chapter 25 vital signs prep u practice questions

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."

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

1700 5 pm

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

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

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.

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 statement describes diastolic blood pressure?

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

The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next?

Inflate the cuff about 30 mm Hg above the auscultatory gap.

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 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 preparing the client to use the hypothermia blanket. How does the nurse measure the client's temperature while the blanket is in use?

Rectal probe continuously

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

a client with low blood volume

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

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 apical pulse

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.

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

increased temperatures

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 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?

rectum

A pulse deficit is the difference between

the apical pulse and the radial pulse rates.

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.

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