Craven Ch 19: Vital Signs

A client is diagnosed with bradycardia. For which symptom should the nurse assess first? - Dizziness - Hypertension - Heart palpitations - Pyrexia

- Dizziness Explanation: Bradycardia is a slow heart rate. In many cases, bradycardia is asymptomatic. However, symptoms may include syncope, dizziness, light-headedness, chest pain, shortness of breath and exercise intolerance. Fever, hypertension and pyrexia are not symptoms of bradycardia.

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 lower arm - Brachial artery - Over the client's thigh - Radial artery

- Over the client's thigh Explanation: The nurse should measure the blood pressure over the client's thigh or the popliteal artery behind the knee. It is inadvisable following a mastectomy to assess blood pressure at the normal site, which is over the brachial artery at the inner aspect of the elbow. In normal cases, the blood pressure may also be assessed at the lower arm and radial artery.

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure? - The blood pressure does not change. - The blood pressure is erratic. - The blood pressure decreases. - The blood pressure increases.

- The blood pressure increases. Explanation: The elasticity and resistance of the walls of the arterioles help to maintain normal blood pressure. With aging, the walls of arterioles become less elastic, which interferes with their ability to stretch and dilate, contributing to a rising pressure within the vascular system. This is reflected in an increased blood pressure. The blood pressure is not erratic or low due to the change in the elasticity and resistance.

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 bpm. The nurse notifies the health care provider because the client is exhibiting signs of: - a dysrhythmia. - tachycardia. - bradycardia. - hypertension.

- a dysrhythmia. Explanation: An irregular pattern of heartbeats is called a dysrhythmia. Tachycardia is an increased heart rate of 100 to 180 bpm. Bradycardia is a pulse rate below 60 bpm. The normal pulse rate ranges from 60 to 100 bpm. Hypertension is a blood pressure that is above normal for a sustained period.

Which is not a characteristic used to describe the pulse? - frequency - quality - depth - rhythm

- depth Explanation: Rate or frequency refers to the number of pulsations per minute. Rhythm refers to the regularity with which pulsation occurs. Quality refers to the strength of the palpated pulsation.

A nurse palpates the pulse of a client and documents the following: 6/6/23 pulse 85 and regular, +3, and equal in radial, popliteal, and dorsalis pedis. What does the number +3 represent? - pulse rate - pulse amplitude - pulse rhythm - pulse deficit

- pulse amplitude Explanation: Pulse amplitude or strength describes the quality of the pulse in terms of its fullness, ranging from absent (0) to bounding (+3). Pulse rates are measured in beats per minute. Pulse rhythm is the pattern of the pulsations and the pauses between them. The pulse deficit is the difference between the apical and radial pulse rates.

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." - "A heart rate of 160 beats/min is a little too fast for an infant, so I will take it again in 5 minutes." - "A heart rate of 160 beats/min is actually slow for an infant, so I will ask the health care provider to reassess." - "Every infant's heart rate is different, so you will need to discuss that with the health care provider."

- "A heart rate of 160 beats/min is normal for a healthy infant." Explanation: The average pulse rate of an infant ranges from 100 to 160 beats/min. There is no need to refer the parent to the health care provider for an answer.

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." - "Dizziness can occur due to changes in the hospital environment." - "Dizziness can occur when baroreceptors overreact to the changes in BP." - "Dizziness is caused by very low blood pressure when you lie down."

- "Dizziness when you change position can occur when fluid volume in the body is decreased." Explanation: Dehydration is a cause for orthostatic hypotension, which causes a temporary drop in BP when the client rises from a reclining position. Dizziness is not associated with environmental changes. Dizziness or changes in orthostatic BP occurs when baroreceptors do not respond quickly enough to restore adequate circulation to the brain. Dizziness may be caused by low blood pressure. However, the client is dizzy with ambulation not when lying down.

A nurse is educating a postoperative adult client about taking daily temperatures. What statement by the client best indicates understanding of education? - "It is okay to take my temperature by mouth right after eating or drinking as long as it is not coffee." - "If my temperature is above 99.6°F( 38.3°C) I should call the health care provider." - "I will use my axillary thermometer because it is convenient and accurate postoperatively." - "I will use an ear thermometer because it is most accurate in postoperative clients."

- "If my temperature is above 99.6°F( 38.3°C) I should call the health care provider." Explanation: Normal temperatures for an adult range from 97.6°F and 99.6°F (36.5°C and 37.5°C) and a temperature above this should be reported. Taking a temperature right after eating or drinking may raise or lower the reading depending on what was consumed. The axillary route is considered the least accurate route. While a tympanic thermometer may be more accurate in some cases, it is not an accurate method for self-administration of temperature or for postoperative monitoring.

A nurse is obtaining an oral temperature on a client, using an electronic thermometer. The client notes having an electronic thermometer at home and asks how to care for it. Which response is appropriate? - "Submerge the probe in water after each use." - "When not in use, keep the probe in the storage place within the unit." - "Allow the unit to lose full charge occasionally to generate full recharging capabilities." - "Do not remove the thermometer from the charging unit unless you are using it."

- "When not in use, keep the probe in the storage place within the unit." Explanation: Return the probe to the storage place within the unit, and return the thermometer to the battery pack. Cleanse according to manufacturer recommendations. Proper storage prevents damage to the sensitive temperature probe and ensures that the unit will be recharged and ready for use. As the unit is electronic, you would not submerge in water as it could corrode the inner workings of the machine. The thermometer is battery charged and does not have to be charging continuously and can be off the charger for short periods of time. Allowing the unit to lose a full charge does not generate full charging capabilities and can yield undue wear on the unit.

The nursing student is selecting a blood pressure cuff prior to obtaining a client's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading? - 40% of the circumference of the limb to be used - 50% of the circumference of the limb to be used - 60% of the circumference of the limb to be used - 70% of the circumference of the limb to be used

- 40% of the circumference of the limb to be used Explanation: The correct cuff should have a bladder width that is at least 40% of the arm circumference and a length that is 80% of the arm circumference, with a length-to-width ratio of 2:1. All the other options would cause the cuff to be too small for a client.

A nurse is assessing the cardiac output of a client at the health care facility. What would the nurse identify as the average cardiac output in a resting person? - 5.5 L/min - 6.5 L/min - 7.5 L/min - 8.5 L/min

- 5.5 L/min Explanation: Average cardiac output in a resting client is 5.5 L/min. Cardiac output is the product of stroke volume or the amount of blood pumped by each ventricle with each heartbeat and the heart rate. The average cardiac output in a resting person is not 6.5 L/min, 7.5 L/min, or 8.5 L/min. A stroke volume of 70 mL and a heart rate of 72 bpm result in a cardiac output of 5 L/min.

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. - Palpate the posterior thorax excursion, count respirations for 30 seconds, and multiply by 2. - Use a pulse oximeter to count the respirations for 1 minute. - Monitor arterial blood gas results for 1 minute.

- Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2. Explanation: Sometimes it is easier to count respirations by auscultating the lung sounds for 30 seconds and multiplying the result by 2. Palpating the posterior thorax excursion detects vibrations in the lungs. Pulse oximeter and arterial blood gas results assess respiratory effectiveness, not respiratory 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? - Notify the health care provider. - Perform a pain assessment. - Administer oxygen. - Auscultate the lung sounds and count respirations.

- Auscultate the lung sounds and count respirations. Explanation: If the respirations are too shallow to count it is easier to count respirations by auscultating the lung sounds. The nurse should auscultate lung sounds and count respirations for 30 seconds, then multiply by 2 to calculate the respiratory rate per minute. If the respiratory rate is irregular, the nurse should count for a full minute. The nurse notifies the health care provider of the respiratory rate and the shallowness of the respirations following assessment. Pain typically causes vital signs to elevate. The nurse cannot administer oxygen without a health care provider's prescriptions.

A client presents to the emergency department with profuse bleeding from a crushing injury while at work. Which set of vital signs does the nurse anticipate finding in such this client? - Blood pressure 130/80 mm Hg, heart rate 74 beats/min, respiratory rate 14 breaths/min - Blood pressure 80/50 mm Hg, heart rate 120 beats/min, respiratory rate 24 breaths/min - Blood pressure 124/74 mm Hg, heart rate 90 beats/min, respiratory rate 14 breaths/min - Blood pressure 140/90 mm Hg, heart rate 84 beats/min, respiratory rate 16 breaths/min

- Blood pressure 80/50 mm Hg, heart rate 120 beats/min, respiratory rate 24 breaths/min Explanation: Profuse bleeding would cause a drop in blood pressure as the client enters hypovolemic shock, which causes the pulse to increase and become thready and respirations to become quick and shallow. Therefore, of the given options, a blood pressure of 80/50 mm Hg, heart rate of 120 beats/min and respiratory rate of 24 breaths/min should be anticipated.

What anatomic site regulates the pulse rate and force? - Thermoregulatory center - Cardiac sinoatrial (SA) node - Cardiac atria and valves - Peripheral chemoreceptors

- Cardiac sinoatrial (SA) node Explanation: The pulse is regulated by the autonomic nervous system through the cardiac sinoatrial (SA) node. The other anatomic sites may affect, but do not regulate, the pulse rate and force.

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 of an oral measurement. - Temporal temperature is close to oral temperature readings. - Research states temporal thermometers are more accurate than axillary temperature measurement. - There is a built-in verification of temperature by touching behind the ear. - The procedure is less invasive than oral or rectal routes and does not have to touch the skin.

- Children often cannot keep lips closed tight enough to capture a true reading of an oral measurement. - Temporal temperature is close to oral temperature readings. - Research states temporal thermometers are more accurate than axillary temperature measurement. - There is a built-in verification of temperature by touching behind the ear. Explanation: The use of a temporal thermometer is less invasive than the oral and rectal routes, but the thermometer must touch the skin of the forehead and then behind the ear for accuracy. The thermometer assesses ambient temperature as well as body temperature to determine accurate thermoregulation of the body. Research, while limited, has noted the temporal thermometer to be more accurate than axillary temperature measurement.

Which statement describes diastolic blood pressure? - During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. - To assess diastolic pressure, the blood pressure measured during ventricular contraction. - The pressure is highest when the ventricles of the heart eject blood into the aorta and pulmonary arteries. - The flow of blood is produced by contractions of the heart and by the resistance to blood flow through the vessels.

- During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. Explanation: Diastolic blood pressure occurs when ventricular relaxation happens, and blood pressure is due to elastic recoil of the vessels. Systolic blood pressure is measured during ventricular contraction. Systolic blood pressure is highest when the ventricles of the heart eject blood into the aorta and pulmonary arteries. Blood pressure in general is measured by taking the flow of blood produced by contractions of the heart and multiplying it by the resistance to blood flow through the vessels (P = F × R).

The nurse is caring for an adult postoperative client. Which physiologic response is related to pain? - Heart rate of 110 beats/min - 2500 milliliters of urine per 24 hours - Oxygen saturation of 98% - Constipation

- Heart rate of 110 beats/min Explanation: Pain medication can cause decreased bowel motility and cause constipation. However, pain itself can cause an increased heart rate which is indicated by the rate of 110 beats/min. Pain can cause decreased urinary output; 2500 milliliters of urine in 24 hours is an indication of increased output. Pain can increase the consumption of oxygen; an O2 saturation of 98% on room air would be a normal reading.

While obtaining a client's blood pressure, the nurse hears faint, clear tapping sounds that gradually increase in intensity. The nurse identifies this as which phase of Korotkoff sounds? - I - II - III - IV

- I Explanation: Phase I sounds are characterized by faint, clear tapping sounds that gradually increase in intensity. This is recorded as the systolic blood pressure. Phase II sounds have a swishing quality. Phase III sounds are marked by crisper, more intense sounds. Phase IV sounds are characterized by muffled blowing sounds.

A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff? - Place cuff 8 cm above the elbow. - Fully inflate cuff for about 1 minute. - Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared. - Elevate arm above heart level before inflating the cuff.

- Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared. Explanation: Inflating the cuff to 30 mm Hg above reading where brachial pulse disappeared ensures accurate assessment of systolic blood pressure. The arm does not need to be elevated above the heart level before inflation as this would give an inaccurate systolic blood pressure. The cuff should be placed in the elbow fold and not 8 cm above the elbow. Inflating the cuff for 1 minute before taking a blood pressure can cause an elevation of the systolic blood pressure.

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. - Count the heartbeat for 2 minutes. - Count each "lub-dub" as two beats. - Palpate the space between the fifth and sixth ribs.

- Listen for heart sounds. Explanation: The apex of the heart is found by palpating between the fifth and sixth ribs, then moving the stethoscope to the left midclavicular line. The apical rate is typically assessed for 1 minute. Each "lub-dub" sound counts as one beat.

The nurse is assessing an adult who has a pulse rate of 150 beats/min. Which action should the nurse take next? - Obtain the client's blood pressure - Assess the client for allergic reaction - Administer epinephrine immediately - Notify the health care provider of tachycardia

- Notify the health care provider of tachycardia Explanation: An adult has tachycardia when the pulse rate is 100 to 180 beats/min. Blood pressure should always be assessed, but the health care provider should be notified immediately. Anaphylaxis and epinephrine are not specific to high pulse rate thus the provider should be called first.

A nurse is caring for a client with increased pulse rate caused by sympathetic nervous system activation. Which factors lead to the activation of the sympathetic nervous system? Select all that apply. - Pain and anxiety - Sudden changes in environment - Ingestion of caffeinated beverages - Changes in intravascular volume - Excess weight loss or weight gain

- Pain and anxiety - Sudden changes in environment - Ingestion of caffeinated beverages - Changes in intravascular volume Explanation: Sympathetic nervous system activation occurs in response to a variety of stimuli, including pain, anxiety, exercise, fever, ingestion of caffeinated beverages, and changes in intravascular volume. Excess weight loss or weight gain are not factors leading to the activation of the sympathetic nervous system.

The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention? - Provide privacy for the client. - Position the client on the stomach. - Insert the thermometer 0.5 in (1.25 cm) into the rectum. - Maintain probe position in rectum for 2 minutes.

- Provide privacy for the client. Explanation: Rectal temperature assessment can be embarrassing for the client, so provision of privacy is a priority. The client should be positioned on the side in Sims position to help facilitate probe insertion. The probe should be inserted 1 to 1.5 in (2.5 to 3.75 cm) in an adult client. The probe should only remain in the rectum until the electronic unit emits an audible sound indicating that the temperature assessment is complete.

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 strong, and light pressure causes it to disappear. - Pulse is felt with difficulty and disappears with slight pressure. - Pulse is felt easily, and moderate pressure causes it to disappear. - Pulse is strong and remains strong despite moderate pressure.

- Pulse is felt with difficulty and disappears with slight pressure. Explanation: A thready pulse is felt with difficulty or not easily felt, and slight pressure causes it to disappear. A weak pulse is stronger than a thready pulse, and light pressure causes it to disappear. A normal pulse is felt easily, and moderate pressure causes it to disappear. A bounding pulse is strong and does not disappear with moderate 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? - Leave the thermometer in and notify the physician. - Remove the thermometer and assess the blood pressure and heart rate. - Remove the thermometer and assess the temperature via another method. - Call for assistance and anticipate the need for CPR.

- Remove the thermometer and assess the blood pressure and heart rate. Explanation: Vagal nerve stimulation may occur when obtaining a rectal temperature. Vagal nerve stimulation can cause the pulse and blood pressure to drop significantly, causing the client to feel lightheaded; therefore, the thermometer should be removed immediately and the pulse and blood pressure assessed. The physician can be called after assessing the client. The temperature is not the priority at this time. Assistance for CPR would be determined if the client's condition worsens.

Which statement is true regarding the autonomic nervous system and its effect on the rate of a person's pulse? - Sympathetic nervous system activation occurs in response to a variety of stimuli, including changes in intravascular volume. - Stimulation of the parasympathetic nervous system results in an increase in the pulse rate. - Stimulation of the sympathetic nervous system results in a decrease in the pulse rate. - The sympathetic nervous system is the dominant activation during resting states.

- Sympathetic nervous system activation occurs in response to a variety of stimuli, including changes in intravascular volume. Explanation: The sympathetic nervous system activation occurs in response to various stimuli, including pain, anxiety, exercise, fever, and changes in intravascular volume. Stimulation of the parasympathetic nervous system results in a decrease in the pulse rate.

After taking vital signs of an older adult, the nurse writes down findings as T = 98.9/37.2 oral, P = 104, R = 18, BP = 120/82. Based on the collected data, which step would the nurse take next? - Recheck BP level to ensure accuracy - Take pulse again to assess for tachycardia - Wait 20 minutes and recheck oral temperature. - Talk with client to allow them to relax before retaking vital signs.

- Take pulse again to assess for tachycardia Explanation: Normal ranges of vital signs for older adults are as follows: Pulse 60-100 Respiration 12-20 Temperature 96.4-99.5F (35.8-37.5C) Blood Pressure 90-120 /60-80. Reassessing pulse would be justified to determine if there is a tachycardia issue or if the client has situational anxiety, etc. that may affect the pulse rate. Talking with the client to help relax them is a common practice, but not warranted in this situation. The oral temperature is within normal limits so there is not need to retake it.

A nurse is preparing to assess a client's temperature and finds the client to be perspiring profusely. Which method would be least appropriate for the nurse to use to assess this client's temperature? - Tympanic membrane temperature - Oral temperature - Temporal artery temperature - Rectal temperature

- Temporal artery temperature Explanation: Diaphoresis causes skin cooling which may cause a false low reading with a temporal artery thermometer. Another method, such as oral, tympanic membrane, or rectal, should be used.

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 thermometer is broken. - The client is showing initial signs of infection. - A rectal thermometer must be used. - The client is covered with a couple of thick blankets.

- The client is covered with a couple of thick blankets. Explanation: Ordinarily, changes in environmental temperatures do not affect core body temperature, but core body temperature can be altered by exposure to hot or cold extremes such as blankets. The degree of change relates to the temperature, humidity, and length of exposure. The body's thermoregulatory mechanisms are also influential, especially in infants and older adults who have diminished control mechanisms. Using a rectal thermometer or assuming the thermometer is broken is not correct. The client is not exhibiting signs of infection as these may include an elevated temperature, an elevated white blood cell count, general malaise, and body aches.

When assessing a client's vital signs, a nursing student has explained to the client each of their next actions prior to assessing the client's temperature, pulse, and blood pressure. However, the nursing student did not announce their intention to assess the client's respiratory rate prior to measuring it. What is the rationale for the nursing student's decision to withhold this information? - The client may alter the rate of respirations if the client is aware that his breaths are being counted. - The nurse likely assessed the client's respiratory rate simultaneous when counting the heart rate. - Temperature, pulse, and blood pressure are more volatile than respiratory rate. - Tachypnea is an expected finding among hospitalized individuals.

- The client may alter the rate of respirations if the client is aware that his breaths are being counted. Explanation: Because respiratory rate is under both autonomic and voluntary control, making the client conscious of his respiratory rate prior to assessment has the potential to affect that accuracy of the assessment. It is not possible to simultaneously assess pulse and respirations. Temperature, pulse, and blood pressure are not necessarily more volatile than respiratory rate. Tachypnea is not an expected finding.

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 places the blood pressure cup on the upper arm just above the antecubital space. - The client sits in the chair with feet flat on the floor and arm supported at the level of the heart. - The client sits in the chair with feet flat on the floor and arm below the level of the heart. - The client uses a blood pressure cuff width at least 40% of the circumference of the midpoint of the arm.

- The client sits in the chair with feet flat on the floor and arm below the level of the heart. Explanation: The client behavior that indicates the need for additional teaching is client sitting in the chair with feet flat on the floor and arm below the level of the heart. Taking a blood pressure with the arm in that position can give a falsely high reading. The client placing the blood pressure on the upper arm just above the antecubital space, the client sitting in the chair with feet flat on the floor and arm supported at the level of the heart, and the client using a blood pressure cuff width at least 40% of the circumference of the midpoint of the arm all indicated correct methodology for self-measuring blood pressure and thus require no need for further teaching.

A nurse assessing a client's blood pressure is obtaining falsely high readings. What would the nurse identify as contributing to this error? Select all that apply. - The client was anxious when the reading was taken. - The cuff is too large for the client. - The client's arm was above heart level. - The cuff was deflated too slowly. - The cuff was wrapped unevenly.

- The client was anxious when the reading was taken. - The cuff was deflated too slowly. - The cuff was wrapped unevenly. Explanation: Causes associated with falsely high blood pressure readings include client anxiety, cuff deflation that is too slow, and an uneven or loosely wrapped cuff. Using a cuff that is too large or having the client's arm above heart level would cause falsely low readings.

The experienced nurse teaching a student to measure an apical pulse includes which critical information? Select all that apply. - Auscultation of the apical pulse requires a cardiac stethoscope placed at the apex of the heart found at the second intercostal space. - A Doppler ultrasound device is required to measure an apical pulse at the fourth intercostal space at the midclavicular line. - The diaphragm of the stethoscope is placed at the fifth intercostal space at the midclavicular line. - To determine the apical pulse, count the heartbeats for 1 full minute. - In adults, the normal rate is 80 to 120 pulsations per minute.

- The diaphragm of the stethoscope is placed at the fifth intercostal space at the midclavicular line. - To determine the apical pulse, count the heartbeats for 1 full minute. Explanation: Auscultation of the apical pulse requires a stethoscope. The nurse will assess the apical pulse by placing the diaphragm of the stethoscope over the apex of the heart, which is located at the fifth intercostal space at the midclavicular line. To determine the apical pulse, the nurse will count the heartbeats for 1 full minute. A Doppler ultrasound device is not required to measure an apical pulse; a stethoscope is most often used to measure an apical pulse. In adults, the normal rate is 60 to 100 pulsations per minute; not 80 to 120 pulsations per minute.

The nurse is assessing the pulse of a young adult who is training for a triathlon competition. The pulse rate is 48 beats/min. What education should the nurse provide to the client? - A medication regimen to bring the heart rate up will be required. - The client will have to be very careful when changing positions since the heart rate is low. - The heart rate is within normal limits due to the exercise regimen the client is following. - There is a conduction abnormality that is most likely congenital since the client is young.

- The heart rate is within normal limits due to the exercise regimen the client is following." Explanation: The client who is young and athletic is exhibiting a training effect where the heart rate is lower than the normal 60 to 100 beats/min. The heart becomes more efficient at supplying body cells with sufficient oxygenated blood with fewer beats. There is no indication that the client should be placed on medications to increase the heart rate since this is most likely a normal state for the client.

A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse? - The blood pressure is elevated. - A baseline pulse rate is needed. - The carotid pulse is bounding. - The radial pulse is difficult to obtain.

- The radial pulse is difficult to obtain. Explanation: Auscultation of the apical pulse provides the most accurate assessment of the pulse rate and is the preferred site when the peripheral pulses are difficult to assess or the pulse rhythm is irregular. While this is an excellent method to determine baseline pulse, it is not the reason for using the apical pulse method. Elevated blood pressure and bounding carotid pulse are not reasons to obtain an apical pulse.

A nurse is assessing the blood pressure on a client with a BMI of 32. What error might occur if the cuff used is too narrow? - The reading will be erroneously high. - The reading will be erroneously low. - The pressure of the cuff will be painful. - It will be difficult to pump up the bladder.

- The reading will be erroneously high. Explanation: If the cuff is too narrow, the reading could be erroneously high because the pressure is not being transmitted evenly to the artery. If the cuff is too large, then the reading could be too low. The pressure is not related to the painfulness of the cuff. It will not be difficult to pump up the bladder of the cuff, whether it is too large or too small.

Which client's blood pressure best describes the condition called hypotension? - The systolic reading is above 110 and diastolic reading is above 80. - The systolic reading is below 100 and diastolic reading is below 60. - The systolic reading is above 102 and diastolic reading is above 60. - The systolic reading is below 120 and the diastolic reading is below 80.

- The systolic reading is below 100 and diastolic reading is below 60. Explanation: Hypotension is defined by a systolic pressure below 100 mm Hg and diastolic pressure less than 60 mm Hg. The top number refers to the amount of pressure in the arteries during the contraction of heart muscle. This is called systolic pressure. The bottom number refers to the blood pressure when the heart muscle is between beats. This is called diastolic pressure. Ideal blood pressure is less than 140/90.

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 Bell side of the stethoscope to listen. - Ask another student nurse to check it for him. - Connect the client to the oxygen saturation monitoring device. - Use the Doppler ultrasound device.

- Use the Doppler ultrasound device. Explanation: Peripheral pulses that cannot be detected by palpation may be assessed with an ultrasonic Doppler device. A conductive gel is first applied to the skin to reduce resistance to sound transmission. The transmitter of the device is then placed over the artery to be assessed. High-frequency waves directed at the artery from the transmitter are disturbed by the pulsating flow of blood and are reflected back to the ultrasound device. The sound disturbances (Doppler shifts) are amplified and heard through earpieces or a speaker attached to the device. The bell effect is created by light pressure on the stethoscope. Using the bell will not facilitate palpation but an auditory assessment. The nursing student should be familiar with other assessment devices such as the Doppler and not asking another nursing student to assess. Connecting the client to the oxygen saturation device does not assist in the assessment of pedal pulses.

A nurse is teaching a client how to monitor the radial pulse after discharge from the hospital. Which instruction by the nurse is most appropriate? - Measure the pulse for 45 seconds and multiply by 2. - Measure the pulse at the wrist on the side of the pinky finger. - Use your thumb to locate the pulse. - Use the fingertips of your second and third fingers.

- Use the fingertips of your second and third fingers. Explanation: The radial pulse is palpated on the thumb side of the inner aspect of the wrist. The pulse should be palpated with the fingertips of the second and third fingers. Using the thumb may result in an inaccurate reading. The pulse should be counted for 1 full minute.

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? - Ask the client to drink a glass of cold water before measuring the oral temperature - Wait for 30 minutes before measuring the oral temperature - Obtain the client's temperature rectally after lubricating the rectum - Use the axillary site for an alternate measurement site

- Wait for 30 minutes before measuring the oral temperature Explanation: The nurse should wait for 15 to 30 minutes and then measure the oral temperature of the client since hot and cold liquids cause slight variations in temperature. Giving the client a glassful of cold water to drink will not help because the thermometer will still show temperature variation, not the accurate body temperature. The rectal route is contraindicated in clients with diarrhea, because it can cause mucosal tearing or perforation. Hence, the nurse should not lubricate the client's rectum or measure the rectal temperature. The axillary route is the least accurate and least reliable site.

Which client would the nurse consider at risk for low blood pressure? - a client with high blood viscosity - a client with low blood volume - a client with decreased elasticity of walls of arterioles - a client with a strong pumping action of blood into the arteries

- a client with low blood volume Explanation: Low blood volume, such as occurs with hemorrhage, causes hypotension. High blood viscosity and decreased elasticity of the arteriole walls would potentially cause increased blood pressure. A strong pumping action of the heart may not affect the blood pressure, or it may cause the blood pressure to increase.

It is very important to assess for the quality of someone's respirations as well as describe what is heard with auscultation. Which describes stridor? - high-pitched musical sound - respirations that require excessive effort - discontinuous popping sounds - a harsh, high-pitched inspiratory sound that may be compared to crowing

- a harsh, high-pitched inspiratory sound that may be compared to crowing Explanation: Stridor is a harsh, high-pitched inspiratory sound that may be compared to crowing. It can indicate an upper-airway obstruction. A high-pitched musical sound describes wheezing. Dyspnea is a term used to describe expirations that require excessive effort. Crackles are discontinuous popping sounds.

A nurse needs to measure the blood pressure of a client with an electronic manometer. Which advantage does an electronic manometer provide over an aneroid manometer or mercury manometer? - ability to read gauge from any direction - accurate for practitioners with hearing loss - inexpensive, depending on quality - need for readjustment is eliminated

- accurate for practitioners with hearing loss Explanation: An electronic manometer is excellent for persons with hearing loss because it eliminates the need for a stethoscope. However, an electronic manometer requires a calibration check and readjustment every 6 months, unlike a mercury manometer, which does not require readjustment. An electronic manometer is expensive, depending on quality when compared to an aneroid manometer. A nurse can read the gauge of an aneroid manometer, not an electronic manometer, from any direction.

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? - brachial - radial - carotid - apical

- apical Explanation: The apical pulse is assessed when a client is being given medications that alter heart rate and rhythm.

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 - provide the client with a larger blood pressure cuff - recommend lower sodium in the client's diet - report readings to primary care provider

- ask the client to demonstrate self-blood pressure assessment Explanation: While all of these interventions would be appropriate if the client is hypertensive, it is important to assess whether the client is measuring their BP correctly before assuming that hypertension is present. It would be very rare to have a BP of the exact same measurement with every assessment. Therefore, providing the client with a larger blood pressure cuff, recommending lower sodium in the client's diet, and reporting the readings to the primary care provider are not priority actions at this time.

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 - call the health care provider - let the client sleep - assess blood pressure

- assess temperature Explanation: The client is showing signs of a fever, which can include pinkish, flushed skin that is warm to touch, restlessness or excessive sleepiness, irritability, poor appetite, glassy eyes and sensitivity to light, increased perspiration, headache, above normal pulse and respiratory rate, disorientation and confusion, convulsions in infants and children, and fever blisters. The nurse should first assess the temperature and then take further steps to care for the client, which will include notifying the health care provider. Letting the client continue to sleep after appropriate treatment will be beneficial to the client. It would also be appropriate to assess all the vital signs; however, the temperature would be the priority in this situation.

Which factor is not known to cause false blood pressure readings? - crossing the legs at the knee - smoking 20 minutes before assessment - eating 5 minutes before assessment - being in a warm environment

- being in a warm environment Explanation: To get an accurate blood pressure assessment, the client should not cross the legs at the knee, smoke tobacco 20 minutes before assessment, nor eat 5 minutes before assessment. The client should sit up straight with both feet on the floor and avoid smoking tobacco, eating, and drinking for 30 minutes before blood pressure assessment. Being in a warm environment does not cause a false reading; however, an increased ambient temperature can causes blood vessels near the skin surface to dilate and decrease blood pressure within the normal fluctuation of 10 mm Hg.

Which pulse site is generally used in emergency situations? - carotid - apical - radial - temporal

- carotid Explanation: The carotid artery is lightly palpated to obtain a pulse in emergency assessments, such as in a client in shock or cardiac arrest. The brachial pulse site is used for infants who have had a cardiac arrest. The apical pulse is the fifth intercostal space for adults and the fourth intercostal space for a young child or infant. Using a stethoscope at the apex of the heart, a nurse can assess the lub dub of the heart sounds. Radial pulse is too distant to assess a pulse in an emergency assessment. Temporal pulse is difficult to assess.

A nurse places a fan in the room of a client who is overheated. This is an example of heat loss related to which mechanism of heat transfer? - evaporation - radiation - conduction - convection

- convection Explanation: Convection is the dissemination of heat by motion between areas of unequal density, as occurs with a fan blowing over a warm body. Evaporation is the conversion of a liquid to a vapor. Radiation is the diffusion or dissemination of heat by electromagnetic waves. Conduction is the transfer of heat to another object during direct contact.

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 - superior to the tongue, with the tip touching the hard palate - in the inferior buccal space on either side of the tongue - along either upper gum line, adjacent to an incisor

- deep in the posterior sublingual pocket Explanation: When the probe rests deep in the posterior sublingual pocket, it is in contact with blood vessels lying close to the surface. None of the other areas provides as much contact with blood vessels and therefore is not an appropriate location to place the thermometer probe.

The body loses heat continually through several different processes. Which process is an example of how heat is lost through evaporation? - diaphoresis - conduction - convection - radiation

- diaphoresis Explanation: Evaporation causes heat loss as water is transformed to gas. An example of this is diaphoresis, or sweating.

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? - absent, unable to palpate - diminished, weaker than expected - brisk, expected (normal) - bounding

- diminished, weaker than expected Explanation: A +1 pulse amplitude indicates that the pulse is diminished and weaker than expected. An absent pulse is a 0. A pulse that is brisk is a +2, and a bounding pulse is +3.

A nurse is caring for a middle-age client who looks worried. The client reports difficulty in breathing, even when walking to the bathroom. Which breathing disorder is appropriate to describe the client's condition? - hyperventilation - hypoventilation - dyspnea - apnea

- dyspnea Explanation: Clients with dyspnea often appear worried. Dyspnea is difficult or labored breathing (shortness of breath). Dyspnea may be the result of heavy exercise or exertion or from a health condition. Dyspnea can be perceived only be the person experiencing it and is characterized by an increased effort to breathe is almost always accompanied by a rapid respiratory rate because clients work to improve the efficiency of their breathing. The client's condition cannot be termed hyperventilation, hypoventilation, or apnea. Hyperventilation and hypoventilation affect the volume of air entering and leaving the lungs. Apnea is total absence of breathing, which is life-threatening if it lasts more than 4 to 6 minutes.

A nurse is caring for a newborn. The nurse knows that the body temperature of infants and older adults is prone to fluctuations. Which of these is the most probable cause for fluctuations in the infant's body temperature? - large amount of subcutaneous white adipocytes (fat cells) - increased ability to shiver and perspire - ability to independently forestall or reverse heat loss or gain - great surface area relative to mass and very high metabolic rate

- great surface area relative to mass and very high metabolic rate Explanation: Newborns and young infants tend to experience temperature fluctuations because they have a 3 times greater surface area relative to their mass from which heat is lost and a metabolic rate twice that of adults. Infants and older adults have difficulty maintaining normal body temperature because they have limited, not large, amounts of subcutaneous white adipocytes (fat cells that provide heat insulation and cushioning of internal structures). The ability of both young and old to shiver and perspire also may be inadequate, putting them at risk for abnormally low or high body temperatures. Infants and older adults are less able to independently forestall or reverse heat loss or gain than are other clients.

The nurse is assessing a client's pedal pulse. The nurse would palpate at which area? - behind the knee - on top of the foot - behind bony protuberance of the inner ankle - level of the fifth intercostal space

- on top of the foot Explanation: The nurse would assess the pedal pulse by placing the fingers on the dorsal aspect of the foot (top of the foot when standing). The popliteal pulse is palpated behind the knee. The posterior tibial pulse is palpated behind the malleolus of the inner ankle. The apical pulse is palpated at the level of the fifth intercostal space.

Which site for taking body temperature with a glass thermometer is contraindicated in clients who are unconscious? - rectal - tympanic - oral - axillary

- oral Explanation: Assessing an oral temperature with a glass thermometer is contraindicated in unconscious, irrational, or seizure-prone adults, as well as in infants and young children. This is due to the danger of breaking the thermometer in the mouth.

What is an average normal temperature in Celsius for a healthy adult? - oral: 37°C - rectal: 36.5°C - axillary: 37.5°C - tympanic: 34.4°C

- oral: 37°C Explanation: The normal range for an oral temperature is 37°C (98.6°F), rectal temperature is 37.5°C (99.5°F), an axillary temperature is 36.5°C (97.7°F), and a tympanic temperature is 37.5°C (99.5°F).

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 - bradypnea - apnea - tachypnea

- orthopnea Explanation: Dyspneic people can often breathe more easily in an upright position, a condition known as orthopnea, because sitting or standing allows gravity to lower organs from the abdominal cavity away from the diaphragm. Bradypnea is a decrease in respiratory rate. Tachypnea is an increased respiratory rate. Apnea refers to periods during which there is no breathing.

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem? - peripheral vascular disease - coronary artery disease - pulmonary embolism - chronic obstructive pulmonary disease (COPD)

- peripheral vascular disease Explanation: A pulse deficit indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated, a finding that is congruent with peripheral vascular disease. It does not signal a lack of circulation to the heart muscle (coronary artery disease), a pulmonary embolism, or COPD.

The nurse understands that accurate blood pressure taking is dependent on several factors. Which example will most likely render an accurate blood pressure reading? - the client reporting moderate pain for the past 4 hours - using a medium size cuff for a 10-year-old, average weight client - the ear tip of the stethoscope pointing backwards while taking blood pressure - placing the client's arm at heart level

- placing the client's arm at heart level Explanation: The nurse should measure blood pressure with the arm at heart level. Elevating the arm above heart level results in a falsely low measurement; positioning the arm below heart level results in a falsely high reading. The ear tip or bell can be pointed in any direction when taking a blood pressure. Using a small cuff is recommended for a 10-year-old normal-sized child. Pain can increase the blood pressure causing a false elevated reporting.

A nurse is caring for a client who has a lack of appetite. What is most likely to influence a client's core body temperature? - minerals - proteins - fiber - vitamins

- proteins Explanation: The nurse should recommend an increase in protein in the client's diet, as it has the greatest thermic effect. Food intake, or lack of it, affects thermogenesis, or heat production. When a person consumes food, the body requires energy to digest, absorb, transport, metabolize, and store nutrients. Thus, both the amount and type of food eaten affect body temperature. Dietary restrictions can contribute to decreased body heat as a result of reduced processing of nutrients. Increased intake of fiber would lead to decreased heat production. Vitamins and minerals would not help in increasing the client's appetite, nor would they reduce appetite.

The nurse has delegated an unlicensed assistive personnel (UAP) to obtain a temperature reading for a client who has neutropenia. Which route used by the UAP requires immediate intervention? - rectal - axillae - tympanic - oral

- rectal Explanation: Assessing a temperature rectally is contraindicated in clients who are neutropenic (have low white blood cell counts, such as in leukemia).

A nurse is taking a client's temperature and wants the most accurate measurement, based on core body temperature. What site should be used? - rectal - oral - axillary - forehead

- rectal Explanation: Heat is generated by metabolic processes in the core tissues of the body, transferred to the skin surface by the circulating blood, and then dissipated to the environment. Core body temperatures may be measured at rectal or tympanic sites. Axillary temperatures are considered not accurate but can be used if rectal and tympanic are not available.

Various sounds are heard when the nurse assesses a blood pressure. What does the first sound heard through the stethoscope represent? - systolic pressure - diastolic pressure - auscultatory gap - pulse pressure

- systolic pressure Explanation: The first sound heard through the stethoscope, which is the onset of phase I of Korotkoff sounds, represents the systolic pressure. The last sound is the diastolic pressure. An auscultatory gap is a period of diminished or absent Korotkoff sounds during the manual measurement of blood pressure. Pulse pressure is the difference between the systolic and diastolic blood pressure. It is measured in millimeters of mercury (mmHg). If the resting blood pressure is 120/80 mmHg, then the pulse pressure is 40 mmHg.

An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding? - bradycardia - tachycardia - dysrhythmia - normal pulse

- tachycardia Explanation: Tachycardia is a rapid pulse (heart) rate. An adult has tachycardia when the pulse rate is greater than100 beats/min. The nurse would document a rate of 140 as tachycardia. Bradycardia is a slower than normal pulse rate or less than 60 beats/min. Dysrhythmia is an irregular pulse rate.

The nurse is preparing discharge teaching for a client admitted for sepsis. The client asks what is included when the nurse checks vital signs. Which assessment(s) is included? Select all that apply. - temperature - pulse - respiratory rate - blood pressure - weight - allergies

- temperature - pulse - respiratory rate - blood pressure Explanation: Vital signs consist of temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation. Pain is considered the sixth vital sign that a nurse should assess. Weight and allergies are other assessment parameters but are not part of the vital signs.

The home care nurse is assessing a 37-year-old client's vital signs at rest. Which finding requires nursing intervention? - blood pressure 116/80 mm Hg - respirations 18 breaths/min - pulse rate 70 beats/min - temporal temperature 100.8º F (38.2º C)

- temporal temperature 100.8º F (38.2º C) Explanation: The nurse should intervene when the client's temperature is 100.5º F (38.2º C) or higher. If the adult's blood pressure is higher than 120/80 mm Hg or respirations more than 20 breaths/min or pulse rate greater than 100 beats/min, then these would also require the nurse to take appropriate action.

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 - the thickness of circulating blood - the oxygen levels in the blood - the volume of air entering the lungs

- the ability of the arteries to stretch Explanation: Measuring the blood pressure helps to assess the efficiency of the client's circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood. Measuring the blood pressure does not help in assessing the thickness of blood, oxygen level in the blood, or the volume of air entering the lungs.

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 - the last sound before there is complete and continuous silence - the first sound that is audible after the auscultatory gap - the transition from tapping sounds to muffled sounds

- the first appearance of faint but distinctive tapping sounds Explanation: Korotkoff sounds (or K-Sounds) are the "tapping" sounds heard with a stethoscope as the cuff is gradually deflated. Traditionally, these sounds have been classified into five different phases (K-1, K-2, K-3, K-4, K-5). The systolic blood pressure reading occurs during phase I, which is characterized by the appearance of faint but clear tapping sounds that gradually increase in intensity (K1). The last sound before there is complete and continuous silence is congruous with the diastolic blood pressure measurement (K5). In some clients, sounds may disappear altogether for a short time between Phase II and III, which is referred to as auscultatory gap. The transition from tapping sounds to muffled sound is K4. K-1 (Phase 1): The appearance of the clear "tapping" sounds as the cuff is gradually deflated. The first clear "tapping" sound is defined as the systolic pressure. K-2 (Phase 2): The sounds in K-2 become softer and longer and are characterized by a swishing sound. since the blood flow in the artery increases. K-3 (Phase 3): The sounds become crisper and louder in K-3, which is similar to the sounds heard in K-1. K-4 (Phase 4): As the blood flow starts to become less turbulent in the artery, the sounds in K-4 are muffled and softer. Some professionals record diastolic during Phase 4 and Phase 5 K-5 (Phase 5): In K-5, the sounds disappear completely, since the blood flow through the artery has returned to normal. The last audible sound is defined as the diastolic pressure.

When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a little bit more pressure. The pulse is beating at 80 bpm. Which of these should the nurse document as the character of the client's pulse? - strong pulse - thready pulse - rapid pulse - bounding pulse

- thready pulse Explanation: A feeble, weak, or thready pulse describes a pulse that is difficult to feel or, once felt, is obliterated easily with slight pressure. A normal pulse is described as strong when it can be felt with mild pressure over the artery. A pulse is considered rapid when the beats exceed 100 bpm, which is not the case here. A bounding or full pulse produces a pronounced pulsation that does not easily disappear with pressure. A strong pulse is felt with a very mild pressure over the artery.

The nurse is teaching a client about variables that can cause temporary alterations in blood pressure. Which variation(s) will the nurse include when teaching the client? Select all that apply. - time of day - physical activity - advanced age - acute pain - gender

- time of day - physical activity - acute pain Explanation: When teaching clients about blood pressure, it is important to help clients understand that there are both temporary and permanent variables that influence this vital sign. Blood pressure tends to be lowest after midnight, begins rising at approximately 4 or 5 a.m., and peaks during late morning or early afternoon. Blood pressure rises during exercise and activity, when the heart pumps more blood. Regular exercise, however, helps maintain blood pressure within normal levels. Acute pain tends to increase blood pressure from sympathetic nervous system stimulation. Although blood pressure tends to become elevated with age as a result of arteriosclerosis, this is not a temporary variable. This process can be slowed with lifestyle changes; however, there is a natural and permanent influence of age on this vital sign. Males tend to have higher blood pressure on average than females; this is not a temporary variable.