ATI Fundamentals Chapter 27: Vital Signs Questions
A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?
16/min The pulse deficit is the difference between the apical and radial pulse rates. It reflects the number of ineffective or nonperfusing heartbeats that do not transmit pulsations to peripheral pulse points. 84-68=16
A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client? a. "Do not measure the client's temperature rectally" b. "Count the client's radial pulse for 30 seconds and multiply it by 2." c. "Do not let the client know you are counting her respirations." d. "Let the client rest for 5 minutes before you measure her blood pressure."
a. "Do not measure the client's temperature rectally" The greatest risk to a client who has a low platelet count is an injury that results in bleeding. Using a thermometer rectally poses a risk of injury to the rectal mucosa. The low platelet count contraindicates the use of the rectal route for this client.
A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3 C (101 F), pulse rate 114/min, and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (select all that apply) a. obtain culture specimens before initiating antimicrobials b. restrict the client's oral fluid intake c. encourage the client to rest and limit activity d. allow the client to shiver to dispel excess heat e. assist the client with oral hygiene frequently
a. obtain culture specimens before initiating antimicrobials c. encourage the client to rest and limit activity e. assist the client with oral hygiene frequently The provider can prescribe cultures to identify any infectious organisms causing the fever. The nurse should obtain culture specimens before antimicrobial therapy to prevent interference with the detection of the infection. Rest helps conserve energy and decreases metabolic rate. Activity can increase heat production. Oral hygiene helps prevent cracking of dry mucous membranes of the mouth and lips.
A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply). a. place the client in Semi-fowler's position b. have the client rest an arm across the abdomen c. observe one full respiratory cycle before counting the rate d. count the rate for 30 sec if it is irregular e. count and report any sighs the client demonstrates
a. place the client in Semi-fowler's position b. have the client rest an arm across the abdomen c. observe one full respiratory cycle before counting the rate Having the client sit upright facilitates full ventilation and gives the students a clear view of the chest and abdominal movements With the client's arm across the abdomen or lower chest, it is easier for the students to see the respiratory movements Observing for one full respiratory cycle before starting to count assists the students in obtaining an accurate count. The students should count the rate for 1 min if its irregular An occasional sigh is an expected finding in adults and can assist to expand airways. Students do not need to count sighs.
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take first? a. request a prescription for an antihypertensive medication b. ask the client if she is having pain c. request a prescription for an antianxiety medication d. return in 30 min to recheck the client's blood pressure
b. ask the client if she is having any pain The first action the nurse should take using the nursing process is to assess the client for pain which can cause multiple complications, including elevated blood pressure. Therefore, the nurse's priority is to perform a pain assessment. If the client's blood pressure is still elevated after pain interventions, the nurse should report this finding to the provider.
