vital signs

a nurse is instructing an AP for caring for a client who has low platelet count. which of the following instructions is the priority for measuring vital signs for this client?

" do not measure the client's temp rectally" rationale = high risk to bleed and injury rectally bc of low platelet

a nurse is performing admission assessment on a client. the rn determines the client's radial pulse is 68/min and the simultaneous apical pulse is 84/min. what is the client's pulse deficit.

16/min rationale = radial - apical = pulse deficit

a nurse is taking a client's vital sign. which of the following findings should the nurse identify as outside the expected reference range?

BP 145/90 mmHg

a nurse is measuring the BP of a client who has a fracturedfemur. the BP is 140/94mmHG, the client denies any hx of HTN. which of the following actions should nurse take first?

ask the client if they are having pain.

a nurse is performing a focused assessment of a client's peripheral vascular system. which of the following locations should the nurse palpate the posterior tibial pulse?

below the medial malleolus

" radial pulses 4+ bilaterally"

bounding = does not disappear w moderate pressure

a nurse is measuring a client's vital signs and notices an irregularity in the pulse. which of the following actions should the nurse take?

count the apical pulse rate for full 1 min and describe the rhythm in the chart

a nurse is assessing a client'e pulses of the lower extremities. the nurse should identify which of the following as the location of most distal pulse?

dorsalis pedis

a nurse is performing a physical assessment of a pt. the nurse should recognize that which of the following findings places the client at risk of impaired skin integrity?

faint pedal pulses rationale = faint pedal pulses can indicate poor circulation and tissue perfusion, which puts risk for impaired skin integrity

a nurse is measuring a client's vital signs. the client's resting radial pulse rate is 55/min. which of the following actions should the nurse take next?

measure the client's apical pulse rate rationale= should measure apical and radial pulse simultaneously to determine if there is any pulse deficit.

a nurse is caring for a client in the emergency department who has an oral body temperature of 38.3 (101 F),pulse 114/min and resp rate 22/min. the client is restless with warm skin. which of the following intervention should rn take?

obtain culture specimen before initiating antimicrobials = encourage the client rest and limit acitivity = assist the client with oral hygiene frequently

a nurse is caring for a client who has dysrhythmia. which of the following techniques should the nurse use to assess for a pulse deficit?

obtain the apical and radial rates simultaneously

a nurse is assessing client's peripheral pulses. which of the following descriptions should the nurse use to document the findings?

peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities

a nurse is instructing a grp of AP in measuring a client's resp rate. which of the following guidelines should the nurse include?

place client in semi fowler = have client rest an arm across the abdomen = observe one full resp cycle before counting the rate

a nurse is measuring a client's vital signs. the client's HR is 105/min the nurse should document this finding as which of the following alteration?

tachycardia

a nurse is planning to obtain the vital signs of a 2 yo who is experiencing diarrhea and may have right ear infection. which of the following routes should the nurse use to obtain the child's temp?

temporal

radial pulses 1 +

weak pulse