Chapter 25- Vital Signs Prep U
What instructions should be provided to a newly diagnosed hypertensive client about home blood pressure monitoring? Select all that apply. 1. Use a validated monitor with an automatic inflation cuff. 2. The proper sized cuff should fit very snugly; there should be no room to place a finger under the cuff. 3. Take three measurements and average together. 4. Take your BP after you eat when you are sitting down. 5. Rest 3 to 5 minutes before taking your BP.
1, 3, and 5 are correct
The nurse must assess a client's systolic blood pressure using a Doppler ultrasound. What are the following steps to the procedure?
1. Center the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. 2. Wrap the cuff around the limb smoothly and snugly, and fasten it. 3. Place a small amount of conducting gel over the artery. 4. Place the Doppler tip in the gel and move it around until hearing the pulse. 5. Inflate the cuff while continuing to use the Doppler device on the artery. 6. Note the point on the gauge where the pulse disappears.
A nurse is assessing clients in the emergency department for body temperature. Which nursing actions reflect proper technique when assessing body temperature by various methods? Select all that apply. 1. When assessing axillary temperature using a glass thermometer, place the bulb at the edge of the axilla and bring the client's arm down close to the body. Leave the thermometer in place for 3 minutes. 2. When assessing temperature with an electronic thermometer, hold the thermometer in place in the assessment site until a beep is heard. 3. Note the assessment site used because axillary temperatures are generally about 1°F (0.5°C) more than oral temperatures and rectal temperatures are generally about 1°F (0.5°C) less than oral temperatures. 4. When assessing an oral temperature with an electronic thermometer, place the probe beneath the client's tongue in the posterior sublingual pocket. 5. When assessing rectal temperature with an electronic thermometer, lubricate about 1 in (2.5 cm) of the probe with a water-soluble lubricant. 6. When assessing tympanic membrane temperature, wipe the tympanic probe cover with alcohol before inserting it snugly into the ear
2, 4, and 5 are correct
TRUE OR FALSE: A person's core body temperature is highest in the early morning and lowest in the late afternoon.
FALSE
TRUE OR FALSE: 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.
TRUE
The nurse has just measured an adult client's oral temperature and obtained a result of 102.4ºF (39.1ºC). The client states, "I just finished my coffee right before you came in. Can I have another cup?" Which response by the nurse is most appropriate? a. "I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return." b. "Before you drink another hot beverage, drink some cool water so I can obtain an accurate oral temperature." c. "I'll be right back with your coffee and a different thermometer. I'm not sure this one measured your temperature correctly." d. "You will need to remain NPO until I notify your health care provider about your increased temperature."
a. "I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return."
When assessing an infant's axillary temperature, it will be: a. 1°F (0.5°C) lower than an oral temperature. b. the same as the tympanic temperature. c. 1°F (0.5°C) higher than a rectal temperature. d. 1°F (0.5°C) higher than an oral temperature.
a. 1°F (0.5°C) lower than an oral temperature.
The normal adult temperature obtained through the oral route ranges from: a. 97.6°F to 99.6°F (36.4°C to 37.6°C). b. 96.6°F to 98.6°F (35.9°C to 37.0°C). c. 98.6°F to 100.4°F (37.0°C to 38.0°C). d. 98.2°F to 100.2°F (36.8°C to 37.9°C).
a. 97.6°F to 99.6°F (36.4°C to 37.6°C).
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? a. Bradypnea is a response to IICP. b. IICP most commonly results in tachypnea. c. This is a normal respiratory rate. d. Bradypnea is uncommon in a client with IICP.
a. 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? a. Client stands at bedside, becomes pale, diaphoretic. b. Client sitting at edge of bed, feet dangling for 3 minutes; asymptomatic c. Client in supine position for 3 minutes and BP 120/70; HR 70; asymptomatic. d. After 3 minutes of sitting, BP 100/50; HR 90.
a. Client stands at bedside, becomes pale, diaphoretic.
Which statement describes diastolic blood pressure? a. During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. b. The flow of blood is produced by contractions of the heart and by the resistance to blood flow through the vessels. c. The pressure is highest when the ventricles of the heart eject blood into the aorta and pulmonary arteries. d. To assess diastolic pressure, the blood pressure measured during ventricular contraction.
a. During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.
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? a. She should place her three fingers just below the wrist on the outside of the arm with the palm up. b. She needs to take her pulse after her medication so that her pulse is stronger. c. She should stand when taking her pulse to increase blood flow. d. She needs to press harder until she feels a pulse.
a. She should place her three fingers just below the wrist on the outside of the arm with the palm up.
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? a. The first faint, but clear, sound appears. b. The initial Korotkoff sounds peak in intensity. c. The first audible sounds cease to be distinct. d. The first audible sounds begin to decrease in intensity.
a. The first faint, but clear, sound appears.
Clients demonstrating apnea have what? a. a temporary cessation of breathing b. normal respiratory rate of 20 c. decreased rate and depth of respirations d. increased rate and depth of respirations
a. 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? a. apical b. brachial c. carotid d. radial
a. apical
An ultrasonic Doppler is used for: a. auscultating a pulse that is difficult to palpate. b. aiding palpation of pulse and rhythm. c. aiding palpation of diastolic blood pressure. d. auscultating diastolic blood pressure.
a. auscultating a pulse that is difficult to palpate.
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? a. deep in the posterior sublingual pocket b. superior to the tongue, with the tip touching the hard palate c. in the inferior buccal space on either side of the tongue d. along either upper gum line, adjacent to an incisor
a. 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: a. orthopnea b. bradypnea c. apnea d. tachypnea
a. orthopnea
Assessment of the pulse amplitude is accomplished by: a. palpating the flow of blood through an artery. b. auscultating the flow of blood through an artery. c. auscultating the area of the left ventricle. d. palpating the area of the left ventricle.
a. palpating the flow of blood through an artery.
Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"? a. palpation of the radial pulse on the thumb side of the inner aspect of the wrist. b. light palpation of the femoral pulse below the inguinal area c. firm placement of thumb on the inner wrist of the opposite arm d. firm palpation of bilateral carotid artery for one minute
a. palpation of the radial pulse on the thumb side of the inner aspect of the wrist.
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? a. the ability of the arteries to stretch b. the oxygen levels in the blood c. the volume of air entering the lungs d. the thickness of circulating blood
a. the ability of the arteries to stretch
The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg/ What should the nurse do next? a. use the Doppler ultrasound device b. connect the client to the oxygen saturation monitoring device c. ask another student nurse to check it for him d. use the bell side of the stethoscope to listen
a. use the Doppler ultrasound device
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. - Research states temporal thermometers are more accurate. - Children often cannot keep lips closed tight enough to capture a true reading. - The procedure is less invasive and does not have to touch the skin. - Temporal temperature is close to oral temperature readings. - There is a built-in verification of temperature by touching behind the ear.
all except the procedure is less invasive and does not have to touch the skin
A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client? a. "Dizziness can occur due to changes in the hospital environment." b. "Dizziness when you change position can occur when fluid volume in the body is decreased." c. "Dizziness is caused by very low blood pressure when you lie down." d. "Dizziness can occur when baroreceptors overreact to the changes in BP."
b. "Dizziness when you change position can occur when fluid volume in the body is decreased."
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? a. Evaluate the client's level of pain. b. Assess the client's ability to stand or sit. c. Place a cover over the sling of the bed scale. d. Monitor for the presence of tubes or lines.
b. Assess the client's ability to stand or sit.
When assessing an adult client's pulse at 125 beats/min, which step would the nurse take first to determine intervention? a. Assess for history of heart disease b. Determine cause c. Evaluate pulse rate quality d. Evaluate blood pressure
b. Determine cause
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? a. Need for readjustment is eliminated. b. No stethoscope is required. c. Inexpensive depending on quality. d. Ability to read gauge from any direction.
b. No stethoscope is required.
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? a. A rectal thermometer must be used. b. The client is covered with a couple of thick blankets. c. The thermometer is broken. d. The client is showing initial signs of infection.
b. The client is covered with a couple of thick blankets.
Which client's blood pressure best describes the condition called hypotension? a. The systolic reading is below 120 and the diastolic reading is below 80. b. The systolic reading is below 100 and diastolic reading is below 60. c. The systolic reading is above 102 and diastolic reading is above 60. d. The systolic reading is above 110 and diastolic reading is above 80.
b. The systolic reading is below 100 and diastolic reading is below 60.
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 from 124/82 to 102/70. She called the nurse concerned about her BP. What is the most appropriate information for the nurse to give this client? a. You should not lay down for a nap during the day to prevent your BP from dropping. b. You may have orthostatic hypotension and should be seen by your health care provider as soon as you can. c. This is called hypotension and may be caused by your medications. d. You should change the batteries in your BP monitor.
b. You may have orthostatic hypotension and should be seen by your health care provider as soon as you can.
A nurse is assessing the blood pressure of an adult client using the Korotkoff sounds technique to document the measurement. Which phase of Korotkoff sounds will the nurse use to document blood pressure measurements in the client? a. phase II b. phase IV c. phase III d. phase I
b. phase IV
Which term indicates a potentially serious client condition? a. pulse pressure b. pyrexia c. eupnea d. afebrile
b. pyrexia
A pulse deficit is the difference between: a. the radial pulse and the ulnar pulse rates b. the apical pulse and the radial pulse rates c. palpated and auscultated blood pressure readings d. the systolic and diastolic blood pressure readings
b. the apical pulse and the radial pulse rates
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: a. "Yes, this is termed tachypnea. I will let the doctor know right away." b. "Yes, this is termed tachycardia. I will let the doctor know right away." c. "I know it seems fast, but normal infant heart rates are 100-160 beats per minute." d. "Yes, it seems fast but actually, normal infant heart rates are 150-200 beats per minute so it is a bit slow."
c. "I know it seems fast, but normal infant heart rates are 100-160 beats per minute."
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? a. 224 mmHg b. 112 mmHg c. 40 mmHg d. 132 mmHg
c. 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? a. Palpate the posterior thorax excursion, count respirations for 30 seconds, and multiply by 2. b. Use a pulse oximeter to count the respirations for 1 minute. c. Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2. d. Monitor arterial blood gas results for 1 minute.
c. 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? a. Page the client's primary care provider. b. Palpate the radial pulse on the opposite wrist. c. Auscultate the client's apical heart rate. d. Reassess the client's radial pulse in 15 minutes.
c. Auscultate the client's apical heart rate.
the correct way of inflating the blood pressure cuff? a. Fully inflate cuff for about 1 minute. b. Elevate arm above heart level before inflating the cuff. c. Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared. d. Place cuff 8 cm above the elbow.
c. Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared.
The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention? a. Maintain probe position in rectum for 2 minutes. b. Insert the thermometer 0.5 in (1.25 cm) into the rectum. c. Provide privacy for the client. d. Position the client on the stomach.
c. Provide privacy for the client.
An 80-year-old client has a body temperature of 97°F (36°C). Which condition best accounts for this client's temperature reading? a. hypothyroidism b. anemia c. advanced age d. altered endocrine function
c. advanced age
When assessing a client's respiratory rate, the nurse should take which action? a. ask the client to breathe deeply b. count the number of respirations for 10 seconds c. do it immediately after the pulse assessment so the client is unaware of it d. remind the client to breathe normally
c. do it immediately after the pulse assessment so the client is unaware of it
Which condition will lead to an increase in cardiac output? a. dehydration b. decrease in blood pressure c. exercise d. sleep
c. exercise
A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs? a. according to medical orders b. every 4 hours c. immediately d. once per day
c. immediately
A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods? a. listen with a stethoscope at the second intercostal space left sternum b. listen with a stethoscope at the neck to the right of the coracoid process c. listen with the stethoscope at the fifth intercostal space left mid-clavicular line d. listen with the stethoscope at the fifth intercostal space at the sternum
c. listen with the stethoscope at the fifth intercostal space left mid-clavicular line
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? a. the parents will not be able to check the pulse accurately; the nurse will need to do home health checks on this infant on a periodic basis b. the infant will need a home cardiac monitor set up c. the parents will have to be taught how to use a stethoscope so they can listen to and count the infant's apical pulse d. the parents should be encouraged to get neighbor or family member to help them check their infant's pulse
c. the parents will have to be taught how to use a stethoscope so 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? a. there is nonauscultatory gap b. there is an adult diastolic pressure c. there is an auscultatory gap d. there is a widening in the diameter of the artery
c. there is an auscultatory gap
A nurse is assessing an adult client's blood pressure. How should the nurse estimate the client's systolic blood pressure (SBP)? a. Simultaneously compare the amplitude of the client's left and right radial pulses. b. Note the SBP that was documented during the client's last vital signs assessment. c. Palpate the client's brachial pulse while having the client slowly raise his or her arm. d. Inflate the blood pressure cuff while palpating the client's brachial artery.
d. Inflate the blood pressure cuff while palpating the client's brachial artery.
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? a. Count each "lub-dub" as two beats. b. Palpate the space between the fifth and sixth ribs. c. Count the heartbeat for 2 minutes. d. Listen for heart sounds.
d. Listen for heart sounds.
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? a. Leave the thermometer in and notify the physician. b. Remove the thermometer and assess the temperature via another method. c. Call for assistance and anticipate the need for CPR. d. Remove the thermometer and assess the blood pressure and heart rate.
d. Remove the thermometer and assess the blood pressure and heart rate.
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will: a. decrease the blood glucose. b. decrease the respiratory rate. c. decrease the blood volume. d. decrease the apical pulse.
d. 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: a. decreased respirations. b. increased cardiac output. c. decreased heart rate. d. increased temperature.
d. increased temperature.
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? a. brachial artery b. over the lower arm c. radial artery d. over the client's thigh
d. over the client's thigh
When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. What statement explains this order? a. the client's respiratory rate is less than 18 breaths per minute b. the client's systolic blood pressure is less than 100mm Hg c. the client is unable to stay upright when blood pressure is checked d. the client's pulse rate is below 60 beats per minute
d. the client's pulse rate is below 60 beats per minute
During the time a client is on a hypothermia blanket, the nurse turns and positions the client every 30 to 60 minutes. What assessments will the nurse complete on each turn? Select all that apply. - Lip and nail bed changes - Neurological assessment - Facial muscle twitching - Sensory impairment - Skin color change
lip and nail bed changes, sensory impairment, and skin color change
Which are considered vital signs? Select all that apply. - weight - pulse - allergies - blood pressure - temperature - respiratory rate
pulse, blood pressure, temperature, respiratory rate
