vitals chp 25 prepU

A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?

"Dizziness when you change position can occur when fluid volume in the body is decreased." 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.

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?

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.

The nurse is performing vital signs for several clients. When assessing body temperature, what should the nurse take into consideration? Select all that apply.

An oral temperature may be taken if the client has oxygen by nasal cannula. Tympanic temperature readings closely reflect core body temperature. Temporal artery thermometer readings may be affected by perspiration or air blowing over Temperatures should not be taken orally in infants due to the inaccuracy of the reading and the potential damage to the mucous membranes. Nasal oxygen is not thought to affect oral temperature readings. Do not assess oral temperatures in patients receiving oxygen by mask. Tympanic temperature readings are closely reflective of core body temperature. Temporal artery thermometer readings may be affected by perspiration or air blowing over the face. A temperature may be delegated to unlicensed assistive personnel, but the RN will be responsible for any complications or the assessment.

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.

Applying too wide a cuff Releasing the valve rapidly Using cracked or kinked tubing 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.

The nurse needs to obtain an admission weight for a client diagnosed with end-stage lung cancer. To obtain the client's weight, what should the nurse do first?

Assess the client's ability to stand or sit. The nurse must first assess the client's ability to sit, stand, or lie still to identify the appropriate type of scale to use. Evaluating pain or presence of lines would be done after identifying the type of scale to use. If a portable bed scale is indicated, the nurse would place a cover over the sling of the bed scale.

Which client should not have a temperature assessed rectally?

Client with diarrhea The rectal route is contraindicated in clients with diarrhea, those who have undergone rectal surgery, those with rectal diseases, and those with cancer who are neutropenic. pg652

A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?

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.

When assessing an adult client's pulse at 125 beats/min, which step would the nurse take first to determine intervention?

Determine cause Following the assessment of the pulse of 125 beats/min, the nurse would first determine the cause which will lead to determining an appropriate intervention. Anxiety, medications, caffeine, and other stimulants and disorders can cause tachycardia. The nurse will also need to check the quality of the pulse to determine regularity, but this would be included in assessing for causes and interventions. The nurse also will check the client's blood pressure, temperature, and pain level because an increase in any of these can be correlated with increased pulse, but again not what should be done first. While assessing a history of heart disease is important, this is not a first step alone and should be included in a full interview upon client intake and triage.

During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant.

During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant. Careful insertion is expected during a rectal temperature procedure. Lubrication of the tip of the thermometer probe is necessary.

A client has smoked most of his life and has labored respirations. He is experiencing:

Dyspnea describes respirations that require excessive effort.

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

Dyspneic people can often breathe more easily in an upright position, a condition known as orthopnea, because sitting or standing allows gravity to lower organs from the abdominal cavity away from the diaphragm. Bradypnea is a decrease in respiratory rate. Tachypnea is an increased respiratory rate. Apnea refers to periods during which there is no breathing.

An overweight, middle-aged client presents with a 15-year history of hypertension. Which health strategy(ies) will the nurse teach this client? Select all that apply.

Eat a low-fat, low-sodium diet Engage in regular aerobic activity at least 5 times per week Avoid fast food venues Engage in muscle strengthening exercises at least 2 times each week A healthy diet low in fats, cholesterol, salt, and sugar and high in fiber helps fight cardiovascular disease. Salt plays a large role in cardiovascular health and a diet that is high in salt can increase blood volume and cardiac output and thus aggravate chronic hypertension or heart failure. Fiber and whole grains are important elements of cardiovascular health, and a diet high, not low, in fiber has been linked to heart health since it helps reduce blood cholesterol. Heart health associations recommends that individuals between the ages of 18 and 65 years engage in aerobic activity of moderate intensity for a duration of 30 minutes five times a week. Adults should also maintain muscle strength by engaging the muscles of the body in activity at least twice a week.

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?

HBPM readings are the ideal method for monitoring response to treatment for high BP. This client's average BP after not taking her medication is 138/87 and is not 10 more than what her HBPM reading has been. Clients should be taught when performing HBPM that they should call the health care provider if the averages of HBPM readings increase/decrease by 10, or if she has any concerns. The client should not be told to take double the dose of medication or to take the doses she missed; this is unsafe advice without consulting a health care provider.

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?

If a radial pulse is difficult to assess accurately because it is irregular, feeble, or extremely rapid, the nurse would need to assess the apical pulse rate. By assessing the apical rate the nurse can hear the rate instead of trying to feel the rate. Assessing the carotid pulse would also be done through touch, so the outcome would be the same and not accurate. If the nurse is concerned about the client, it does not hurt to have another nurse check the pulse, but the nurse should assess the apical pulse first. The findings should be documented, but only after all assessments have been completed.

The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct?

Lightly compress the client's radial artery using the first, second, and third fingers. The radial artery is the most common place to assess a peripheral pulse on an adult. The fingertips are sufficiently sensitive to palpate arterial pulsations using light compression and thus should be used, not the thumbs. The first, second, and third fingers of one hand are used to assess peripheral pulse, not the first fingers of each hand. Take care to avoid completely compressing the artery.

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?

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 physician 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 physician's order.

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 artery. 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.

An 80-year-old client has a body temperature of 97°F (36°C). Which condition best accounts for this client's temperature reading?

It is common for older adults to have body temperatures less than 97°F (36°C), because normal temperature drops as a person ages.

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

No stethoscope is required. An electronic manometer eliminates the need for a stethoscope. However, an electronic manometer requires a calibration check and readjustment every 6 months, unlike a mercury manometer which does not require readjustment. An electronic manometer is expensive depending on quality when compared to an aneroid manometer. A nurse can read the gauge of an aneroid manometer, not an electronic manometer, from any direction.

Which pulse site should the nurse recommend the client use for home monitoring?

Radial 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. The femoral and pedal pulses are not as easily palpated.

The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention?

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.

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?

Risk for falls related to inadequate physiologic response to postural (positional) changes 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.

After taking vital signs of an older adult, the nurse writes down findings as T = 98.9/37.2 oral, P = 104, R = 18, BP = 130/82. Based on the collected data, which step would the nurse take next?

Take pulse again to assess for tachycardia Normal ranges of vital signs for older adults are as follows: Pulse 60 to 100 beats/min, Respiration 12 to 20 breaths/min, Temperature 95°F to 99°F (35°C to 37.5°C), Blood pressure 90 to130/60 to 80 mm Hg. Reassessing pulse would be justified to determine if there is a tachycardia issue or if the client has situational anxiety, etc. that may affect the pulse rate. Talking with the client to help the client relax is a common practice, but not warranted in this situation. The oral temperature is within normal limits so there is not need to retake it.

Which peripheral pulse site is generally used in emergency situations?

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.

When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. Which statement explains this order?

The client's pulse rate is below 60 beats per minute. An abnormally slow pulse rate is called bradycardia. In adults, a pulse rate below 60 beats per minute is considered bradycardic. The normal respiratory rate is 12 to 24 breaths per minute. A client with a systolic blood pressure less than 100 mm Hg would be hypotensive as the normal systolic blood pressure is less than 140 mm Hg. Bradycardia is not associated with a client having to sit upright when the blood pressure is checked.

A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?

The nurse should measure the blood pressure over the client's thigh or the popliteal artery behind the knee. It is inadvisable following a mastectomy to assess blood pressure at the normal site, which is over the brachial artery at the inner aspect of the elbow. In normal cases, the blood pressure may also be assessed at the lower arm and radial artery.

A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature?

The rectal temperature, a core temperature, is considered to be one of the most accurate routes. pg 652

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. 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.

Which are considered vital signs? Select all that apply.

Vital signs consist of temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation. Pain is considered the sixth vital sign that a nurse should assess. Weight and allergies are other assessment parameters but are not part of the vital signs. pg669

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?

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. Do NOT put it in the inferior buccal space on either side of the tongue. doesnt take accurate reading...

Clients demonstrating apnea have what?

a temporary cessation of breathing Apnea, the absence of respirations, is often described by the length of time in which respirations do not occur.

The nurse assesses that a client is shivering. Which intervention is most appropriate to prevent further stress on the body?

applying a blanket Covering prevents heat loss, and the shivering will not stop until the hypothalamus readjusts to a higher set point. A cooling blanket will make the shivering worse, because it will make the client feel cold. Raising the room temperature warms the body surface and is only appropriate for subnormal temperatures. Warm fluids conduct heat to internal organs and this client is febrile; the goal is to reduce to heat.

An ultrasonic Doppler is used for:

auscultating a pulse that is difficult to palpate. A Doppler device can be used to detect a pulse that is not easily palpable.

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. Certain cardiac medications, such as digoxin, decrease the heart rate. pg 655-656

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

orthopnea Dyspneic people can often breathe more easily in an upright position, a condition known as orthopnea, because sitting or standing allows gravity to lower organs from the abdominal cavity away from the diaphragm. Bradypnea is a decrease in respiratory rate. Tachypnea is an increased respiratory rate. Apnea refers to periods during which there is no breathing.

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 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. pg659

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 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.

A pulse deficit is the difference between:

the apical pulse and the radial pulse rates. When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate.