Ch. 25: Vital Signs (PrepU)

The nurse instructs a mother of young children how to properly use a nonmercury glass thermometer. Which statement made by the client indicates a need for further instruction?

"I will clean the thermometer in the dishwasher."

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."

When taking the client's temperature, the student nurse will require further education when they state:

"The axillary route is the most accurate of all routes."

The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that would explain the tachycardia? Select all that apply.

- The client has reports of pain of 8 on a scale of 0 to 10 -the client just finished ambulating w/ physical therapy -the client has a temp of 101.8 F (38.8 C)

The nurse is caring for several clients on a telemetry unit. Which client(s) requires the nurse to assess the pulse rate need for 1 full minute? Select all that apply.

-A client with a pulse rate of 38 beats/min. -A client diagnosed with a arrhythmia. -A client with a pulse rate of 130 beats/min.

While assessing for orthostatic hypotension, the nurse follows which step(s) when taking the blood pressure? Select all that apply.

-Check and record blood pressure taken while the client is in the bed. -Assist client to standing position and wait 2 to 3 minutes before taking blood pressure. -Record measurements and note if the drop is ≥20 mm Hg systolic and ≥10 mm Hg diastolic. -Use the same blood pressure cuff the whole time.

The nurse is preparing to measure a child's temperature with a temporal artery thermometer. For which reason(s) would the nurse choose this method of obtaining temperature in this client? Select all that apply.

-Children often cannot keep lips closed tight enough to capture a true reading. -Temporal temperature is close to oral temperature readings. -Research states temporal thermometers are more accurate. -There is a built-in verification of temperature by touching behind the ear.

The nurse is preparing to measure a client's rectal temperature. Which supplies and equipment should the nurse have available before beginning the procedure? Select all that apply.

-an electronic thermometer with a rectal probe -disposable probe cover -water-soluble lubricating gel

The nurse has assessed a pulse deficit when taking the pulse of a client. What does this assessment indicate for the client? Select all that apply.

-the difference between apical and peripheral pulse rate -The apical pulse is higher than the radial pulse. -The health care provider should be notified of any increase in pulse deficit.

The nurse is preparing to measure an adult's orthostatic blood pressure. Place the following steps of the procedure in the correct order. Use all options.

1) Assist the client into a supine position. 2) Wait 3 to 10 minutes, then measure the client's blood pressure. 3) Assist the client to the sitting position with legs dangling. 4) Wait 1 to 3 minutes, then measure the client's blood pressure. 5) Assist the client to a standing position. 6) Wait 2 to 3 minutes, then measure the client's blood pressure.

The nurse has requested the unlicensed assistive personnel (UAP) check the temperature of a 19-month-old client who has been admitted for pneumonia. Which reading should the nurse question if noted in the record?

102.4°F/39.1°C (T)

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

1700

When assessing an infant's axillary temperature, it will be:

1°F (0.5°C) lower than an oral temperature.

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 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.

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.

While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute. How will the nurse interpret this finding?

Bradypnea is a response to IICP.

The nurse is assessing the client's blood pressure (BP) and heart rate (HR) for orthostatic hypotension. In which step should this nurse intervene because of potential danger?

Client stands at bedside, becomes pale, diaphoretic.

The nurse notes that the temperature of an ill client is 101°F (38.3°C). Which intervention would the nurse take to regulate the client's body temperature?

Give the client a bath in tepid water.

During a routine vital sign assessment, the nurse notes that the client's blood pressure is 212/110 mm Hg. Which is the nurse's next action?

Have the client rest for 5 minutes, then retake the blood pressure.

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 or radial artery.

A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff?

Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared.

A client monitoring his BP at home notices that his BP is higher in one arm than the other. He calls his health care provider for guidance. What is the most appropriate information for the nurse to give this client?

It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results.

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.

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.

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?

Over the client's thigh

A nurse is using a hypothermia blanket as ordered on an adult client with an uncontrolled fever. Which statement accurately describes the safe and effective use of this type of equipment?

Position the blanket under the client so that the top edge of the pad is aligned w/ the client's neck

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

Provide privacy for the client.

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 51 beats/min

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.

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.

A client who has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong?

She should place her three fingers just below the wrist on the outside of the arm with the palm up.

The nurse assesses a client admitted with multiple trauma including basilar skull fracture and rhinorrhea (drainage from nose), bilateral otorrhea (drainage from ear), and multiple fractures requiring a full body cast. The client is on a 40% Venturi oxygen mask. What is the best way to evaluate the client's temperature?

Temporal artery

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.

The client's pulse rate is below 60 beats per minute.

The client's pulse rate is below 60 beats per minute.

The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate?

The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse.

A nurse is explaining to a nursing student why blood pressure is a frequently used assessment parameter in a wide variety of care settings. What can be inferred from an assessment of a client's blood pressure?

The resistance that the client's heart must overcome when pumping blood

Which client's blood pressure best describes the condition called hypotension?

The systolic reading is below 100 and diastolic reading is below 60.

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.

Which statement describes diastolic blood pressure?

To assess diastolic pressure, the blood pressure measured during vernacular contraction

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?

To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns.

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.

The nurse is trying to obtain a temperature and the client continues to bite down on the oral thermometer. The nurse determines a rectal thermometer should be used. What actions demonstrates the nurse's understanding of the client's well-being and safety during this procedure?

Using a digital thermometer, the nurse inserts the covered, lubricated probe 1.5 in (3.75 cm) into the rectum for 1 minute.

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 dysrhythmia. 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

Which pulse site is generally used in emergency situations?

carotid

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 a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:

decrease the apical pulse.

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?

deep in the posterior sublingual pocket

Which is not a characteristic used to describe the pulse?

depth

The nurse is assessing the pulse amplitude for a client. Documentation by the nurse states, "Pulses are +1 in the lower left extremity." What amplitude is the nurse assessing?

diminished, weaker than expected

The nurse is caring for a client who has smoked for more than 20 years and is now experiencing labored respirations. The nurse documents the client is experiencing:

dyspnea.

The nurse is caring for a 72-year-old client who has a history of asthma and hypertension and recently had some medication changes. Which action should the nurse prioritize after noting the client has a diminished appetite with reports of nausea as well as dizziness upon standing?

evaluate new cardiovascular medications

The nurse knows that a client who is being taught to perform home blood pressure monitoring (HBPM) understands the teaching plan when he makes which statement about the size of the BP cuff? The cuff should:

fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow.

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?

listen with the stethoscope at the fifth intercostal space left mid-clavicular line

The nurse undrestands that accurate blood pressure taking is dependent on several factors. Which example will most likely render an accurate blood pressure reading?

placing the client's arm at heart level

A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing?

prodromal

Which term indicates a potentially serious client condition?

pyrexia

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

rectum

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

A pulse deficit is the difference between:

the apical and the radial pulse rates.

The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8 F (37.1 C). Which statement could explain this?

the client is covered with a couple of thick blankets

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