Prep U Chapter 5

A nurse is completing a general survey of a client's health and is beginning by measuring the client's vital signs. What assessment question constitutes the "fifth vital sign"?

"Are you having any pain right now?"

The nurse assesses the amplitude of the client's radial pulse and finds it to be weak and diminished. Which of the following scores should the nurse record?

1+

A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75mmHg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension?

120/55 mmHg

A nurse should anticipate the normal respiratory rate of an elderly client to be how many breaths per minute?

18 breaths/min

A normal pulse pressure range for an adult client is typically

30 to 50 mm Hg.

The nurse has completed the initial assessment of a client and is now performing data analysis. The nurse obtained a blood pressure reading of 114/70 mm Hg. What is this client's pulse pressure?

44 mm Hg

What population is at greatest risk for hypertension

African American

What are various measurements of the human body, including height and weight, called?

Anthropometric

The nurse has assisted a 74-year-old woman from a chair to the examination table during an assessment, and the nurse observes that the client moves particularly slowly and stiffly. The nurse should question the client regarding a possible history of what health problem?

Arthritis

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?

Ashen gray

A patient has arrived to the clinic for a routine physical examination. Prior to assessing the patient's blood pressure, what should the nurse do?

Ask the patient to sit quietly in a chair for 5 minutes.

The nurse palpates a client's pulse and notes that the rate is 61 beats per minute, with an amplitude that is weak and thready. What would the nurse do next?

Assess the client's pulse at the carotid site

The nurse palpates a client's pulse and notes that the rate is 71 beats per minute, with an irregular rhythm. How should the nurse follow up this assessment finding?

Auscultate the client's apical pulse.

A nurse obtains a pulse rate on an adult client of 56 beats per minute. What is the correct term that the nurse should use to document this finding?

Bradycardia

The nurse is admitting a client to surgical day care and is assessing the client's vital signs. When obtaining the client's oral temperature, where should the nurse insert the thermometer?

Deep in the posterior sublingual pocket

When obtaining an oral temperature on a client, the nurse inserts the thermometer

Deep in the posterior sublingual pocket

The nurse is performing vital signs during the routine assessment of an adult client who twisted his ankle during a mini-marathon. The client's pulse is 52 bpm. The nurse retakes the pulse; the finding is the same. The client tells the nurse that he has been training for 6 months for this mini-marathon. What should the nurse do in regard to this reading?

Document the finding

A nurse notes that the pulse rate of a client is less than 60 beats per minute. Which question is appropriate for the nurse to ask the client in regards to this finding?

Have you been sitting for a long time?"

The nurse explains to the client that smoking has what effect on the body? Select all that apply

Hypertension Vasoconstriction Peripheral vascular disease

A nurse obtains the blood pressure in a client who is lying down. Which of the following would the nurse expect?

It will be slightly lower than standing readings

A nurse observes that a young man's arm span appears to be greater than his height. Which condition should the nurse suspect in this client?

Marfan's syndrome

The nurse is admitting an elderly client with a diagnosis of congestive heart failure. Admission vital signs are respirations 38; pulse 172; blood pressure 86/72. How should the nurse best respond?

Notify the rapid response team

During a busy shift, Nurse R. admitted a postsurgical patient who is obese. Nurse R. used the standard size of blood pressure cuff available on the unit, despite the fact that the patient's upper arms have a high circumference. What are the potential consequences of Nurse R.'s action?

Nurse R. may obtain a blood pressure reading that is higher than actual blood pressure.

A nurse is filling out an incident report after an older adult patient fell while attempting to transfer from her bed to a commode. Which of the following health problems should the nurse consider when patient falls occur?

Orthostatic hypotension

A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?

Over the client's thigh

the nurse places the following device on a client's finger. What information is this device providing to the nurse?

Oxygen saturation

A patient rates the current pain level as being a 5 on the Numeric Rating Scale. How should the nurse document this pain assessment?

Patient rated pain level as being a 5 using the rating scale.

The nurse is performing an assessment of a hospital client at the beginning of a shift. When assessing the client's heart rate, the nurse will most likely palpate what artery?

Radial artery

When assessing a client's pulse, the nurse should be alert to which of the following characteristics?

Rate, rhythm, amplitude and contour, and elasticity.

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?

Reading is erroneously high

The nurse is reviewing the following vital signs of a client who is lying in bed. Which of the following would the nurse identify as being abnormal?

Respirations 28 breaths/minute

The nurse is taking routine vital signs toward the end of shift. A client's BP reads 204/148. The client's baseline BP has been in the 130's systolic. What should the nurse do first?

Retake the blood pressure

A client comes to the clinic for a follow-up evaluation of his blood pressure. On two previous visits his values were 140/88 mmHg and 144/92 mmHg. Today, the client's blood pressure is 146/94 mmHg. The nurse would categorize this client's blood pressure as which of the following?

Stage 1 hypertension

A nurse measures a client's blood pressure at 174/102 mm Hg. The nurse recognizes this as what classification of blood pressure measurement?

Stage 2 hypertension

A patient arrives in the emergency department in diabetic ketoacidosis. What assessment finding would the nurse expect in this patient?

Sweet-smelling breath

A client has a pulse rate of 28 beats/15 seconds. How should the nurse document this finding?

Tachycardia

The nurse is preparing to assess a client's vital signs. Which vital sign should the nurse assess first?

Temperature

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure?

The ability of the arteries to stretch

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 increases.

Which of the following would the nurse need to keep in mind when assessing the blood pressure of a client who is receiving anticoagulant therapy?

The blood viscosity would be thinner, causing the blood pressure to decrease.

The nurse is assessing a client's respiratory rate. Which of the following should the nurse do to ensure accuracy of this assessment? A nurse obtains the blood pressure of a client who is uncharacteristically fatigued and who is lying in bed rather than sitting in a chair. The nurse should interpret the client's blood pressure reading in light of what principle?

The client's blood pressure will be slightly lower than standing readings.

An 84-year-old man has been admitted to the emergency department from an extended care facility. Facility staff suspect that the client has pneumonia, and his malaise, productive cough, shortness of breath, and adventitious breath sounds are consistent with this diagnosis. However, the nurse's assessment of the client's vital signs yields an oral temperature of 97.5°F. How should the nurse best interpret this assessment finding?

The client's normothermic temperature does not rule out the presence of an infection.

The nurse has begun a client's assessment and is applying the blood pressure cuff on a client's arm. Which action would be most appropriate?

The cuff is placed about 1 inch above the antecubital area.

A client comes to the cardiovascular intensive care unit (CVICU) directly after a three-vessel coronary artery bypass graft (CABG). The client's orders state "maintain systolic blood pressure >90 but <120." How does this order affect the monitoring of the client's blood pressure?

The nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits

Before calling a client back to an examination room, the nurse quickly observes the client in the waiting room from head to toe. Which of the following is the best rationale for this action? You Selected:

To see the client before the client assumes a social face or behavior

A nurse is obtaining a client's radial pulse. Which of the following actions demonstrates correct technique for this assessment?

Use of two middle fingers lightly applied to wrist area along the thumb side

The nurse is assessing a client's respiratory rate. Which of the following should the nurse do to ensure accuracy of this assessment?

Watch chest movement before removing the stethoscope after counting the apical beat

A client is concerned that a blood pressure reading of 180/78 mm Hg is extremely high when the readings usually are around 130/60 mm Hg. What could have caused this elevation in blood pressure?

arm below the level of the heart

While caring for an 80-year-old client in his home, the nurse determines that the client's oral temperature is 35.8 °C (96.5 °F). The nurse determines that the client is most likely exhibiting

normal changes that occur with the aging process.

Which of the following is an average normal temperature in centigrade for a healthy adult?

oral: 37.0°C

The current blood pressure measurement on a 24-hour uncomplicated postoperative patient while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of

orthostatic hypotension

A nurse is taking a patient's temperature and wants the most accurate measurement, based on core body temperature. What site should be used?

rectal

The nurse is going to take a blood pressure on a patient who has had a previous left mastectomy with lymph node dissection. What would be an appropriate action by the nurse?

take the blood pressure in the right arm

the nurse is assessing an elderly postsurgical client in the home. To begin the physical examination, the nurse should first assess the client's

vital signs.