CH 25 Vital Signs-PrepU

Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"?

palpation of the radial pulse on the thumb side of the inner aspect of the wrist.

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

While recording the pulse of an infant at 160 beats/min, the parent asks if it is normal for the infant's pulse rate to be so high. Which statement by the nurse best answers the parent's question?

"A heart rate of 160 beats/min is normal for a healthy infant."

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

The nurse is caring for a newborn with bluish nails and lips, rapid respirations, sweating, and having difficulty feeding. Which considerations should the nurse use when assessing the blood pressure to screen for potential cardiac problems? Select all that apply.

Assess blood pressure in upper extremities. Assess blood pressure in lower extremities. If the diastolic blood pressure continues to "0," document as the reading/P for "pulse."

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.

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 registered nurse is collaborating in the care of several medical clients. Which tasks may the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply.

Assessment of a client's axillary temperature Assessment of a client's radial pulse

The surgical nurse is caring for four clients. Which tasks can the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply.

Attaining an admission weight for a client using a portable bed scale. Ambulating the client who is third day postoperative from right knee surgery. Documenting the urinary output of the client with a Foley catheter.

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

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.

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?

Auscultate the lung sounds and count respirations.

Which peripheral pulse site is generally used in emergency situations?

Carotid

Which statement describes diastolic blood pressure?

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.

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

Which term indicates a potentially serious client condition?

Pyrexia (raised body temperature)

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

Radial

The nurse prepares to take a temperature of a client admitted with a myocardial infarction. The client is eating breakfast. Which action should the nurse choose?

Take the temperature the axillary route

A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify?

The client's most recent temperature

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.

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

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

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

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.

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

The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:

Increased temperature.

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.

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."

A nurse is assessing a client's blood pressure manually. The nurse should identify the client's systolic blood pressure (SBP) when which event occurs?

The first faint, but clear, sound appears.

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 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 client is self-monitoring blood pressure at home and reports that every reading is 150/90 mmHg. What is the priority nursing intervention?

ask the client to demonstrate self-blood pressure assessment

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

elevating the client's arm at heart level

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

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."

The nurse is taking the apical pulse of a 6-month-old infant. Upon completion, the nurse tells the parent the baby's pulse is 140 beats per minute. The parent is concerned, stating, "That seems kind of high!" The nurse responds:

"I know it seems fast, but normal infant heart rates are 100-160 beats per minute."

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

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

A nurse is assessing the respiratory rate of a sleeping 28-day-old infant. What would the nurse document as a normal finding?

30 to 60 breaths/min

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

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.

When assessing a client's radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next?

Auscultate the apical pulse for 60 seconds

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.

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.

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.

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

Provide privacy for the client.

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.

A nurse needs to assess the temperature of a client with high fever. Which site will most closely reflect core body temperature of the client?

Rectum

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.

Which are considered vital signs? Select all that apply.

Temperature, pulse, respiratory rate, and blood pressure.

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 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 just finished ambulating with physical therapy The client has reports of pain of 8 on a scale of 0 to 10 The client has a temperature of 101.8°F (38.8°C)

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.

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

A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which action should the nurse perform to obtain the accurate temperature of the client?

Wait for 30 minutes before measuring the oral temperature

Which client would the nurse consider at risk for low blood pressure?

a client with low blood volume

The nurse is assessing a client's blood pressure and is having difficulty hearing Korotkoff sounds. What is the most appropriate nursing action?

ask the client to make a fist after cuff inflation

An ultrasonic Doppler is used for:

auscultating a pulse that is difficult to palpate.

The community nurse working at a community health fair is assessing a client's vital signs at rest. Which finding requires nursing intervention?

blood pressure 180/90 mmHg

A nursing student is assessing blood pressure in an adult client. Which action by the nursing student would require intervention from the nursing instructor?

pumping the blood pressure cuff up to 200 mmHg routinely

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

Infants' and children's pulses vary most with:

respirations.