Fundamentals Module 2 Questions

The nurses obtaining serial blood pressure measurements on a client having hypertension medication adjustment. What assessment is MOST important for the nurse to perform frequently

Determine if there is compromised circulation in the limb

When taking an axillary temperature, the nurse exposes only the axilla area. What reasons does the nurse tell the client?

It maintains the client's dignity keeps the client warm

The nurse is measuring a client's blood pressure using an electronic device. What is important for the nurse to do to ensure accurate results?

check to make sure the client's heart rate is regular

which client would require the nurse to obtain an apical-radial pulse?

client with atrial fibrillation Atrial fibrillation is a condition in which the radial pulse and the apical pulse exhibit different measurements this offers due to the frequent and ineffective apical beats that do not reach the periphery although atrial fibrillation can occur with other conditions, atrial fibrillation is not expected with aortic stenosis or heart failure tachycardia indicates the client has a faster than normal rhythm, but it is a regular rhythm that does not create a pulse deficit

Factors that can interfere with the accuracy of BP readings with an electronic BP device

irregular heart rate, excessive client movement, and environmental noise can interfere with the accuracy of the readings

Which action does the nurse include when measuring the client's pulse deficit?

measure the apical and radial pulse separately the apical and radial pulses can be auscultated and palpated at the same time, but they must be MEASURED SEPARATELY to obtain the actual pulse deficit the pulse oximetry monitor may deliver an inaccurate reading the carotid pulse is not used in the measurement of pulse deficit

When preparing to measure orthostatic hypotension, the nurse should place the bed in which position

the lowest position when measuring for orthostatic hypotension, lower the head of the bed to a flat position position the bed in the lowest position so that when client sits up, the feet can be placed on the floor and the lowest position allows for easier standing

When taking a tympanic temperature on a client, the nurse should place the thermometer in the client's ear at what angle?

toward the jawline this is the anatomical position of the ear canal this angle also helps to provide a better seal if the thermometer is resting out too the ear it'll be inaccurate

The nurse is providing care to a client who has had a left modified radical mastectomy 2 days ago. The woman also has an intravenous line inserted in the right antecuital space. Which would be most appropriate when assessing the client's blood pressure

use either the client's right or left thigh to obtain blood pressure

The nurse is providing care for a 3 year old toddler and needs to take a child's temperature rectally. How far should the nurse insert the probe in to the rectum?

1 inch (2.5cm) this ensures that their bowels aren't perforated

When obtaining a pulse rate for a client with an irregular heart rhythm, how long does the nurse count?

1 minute when a client has an irregular rhythm, the pulse rate is counted for one full minute to get an accurate measure of beats per minute 5 minutes is not necessary any amount less than 1 minute is inaccurate for a client without a regular rhythm

Prior to administering a heart medication, the nurse takes an apical pulse. For how long should the nurse count the pulse?

1 minute or 60 seconds and multiply by 1 a full minute increases the accuracy of the assessment many times, a client can have cardiocascular problems causing irregular heartbeats certain meds have parameters for the range needed to administer the medication the apical pulse rate for a minute provides accurate data

The nurse prepare to obtain a rectal temperature on an adult client. To which distance should the nurse insert the thermometer?

1.5 inches

A client's apical-radial pulse reveals an apical pulse of 72 beats per minute and a radial pulse of 60 beats per minute. How does the nurse document the pulse deficit?

12 the pulse deficit refers to the difference between the apical and radial pulse rates, which in this case would be 12

The nurse estimates a client's systolic pressure to be 150mmHg. When obtaining the client's blood pressure measurement with a sphygmomanometer, the nurse would inflate the cuff to which pressure?

180mmHg when measuring a client's BP, the nurse inflates the cuff to a pressure 30 mmHg above the estimated systolic pressure this ensures a period before hearing the first sound that corresponds to the systolic pressure and prevents misinterpreting phase II sounds as phase I sounds. Anything lower than 180 would be too low

The nurse is giving instructions to the client about the procedure for measuring orthostatic hypotension. The nurse explains that for each measurement, the client will have to remain in the position for approximately how long?

3 minutes the time for each position is approximate, with 3 mins being the common denominator in each position The client can remain supine for 3 - 10 mins

A nurse is measuring a client's blood pressure in the right arm and is having difficulty auscultating the sounds. Which would be least appropriate for the nurse to do?

Apply less pressure with the stethoscope

The nurse is planning to take a client's temperature orally. The nurse enters the room and observes the client drinking a cup of coffee. Which action would be most approbate?

Assess the client's temperature about 30 minutes after the client has finished drinking the coffee

To assess the apical pulse, the nurse should place the stethoscope at which location on the left side of the client's chest?

Between the fifth and sixth ribs at the left midclavicular line of the client's chest the midclaviular lint is the point of maximum impulse this is the location of the apex of the heart it is where the strongest heart sounds are located

A group of students are reviewing information about taking an apical radial pulse. Which information is accurate

Both rates are assessed simultaneously An apical-radial pulse involves assessing the apical and radial pulse rates simultaneously, with both counts starting at the same specified time two nurses are needed one counts radial one counts apical over 1 minute compare difference

What is most important for the nurse to do when using an automatic electronic device to obtain serial blood pressure?

Check if the cuff has deflated completely after reading

The nurse will assess the client for orthostatic hypotension. What symptoms would alert the nurse that the client is experiencing hypotension?

Dizziness Diaphoresis (sweating) Pallor (paleness) dizziness, light-headedness, pallor, diaphoresis or syncope

The nurse reads the client's history and notes the client has vascular insufficiency in one upper extremity and both lower extremities. Which device would be MOST appropriate for assessing the client's blood pressure?

Doppler ultrasound if a client has venous insufficiency, it may be difficult to hear the blood pressure doppler ultrasound will help because it amplifies the sound

The nurse is assessing a client for orthostatic hypotension and is obtaining the blood pressure while the client is sitting at the end of the bed with the feet dangling. The client states, "I'm feeling a bit dizzy." The client is pale and beginning to perspire. What should the nurse do first?

Have the client lie down int he bed they are at risk of falling if told to stand longer

The unlicensed assistive personal (UAP) measures the client's axillary temperature shortly after the client has taken a shower. The temperature is lower than the client's previous baseline. What should the UAP do next?

Have the nurse retake the temperature if the axillary temperature is taken within 30 minutes of the client bathing, it will be INACCURATE because the difference in the temperature readings, it is important for the nurse to retake the temperature at the appropriate time

When measuring a client's axillary temperature, the nurse would position the thermometer at which location?

In the center of the axilla this ensures the most accurate reading placing the probe in the center of the axilla, the probe is the deepest part of the axilla and closes to the body if the probe is placed in other surrounding areas it will not provide an accurate reading, because the probe will not be in close enough contact with the body

The nurse would use which part of the hand when assessing radial BP?

Pads of first, second, and third fingers

When preparing to obtain vital signs on a client, which action would the nurse perform first?

Perform hand hygiene! then confirm id and dob

The nurse is providing care to the client who has a low platelet and white blood cell count. when assessing the client's temperature, which method would be contraindicated?

Rectal patient's with low platelet and WBCs should not have rectal temps performed as they are at risk of bleeding and infection oral tympanic axillary would be appropriate to use

The unlicensed assistive personal (UAP) reports to the nurse that the client's pulse is difficult to feel and is skipping beats. What action should you take?

Take an apical pulse when the radial pulse is difficult to palpate or is irregular, the most accurate way to assess the client's pulse is by assessing the apical pulse the stethoscope allows for the ampilfication of the sounds so that pulse may be counted when clients have: -weak or irregular pulses -are on on certain medications -or debilitated, the apical pulse provides the most accurate information

The client is experiencing a neuromuscular condition with frequent tremors. The nurse determines to manually check the client's blood pressure instead of using the electronic blood pressure machine. What is the rationale behind the nurse's decision?

The blood pressure machine would not be accurate Electronic BP machines are not recommended for clients with irregular heart rates, tremors, and the ability to hold extremely still. The presence of these conditions may cause the monitor to incorrectly overinflated the cuff

The nurses prepares to obtain a rectal temperature on an adult client. What lubricant should the nurse prepare for the thermometer probe?

Water soluble lubricant tip of prob is lubricated to reduce friction and facilitate insertion, and to minimize the risk of irritation or injury to the rectal mucosa

A client's blood pressure is very low and the nurse needs to assess it using a Doppler. To get an accurate reading the nurse would inflate the cut to what level on the manometer?

Where the pulse disappears this is the systolic estimate

The nurse has completed assessing for orthostatic hypotension and documents the result. What results would indicate to the nurse the client is experiencing orthostatic hypotension?

a decrease in systolic pressure > 20 mmHG or a decrease in diastolic pressure of > 10mmHg would indicate orthostatic hypotension

The nurse is taking a rectal temperature on a client. The client reports dizziness and then faints. What actions would the nurse take?

assess the blood pressure assess the heart rate remove the thermometer probe notify the health care provider keeping the patient warm will promote comfort but doesn't do anything for vital signs

the nurse has taken a client's temperature using a tympanic thermometer. What should the nurse do next?

discard the probe cover maintains medical and surgical asepsis the nurse should then remove gloves and purell those hands

The nurse obtains a blood pressure on a client using a Doppler ultrasound device but is unsure if the results are accurate. The nurse places to repeat the measurement. What step would the nurse take to ensure a correct reading

ensure that the cuff is completely deflated before attempting another reading

The nurse is preparing to measure a client's tympanic temperature. After performing hand hygiene and identifying the client, what should the nurse do next?

ensure that the thermometer is on and ready to go

the nurse determines that it would be inappropriate to obtain a tympanic temperature for the client with which problem

fluid draining form the ear

What is the BEST way for the nurse to promote comfort for the client when assessing apical pulse

holding the stethoscope's diaphragm against th palm of the hand for a few seconds holding the diaphragm warms it and as a result is less jarring for the patient when the pulse is measured

A nurse is having difficulty observing the rise and fall of a client's chest when assessing respirations. Which action would be most appropriate?

put the stethoscope at the apical site and watch its movement