. To assess for a pulse deficit, what action will the nurse take?

Obtain help from a colleague to assist with the assessment.

The nurse is planning the discharge teaching for a client with a arrhythmia. Which outcome reflects achievement of the goal, "The client will demonstrate correct technique in taking their pulse rate"?

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

The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation?

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

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 is assessing clients in the emergency department for body temperature. Which nursing actions reflect proper technique when assessing body temperature by various methods? Select all that apply.

When assessing an oral temperature with an electronic thermometer, place the probe beneath the client's tongue in the posterior sublingual pocket. When assessing rectal temperature with an electronic thermometer, lubricate about 1 in (2.5 cm) of the probe with a water-soluble lubricant. When assessing temperature with an electronic thermometer, hold the thermometer in place in the assessment site until a beep is heard.

Which client would the nurse consider at risk for low blood pressure?

a client with low blood volume

Clients demonstrating apnea have what?

a temporary cessation of breathing

The nurse is preparing to administer a medication that the client takes to treat a cardiac arrythmia. Which site should the nurse use to assess pulse in this client?

apical

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

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

decrease the apical pulse.

A nurse is assessing an apical pulse on an older adult client who takes metoprolol daily. The nurse can anticipate that the client's medication will:

decrease the apical pulse.

Which is not a characteristic used to describe the pulse?

depth

An older adult client monitors their blood pressure at home. Lately the client has been experiencing dizziness and nausea, followed by a headache when arising from lying down for a nap. The client was worried it was their blood pressure and began measuring their blood pressure arising from their nap. The client found that their blood pressure would drop shortly after getting. The client followed up with their health care provider and was diagnosed with orthostatic hypotension. What is the most important concern the nurse will include in the teaching plan?

falls risk related to inadequate physiologic response to postural (positional) changes

When performing hourly checks, a client reports feeling "different" than earlier in the day. On what schedule will the nurse assess the client's vital signs?

immediately

A nurse walks into the room of a client, who is to be discharged, and notes the client appears to be sleeping. The nurse observes the client's breathing pattern. The client is not breathing; then appears to breathe with the depths of the respirations appearing to increase, then decrease; and then stops breathing again. Which action should the nurse prioritize?

notify the health care provider

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?

peripheral vascular disease

The nurse is obtaining and recording vital signs of an adult client in the emergency department. Which finding should be reported to the health care provider?

pulse rate 51 beats/min

Which term indicates a potentially serious client condition?

pyrexia

The nurse is assessing a new client's blood pressure, using a manual sphygmomanometer. Which sound constitutes the client's systolic blood pressure?

the first appearance of faint but distinctive tapping sounds