Taylor Chapter 24 Vital Signs Prep U
A nurse is assessing the respiratory rate of a sleeping infant. Which of the following would the nurse document as a normal finding?
30 to 60 breaths per minute Explanation: When assessing the respiratory rate of an infant, the nurse knows that the normal respiratory rate of an infant at rest is approximately 30 to 60 breaths per minute. The normal respiratory rate of an adult is 12 to 20 breaths per minute. A respiratory rate of 60 to 80 breaths per minute or 80 to 100 breaths per minute is abnormal and is not seen in infants or adults when they are at rest. Tachypnea is an abnormally fast respiratory rate, usually above 20 breaths per minute in the adult, whereas bradypnea is an abnormally slow respiratory rate, usually less than 12 breaths per minute in the adult.
The nursing student is selecting a blood pressure cuff prior to obtaining a patient'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 Explanation: The width of the cuff should be about 40% of the circumference of the limb to be used.
What is the pulse pressure of a patient whose blood pressure is 132/82 mm Hg?
50 Explanation: Blood pressure is measured in millimeters of mercury (mm Hg) and is recorded as a fraction. The numerator is the systolic pressure; the denominator is the diastolic pressure. The difference between the two is called the pulse pressure.
Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?
5:00 PM Explanation: Body temperature fluctuates throughout the day. Temperature is usually lowest around 3 AM and highest from 5 to 7 PM.
An obese patient has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the patient's peripheral pulses. How should the nurse proceed with this assessment?
Auscultate the patient's apical pulse Explanation: When peripheral pulses are difficult to palpate, it is appropriate to auscultate the patient's 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
Which peripheral pulse site is generally used in emergency situations?
Carotid Explanation: The carotid artery is lightly palpated to obtain a pulse in emergency assessments, such as in a patient in shock or cardiac arrest. The brachial pulse site is used for infants who have had a cardiac arrest
A person's core body temperature is highest in the early morning and lowest in the late afternoon.
False
The temperature is 102° during a heat wave. The nurse can expect admissions to the emergency room to present with
Increased temperature Explanation: Body temperature can fluctuate with exercise, changes in hormone levels, changes in metabolic rate, and extremes of external temperature.
The nurse is assessing the apical pulse of a patient using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?
Listen for heart sounds. Explanation: The apex of the heart is found after palpating between the fifth and sixth ribs, then moving the stethoscope the left midclavicular line. The apical rate is typically assessed for 1 minute. Each "lub-dub" sound counts as one beat.
The nurse is teaching a newly diagnosed hypertensive client how to take his or her own BP at home. The client asks why it is so important to do this. What is the nurse's best response?
Monitoring your BP at home will assist in controlling your BP, thereby decreasing your risk for heart attack and stroke.? Explanation: Teaching a client to monitor his or her BP at home has been shown to increase compliance with a treatment plan, thereby assisting in the control of blood pressure and decreasing the risk for stroke and heart attack. The other three answers are not appropriate statements to encourage the client?s participation in this activity.
When assessing an infant's axillary temperature, it will be
One degree lower than an oral temperature Explanation: Rectal temperatures may be one degree higher than oral temperatures, and axillary temperatures are one degree lower than oral temperatures.
Assessment of the pulse amplitude is accomplished by which of the following?
Palpating the flow of blood through an artery Explanation: 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.
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?
Perform the blood pressure measurement last. Explanation: 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 prevent obtaining 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 call more anxiety. Being quick with a serious demeanor does not help decrease the child's anxiety.
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 of the following health problems?
Peripheral vascular disease Explanation: 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.
A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?
Pulse is felt with difficulty and disappears with slight pressure. Explanation: Thready pulse is felt with difficulty or not easily felt, and slight pressure causes it to disappear. A weak pulse is stronger than a thready pulse, and light pressure causes it to disappear. A normal pulse is felt easily, and moderate pressure causes it to disappear. A bounding pulse is strong and does not disappear with moderate pressure.
Which of the following terms indicates a potentially serious patient condition?
Pyrexia Explanation: 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.
What pulse should the nurse recommend the client use for home monitoring?
Radial Explanation: The peripheral pulse is a throbbing sensation that can be palpated over a peripheral artery, such as the radial artery or the carotid artery. Peripheral pulses are palpable when blood is ejected as the left ventricle contracts and pumps blood into the vascular system. Peripheral pulses are easily accessible and recommended for home monitoring. The apical pulse can be monitored but requires the use of a stethoscope and the femoral and pedal pulses are not as easily palpated.
A pulse deficit is the difference between
The apical pulse and the radial pulse rate Explanation: When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate.
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 Explanation: An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. 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.
A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which of the following actions should the nurse perform in order to obtain the accurate temperature of the client?
Wait for 15 to 20 minutes before measuring the oral temperature Explanation: The nurse should wait for 15 to 20 minutes and then measure the oral temperature of the client because 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 and 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 because temperature may reflect the temperature of the water used during sponging. Friction used to dry the skin may also influence the temperature.
