TLB-Chapter 25: Vital Signs

The rectal temperature, a core temperature, is considered to be one of the most accurate routes. In which cases would taking a rectal temperature be contraindicated? Select all that apply. A. A newborn who has hypothermia B. A child who has pneumonia C. An older adult who is post MI (heart attack) D. A teenager who has leukemia E. A patient receiving erythropoietin to replace red blood cells F. An adult patient who is newly diagnosed with pancreatitis

A. A newborn who has hypothermia C. An older adult who is post MI (heart attack) D. A teenager who has leukemia E. A patient receiving erythropoietin to replace red blood cells RATIONALE The rectal site should not be used in newborns, children with diarrhea, and in patients who have undergone rectal surgery. The insertion of the thermometer can slow the heart rate by stimulating the vagus nerve, thus patients post-MI should not have a rectal temperature taken. Assessing a rectal temperature is also contraindicated in patients who are neutropenic (have low white blood cell counts, such as in leukemia), in patients who have certain neurologic disorders, and in patients with low platelet counts.

A patient reports severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments? Select all that apply. A. An increase in the pulse rate B. A decrease in body temperature C. A decrease in blood pressure D. An increase in respiratory depth E. An increase in respiratory rate F. An increase in body temperature

A. An increase in the pulse rate E. An increase in respiratory rate RATIONALE The pulse often increases when a person is experiencing pain. Pain does not affect body temperature and may increase (not decrease) blood pressure. Acute pain may increase respiratory rate but decrease respiratory depth.

A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient? A. Follow-up measurements of blood pressure B. Immediate treatment by a health care provider C. No action, because the nurse considers this reading is due to anxiety D. A change in dietary intake

A. Follow-up measurements of blood pressure RATIONALE A single blood pressure reading that is mildly elevated is not significant, but the measurement should be taken again over time to determine if hypertension is a problem. The nurse would recommend a return visit to the clinic for a recheck.

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will: A. decrease the blood glucose. B. decrease the blood volume. C. decrease the apical pulse. D. decrease the respiratory rate.

C. decrease the apical pulse. RATIONALE Some cardiac medications, such as digoxin, whose action is specific to the work of the heart, slow the heart rate while also strengthening the force of contraction to increase cardiac output.

While taking an adult patient's pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next? A. Check the pulse again in 2 hours. B. Check the blood pressure. C. Record the information. D. Report the rate to the primary care provider.

D. Report the rate to the primary care provider. RATIONALE A rate of 140 beats/min in an adult is an abnormal pulse and should be reported to the primary care provider or the nurse in charge of the patient.

When assessing a client's radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next? Report the findings to the health care provider Obtain a bedside electrocardiogram Compare with previously documented findings Auscultate the apical pulse for 60 seconds

Auscultate the apical pulse for 60 seconds Explanation: Palpating the radial pulse is the most convenient method for assessing the pulse but not always the most accurate. Because the rhythm is irregular, a more accurate assessment method is required for a full minute. Auscultating the apical pulse for a full minute provides more accuracy. The other interventions would be implemented after a more accurate assessment is obtained.

The nurse is caring for several clients on a telemetry unit. Which client(s) requires the nurse to assess the pulse rate need for 1 full minute? Select all that apply. A client with a pulse rate of 38 beats/min. A client with a temperature of 97.7°F (36.5°C). A client diagnosed with a arrhythmia. A client recovering from anesthesia. A client with a pulse rate of 130 beats/min.

A client with a pulse rate of 38 beats/min. A client diagnosed with a arrhythmia. A client with a pulse rate of 130 beats/min. Explanation: The nurse assesses clients with irregular or abnormally slow or fast pulse rates for 1 full minute. The time interval used to assess the pulse depends on the client's condition and the agency's norms. Clients with regular rhythms and normal rates may be assessed for a shorter time. Intervals of 15 seconds may be used for clients with regular rhythms when the pulse is reassessed frequently, as during recovery from anesthesia. Clients with normal temperatures should not require the pulse rate to be assessed for 1 full minute. Tachycardia is associated with high body temperature. The nurse may assess the pulse rate for 1 full minute if there is an unexpected change in other vital signs.

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.

An ultrasonic Doppler is used for: A. auscultating a pulse that is difficult to palpate. B. auscultating diastolic blood pressure. C. aiding palpation of pulse and rhythm. D. aiding palpation of diastolic blood pressure.

A. auscultating a pulse that is difficult to palpate. RATIONALE A Doppler device can be used to detect a pulse that is not easily palpable.

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period? A. 0300 B. 1100 C. 1500 D. 1700

D. 1700 RATIONALE Body temperature fluctuates throughout the day. Temperature is usually lowest around 0300 and highest from 1700 to1900.

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.

The nurse is preparing to assess the client's vital signs. The client just had morning coffee. What explanation and action does the nurse take in this situation? A. take a rectal temperature before the client needs to have a bowel movement B. assess and document the oral temperature noting the client had a hot beverage C. wait 30 minutes, then assess the oral temperature because the client had a beverage D. skip the temperature during this vital sign rotation because the client had a beverage

.C wait 30 minutes, then assess the oral temperature because the client had a beverage RATIONALE The hot beverage will affect the oral temperature. The best answer is to wait 30 minutes and then assess the temperature. A rectal temperature is invasive and not warranted. Taking the temperature at that moment will result in an inaccurate measurement. Skipping the temperature assessment is not appropriate nursing care.

A nurse is assessing the respiratory rate of a sleeping infant. What would the nurse document as a normal finding? 12 to 20 breaths/min 30 to 60 breaths/min 60 to 80 breaths/min 80 to 100 breaths/min

30 to 60 breaths/min Explanation: When assessing the respiratory rate of an infant, the nurse knows that the normal respiratory rate of an infant at rest is approximately 30 to 60 breaths/min. The normal respiratory rate of an adult is 12 to 20 breaths/min. A respiratory rate of 60 to 80 breaths/min or 80 to 100 breaths/min is abnormal and is not seen in infants or adults when they are at rest. Tachypnea is an abnormally fast respiratory rate, usually higher than 20 breaths/min in the adult; bradypnea is an abnormally slow respiratory rate, usually lower than 12 breaths/min in the adult.

A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client? A. "Dizziness when you change position can occur when fluid volume in the body is decreased." B. "Dizziness can occur due to changes in the hospital environment." C. "Dizziness can occur when baroreceptors overreact to the changes in BP." D. "Dizziness is caused by very low blood pressure when you lie down."

A. "Dizziness when you change position can occur when fluid volume in the body is decreased." RATIONALE 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.

When assessing an infant's axillary temperature, it will be: A. 1°F (0.5°C) lower than an oral temperature. B. 1°F (0.5°C) higher than a rectal temperature. C. 1°F (0.5°C) higher than an oral temperature. D. the same as the tympanic temperature.

A. 1°F (0.5°C) lower than an oral temperature. RATIONALE Rectal temperatures may be 1°F (0.5°C) higher than oral temperatures and axillary temperatures are 1°F (0.5°C) lower than oral temperatures.

A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variations in normal vital signs, which patients would the nurse document as having a vital sign within normal limits? Select all that apply. A. A 4-month-old infant whose temperature is 38.1°C (100.5°F) B. A 3-year-old whose blood pressure is 118/80 C. A 9-year-old whose temperature is 39°C (102.2°F) D. An adolescent whose pulse rate is 70 beats/min E. An adult whose respiratory rate is 20 breaths/min F. A 72-year-old whose pulse rate is 42 beats/min

A. A 4-month-old infant whose temperature is 38.1°C (100.5°F) D. An adolescent whose pulse rate is 70 beats/min E. An adult whose respiratory rate is 20 breaths/min F. A 72-year-old whose pulse rate is 42 beats/min RATIONALE The normal temperature range for infants is 37.1° to 38.1°C (98.7° to 100.5°F). The normal pulse rate for an adolescent is 55 to 105. The normal respiratory rate for an adult is 12 to 20 breaths/min and the normal pulse for an older adult is 40 to 100 beats/min. The normal blood pressure for a toddler is 89/46 and the normal temperature for a child is 36.8° to 37.8°C (98.2° to 100°F; refer to Table 25-1).

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

A. Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2. RATIONALE 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 notices a student is taking a blood pressure measurement on a patient with a cuff that is too large. What should be the nurse's response to the student? A. If you use the wrong cuff you will get an incorrect reading. B. If you use the wrong cuff you will cause injury to the patient. C. If you use the wrong cuff you will cause dangerous pressure on the arm. D. If you use the wrong cuff you will cause the loss of Korotkoff sounds.

A. If you use the wrong cuff you will get an incorrect reading. RATIONALE A blood pressure cuff that is not the right size may cause an incorrect reading. It will not cause serious injury to the patient, but a small amount of pressure may be felt on the arm from a too tight cuff. It will not cause the loss of Korotkoff sounds.

The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct? A. Lightly compress the client's radial artery using the first, second, and third fingers. B. Encircle the client's antecubital fossa with both hands and lightly compress the brachial artery with the first fingers of both hands. C. Grasp the client's inner wrist with the nondominant thumb positioned over the radial artery. D. Compress the radial artery until no pulsation is felt, then gently remove the fingertips until the pulsation returns.

A. Lightly compress the client's radial artery using the first, second, and third fingers. RATIONALE The radial artery is the most common place to assess a peripheral pulse on an adult. The fingertips are sufficiently sensitive to palpate arterial pulsations using light compression and thus should be used, not the thumbs. The first, second, and third fingers of one hand are used to assess peripheral pulse, not the first fingers of each hand. Take care to avoid completely compressing the 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. Listen for heart sounds. B. Count the heartbeat for 2 minutes. C. Count each "lub-dub" as two beats. D. Palpate the space between the fifth and sixth ribs.

A. Listen for heart sounds. RATIONALE The apex of the heart is found after 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.

Two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 beats/min. How will the nurse document this difference? A. Pulse deficit B. Pulse amplitude C. Ventricular rhythm D. Heart arrhythmia

A. Pulse deficit RATIONALE The difference between the apical and radial pulse rate is called the pulse deficit.

The nurse prepares to take a temperature of a client admitted with a myocardial infarction. The client is eating breakfast. Which action should the nurse choose? A. Take the temperature using the axillary route. B. Wait 3 to 5 minutes after breakfast to take the oral temperature. C. Assess the temperature using the rectal route. D. Cleanse the temporal artery thermometer to prevent a false high reading.

A. Take the temperature using the axillary route. RATIONALE The client had a myocardial infarction, so the rectal route is contraindicated because the stimulation of the vagus nerve could lead to an excessive decrease in the heart rate. The axillary route is the best action to use since the client has recently eaten food and drunk fluids. If the client smoked, chewed gum, or consumed hot or cold food or fluids recently, the nurse should wait 15 to 30 minutes before taking an oral temperature to allow the oral tissues to return to baseline temperature. A dirty probe lens and cone on the temporal artery thermometer can cause a falsely low reading.

The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that would explain the tachycardia? Select all that apply. A. The client has reports of pain of 8 on a scale of 0 to 10 B. The client has a blood pressure of 122/70 mm Hg C. The client just finished ambulating with physical therapy D. The client has a temperature of 101.8°F (38.8°C) E. The client has been drinking water

A. The client has reports of pain of 8 on a scale of 0 to 10 C. The client just finished ambulating with physical therapy D. The client has a temperature of 101.8°F (38.8°C) RATIONALE There are several factors that may cause an increase in heart rate due to an increase in metabolic rate. This can occur with pain, exercise, fever, medications, and strong emotions. A blood pressure of 120/70 mm Hg does not indicate an association with tachycardia or that a client has been drinking water. Caffeinated beverages may cause an increase in heart rate but water would not.

Upon assessment of a patient, the nurse determines that a patient is at risk of losing body heat through the process of convection. What would be the nurse's best response? A. Turn off the overhead fan in the patient's room. B. Remove the patient's ice pack. C. Reduce the temperature in the room. D. Increase the temperature in the room.

A. Turn off the overhead fan in the patient's room. RATIONALE With convection, the heat is disseminated by motion between areas of unequal density, for example, the action of a fan blowing cool air over the body. Turning off the fan would reduce heat loss via convection. Removing the patient's ice pack is an intervention to prevent heat loss via conduction. Reducing the temperature in the room may decrease heat loss via perspiration (evaporation); increasing the temperature in the room might increase heat loss via evaporation.

The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with: A. increased temperature. B. increased cardiac output. C. decreased heart rate. D. decreased respirations.

A. increased temperature. RATIONALE Body temperature can fluctuate with exercise, changes in hormone levels, changes in metabolic rate, and extremes of external temperature.

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods? A. listen with the stethoscope at the fifth intercostal space left mid-clavicular line B. listen with the stethoscope at the fifth intercostal space at the sternum C. listen with a stethoscope at the neck to the right of the coracoid process D. listen with a stethoscope at the second intercostal space left sternum

A. listen with the stethoscope at the fifth intercostal space left mid-clavicular line RATIONALE To assess the apical pulse, the nurse places the stethoscope over the left ventricle. The stethoscope is placed at the level of the fifth intercostal space, left mid-clavicular line. Reference:

A client has an axillary temperature of 102.6 F (39.2°C). Which clinical manifestations would the nurse anticipate? Select all that apply. A. respiratory rate 30/min B. headache C. hunger D. cold, clammy skin E. red or flushed skin

A. respiratory rate 30/min B. headache E. red or flushed skin RATIONALE The following are clinical signs associated with a fever: pinkish or red skin (skin that is warm to the touch), headache, and above-normal pulse or respiratory rates. Clients who are febrile may or may not be hungry. Clients who are febrile have warm, not cold and clammy, skin.

The nurse is talking to an older adult client who performs home blood pressure monitoring (HBPM) and finds that recently her BP measurements have consistently been low. Which factors may contribute to causing this client's BP to be falsely decreased? Select all that apply. Applying too wide a cuff Applying a cuff that is too narrow Assessing the BP immediately after exercise Releasing the valve rapidly Using cracked or kinked tubing

Applying too wide a cuff Releasing the valve rapidly Using cracked or kinked tubing Explanation: Some factors that may contribute to a falsely decreased BP include a cuff that is too wide, releasing the valve too rapidly, and using cracked or kinked tubing. A cuff that is too narrow may cause a falsely elevated BP. Assessing the BP immediately after exercise may cause a falsely elevated BP.

The nurse is attempting to assess a client's radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurse take next? Assess the apical pulse. Assess the carotid pulse. Get another nurse for validation. Document the findings.

Assess the apical pulse. Explanation: If a radial pulse is difficult to assess accurately because it is irregular, feeble, or extremely rapid, the nurse would need to assess the apical pulse rate. By assessing the apical rate the nurse can hear the rate instead of trying to feel the rate. Assessing the carotid pulse would also be done through touch, so the outcome would be the same and not accurate. If the nurse is concerned about the client, it does not hurt to have another nurse check the pulse, but the nurse should assess the apical pulse first. The findings should be documented, but only after all assessments have been completed.

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? Assess the client's ability to stand or sit. Evaluate the client's level of pain. Monitor for the presence of tubes or lines. Place a cover over the sling of the bed scale.

Assess the client's ability to stand or sit. Explanation: The nurse must first assess the client's ability to sit, stand, or lie still to identify the appropriate type of scale to use. Evaluating pain or presence of lines would be done after identifying the type of scale to use. If a portable bed scale is indicated, the nurse would place a cover over the sling of the bed scale.

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? Reassess the client's radial pulse in 15 minutes. Page the client's primary care provider. Auscultate the client's apical heart rate. Palpate the radial pulse on the opposite wrist.

Auscultate the client's apical heart rate. Explanation: Palpation of an irregular radial pulse should be followed by assessment of the apical pulse in order to confirm the finding. Informing the health care provider is generally necessary only when this is a new finding.

A nurse assesses orthostatic hypotension in an older adult. What would be an appropriate intervention for this patient? A. Encourage the patient to rise from a sitting position quickly to improve blood flow. B. Allow the patient to "dangle" for a few minutes prior to rising to a standing position. C. If the patient feels faint or dizzy, return the patient to bed and place in Fowler's position. D. Administer a beta-adrenergic blocker to increase blood pressure.

B. Allow the patient to "dangle" for a few minutes prior to rising to a standing position. RATIONALE Allowing the patient to "dangle" on the edge of the bed prior to rising might prevent orthostatic hypotension. Arising and moving about slowly, especially after a period of bed rest, might also prevent orthostatic hypotension. If a patient becomes dizzy or feels faint, the nurse should return the patient to bed and place in a supine position, which restores blood flow to the brain. A beta blocker is given to decrease blood pressure for a patient with hypertension. There are several medications that raise blood pressure and are used to treat orthostatic hypotension.

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. Reassess the client's radial pulse in 15 minutes. B. Page the client's primary care provider. C. Auscultate the client's apical heart rate. D. Palpate the radial pulse on the opposite wrist.

C. Auscultate the client's apical heart rate. RATIONALE Palpation of an irregular radial pulse should be followed by assessment of the apical pulse in order to confirm the finding. Informing the health care provider is generally necessary only when this is a new finding.

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 uncommon in a client with IICP. B. IICP most commonly results in tachypnea. C. Bradypnea is a response to IICP. D. This is a normal respiratory rate.

C. Bradypnea is a response to IICP. Explanation: The normal respiratory rate for adults is 12 to 20 breaths/min. Bradypnea, a decrease in respiratory rate, characteristically occurs in some pathologic conditions. An increase in intracranial pressure depresses the respiratory center, resulting in slow breathing.

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? A. Notify the health care provider. B. Perform a pain assessment. C. Administer oxygen. D. Auscultate the lung sounds and count respirations.

D. Auscultate the lung sounds and count respirations. RATIONALE 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 nurse assesses an oral temperature for an adult patient and records that the patient is "afebrile." What would be the nurse's best response to this finding? A. Check the patient record for prescribed antipyretic medication. B. Report the finding to the primary care provider. C. Take the patient temperature using a different method. D. No action is necessary; this is a normal reading.

D. No action is necessary; this is a normal reading. RATIONALE Afebrile means without fever. Therefore the temperature assessed is within the normal range for an adult. The nurse does not need to perform any other actions based on this finding.

A nurse documents the following assessment for an infant: temperature 98.9°F (37.2°C), pulse 90 beats/min, respirations 35 breaths/min, and blood pressure 85/37 mm Hg. What is the next appropriate action of the nurse based on these assessments? A. Report an abnormal temperature. B. Report abnormal pulse and respirations. C. Report low blood pressure reading. D. No action is needed; these are normal assessments.

D. No action is needed; these are normal assessments. RATIONALE All of these measurements are within the normal ranges for an infant.

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 needs to press harder until she feels a pulse. 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 should place her three fingers just below the wrist on the outside of the arm with the palm up.

D. She should place her three fingers just below the wrist on the outside of the arm with the palm up. RATIONALE A client is taught to take his or her own pulse before certain medications or after exercise, depending on the individual client's needs. When teaching a client to take his or her own pulse, the nurse should teach the client to sit down and place an arm on a hard service with the palm upward. Using three fingers, the client should feel just below the wrist on the outer side of the arm for the pulse. The client should be taught not to press too hard or the pulse can be obliterated.

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

D. The client is covered with a couple of thick blankets. RATIONALE 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.

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

D. placing the client's arm at heart level RATIONALE 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. Reference:

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.

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 notes that the temperature of an ill client is 101°F (38.3°C). Which intervention would the nurse take to regulate the client's body temperature? Apply a blanket on the client. Give the client a bath in tepid water. Increase the client's metabolic rate. Set up a fan to blow warm air on the client.

Give the client a bath in tepid water. Explanation: The body loses heat to the water through conduction during tepid baths. Applying a blanket would reduce radiant heat loss and would raise the client's temperature. Increasing the body's metabolic rate will result in an increase in temperature. Blowing warm air over the client will increase the temperature.

The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next? Record the reading in the chart. Inflate the cuff about 30 mm Hg above the auscultatory gap. Use the bell of the stethoscope to listen for the diastolic sound. Inflate the cuff about 10 mm Hg above the auscultatory gap.

Inflate the cuff about 30 mm Hg above the auscultatory gap. Explanation: To find the auscultatory gap, palpate the brachial or radial pulse while inflating the cuff. Inflate the cuff about 30 mm Hg above the number where palpable pulsation disappears. In addition to detecting an auscultatory gap, palpation gives an initial estimate of systolic blood pressure and eliminates the need to inflate the cuff to extremely high pressures in people with normal or low blood pressure. Using the bell of the stethoscope to listen for the systolic and diastolic sound is expected. Recording of the blood pressure should occur after the blood pressure is obtained.

A client monitoring his BP at home notices that his BP is higher in one arm than the other. He calls his health care provider for guidance. What is the most appropriate information for the nurse to give this client? It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results. It has been found that most people have differences in BP between arms and that he should use the arm that gives him the lowest reading for accurate results. This has no impact on BP readings and he should continue doing what he has been doing. This is unusual and he should be seen by the physician as soon as possible.

It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results. Explanation: It has been found that most people have differences in BP between arms. For accurate results, the client should use the arm that gives him or her the highest reading.

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 patients, 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.

A patient is experiencing dyspnea. What is the nurse's priority action? A. Remove pillows from under the head. B. Elevate the head of the bed. C. Elevate the foot of the bed. D. Take the blood pressure.

B. Elevate the head of the bed. RATIONALE Elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm greater room for expansion and facilitating lung expansion.

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 15 to 20 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 15 to 20 minutes before measuring the oral temperature Explanation: The nurse should wait for 15 to 20 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, inspiratory sound that may be compared to crowing

a harsh, inspiratory sound that may be compared to crowing Explanation: Stridor is a harsh, 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.

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.

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 client's blood pressure has gradually decreased in the last 2 days. Which condition would cause this change? the client who has unresolved pain issues the client who has been given 3 units of whole blood the client who has had persistent diarrhea the client who is to be discharged home on hospice

the client who has had persistent diarrhea Explanation: Vital signs—body temperature (T), pulse (P), respirations (R), and blood pressure (BP)—indicate the function of some of the body's homeostatic mechanisms. Measurement and interpretation of the vital signs are important components of assessment that can yield information about underlying health status.

Which client's blood pressure best describes the condition called hypotension? A. 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. C. The systolic reading is above 102 and diastolic reading is above 60. D. 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. RATIONALE 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 nurse instructor is teaching student nurses about the factors that may affect a patient's blood pressure. Which statements accurately describe these factors? Select all that apply. A. Blood pressure decreases with age. B. Blood pressure is usually lowest on arising in the morning. C. Women usually have lower blood pressure than men until menopause. D. Blood pressure decreases after eating food. E. Blood pressure tends to be lower in the prone or supine position. F. Increased blood pressure is more prevalent in African Americans.

B. Blood pressure is usually lowest on arising in the morning. C. Women usually have lower blood pressure than men until menopause. E. Blood pressure tends to be lower in the prone or supine position. F. Increased blood pressure is more prevalent in African Americans. RATIONALE Blood pressure increases with age due to a decreased elasticity of the arteries, increasing peripheral resistance. Blood pressure is usually lowest on arising in the morning. Women usually have lower blood pressure than men until menopause occurs. Blood pressure increases after eating food. Blood pressure tends to be lower in the prone or supine position. Increased blood pressure is more prevalent and severe in African American men and women.

The nurse needs to assess the carotid arteries of the client. Which assessment technique would be appropriate for the nurse to use? A. Palpate both arteries at the same time. B. Palpate one artery at a time. C. Measure the rate for 1 full minute. D. Measure the rate for 30 seconds and multiply by 2.

B. Palpate one artery at a time. RATIONALE To palpate the carotid arteries, the nurse would lightly press on one side of the neck at a time. Never attempt to palpate both carotid arteries at the same time as bilateral palpation could result in reduced cerebral blood. It is not necessary to count the carotid rate.

A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature? A. Ear B. Rectum C. Axilla D. Mouth

B. Rectum RATIONALE The rectal temperature, a core temperature, is considered to be one of the most accurate routes.

A patient has intravenous fluids infusing in the right arm. How should the nurse obtain the blood pressure on this patient? A. Take the blood pressure in the right arm. B. Take the blood pressure in the left arm. C. Use the smallest possible cuff. D. Report inability to take the blood pressure.

B. Take the blood pressure in the left arm. RATIONALE The blood pressure should be taken in the arm opposite the one with the infusion.

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. This infant will need a home cardiac monitor set up. B. The parents should be encouraged to get a 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 that they can listen to and count the infant's apical pulse. D. 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.

C. The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse. RATIONALE If a peripheral pulse is difficult to assess accurately because it is irregular, weak, or very rapid, the apical rate should be assessed using a stethoscope. An apical pulse is also assessed when giving medications that alter heart rate and rhythm. Apical pulse measurement is also the preferred method of pulse assessment for infants and children younger than 2 years of age. Families can be taught to use a stethoscope to check a pulse. This infant does not need a cardiac monitor, the parents should not be encouraged to get a neighbor or family friend to help, and these parents can be taught to check this infant's pulse accurately.

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 a nonauscultatory gap. B. There is a widening in the diameter of the artery. C. There is an auscultatory gap. D. There is an adult diastolic pressure.

C. There is an auscultatory gap. RATIONALE An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mmHg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff sound technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff sound technique.

A nurse is documenting a blood pressure of 120/80 mm Hg. The nurse interprets the 120 to represent: A. the rhythmic distention of the arterial walls as a result of increased pressure due to surges of blood with ventricular contraction. B. the lowest pressure present on arterial walls while the ventricles relax. C. the highest pressure present on arterial walls while the ventricles contract. D. the difference between the pressure on arterial walls with ventricular contraction and relaxation.

C. the highest pressure present on arterial walls while the ventricles contract. RATIONALE The systolic pressure is 120 mm Hg. The diastolic pressure is 80 mm Hg, the lowest pressure present on arterial walls when the heart rests between beats. The difference between the systolic and diastolic pressures is called the pulse pressure. The rhythmic distention of the arterial walls as a result of increased pressure due to surges of blood with ventricular contraction is the pulse.

Which guideline should the nurse follow when assessing a client's blood pressure using a Doppler ultrasound? Take the measurement with the client in a standing position with the appropriate limb exposed. Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery. If using a mercury manometer, check to see that the manometer is in the horizontal position and that the mercury is within the zero level. Monitor for serial readings and check the cuffed limb frequently for inadequate arterial perfusion and venous drainage.

Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery. Explanation: When performing blood pressure assessment via Doppler ultrasound, the nurse will have the client assume a comfortable lying or sitting position with the appropriate limb exposed and center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery. If using a mercury manometer, the nurse will check to see that the manometer is in the vertical position and that the mercury is within the zero level with the gauge at eye level. The nurse then hold the Doppler in the nondominant hand. Using the dominant hand, the nurse places the Doppler tip in the gel, adjusts the volume as needed, and moves the Doppler tip around until hearing the pulse.

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 the systolic blood pressure measurement in the client? Phase I Phase II Phase III Phase IV

Phase I Explanation: Phase I is when the nurse will hear and document systolic blood pressure. There has been discussion in the past as to using phase IV or V of the Korotkoff sounds for recording diastolic pressure, but there is now a general consensus that phase V should be used to define diastolic pressure for all age groups.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 nurses 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.

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. Skin color change Neurological assessment Lip and nail bed changes Facial muscle twitching Sensory impairment

Skin color change Lip and nail bed changes Sensory impairment Explanation: On each client turn, the nurse assesses the client's skin, looking for any color changes to the skin, lips, and nail beds, as well as any areas where there is sensory deficit. A neurological assessment is completed every 15 minutes until the body temperature is stabilized. Additional assessments would include evaluating for shivering and facial muscle twitching, but these are not part of a skin assessment.

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 will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify? Preferred site for temperature assessment The client's nutritional status The client's most recent temperature The client's wellness goals

The client's most recent temperature Explanation: Prior to assessment, the nurse should note the client's baseline or previous temperature measurements. Assessment results must always be considered in light of client-specific baselines. The client's wellness goals are important, but these are not directly relevant to temperature assessment. Similarly, nutritional status has a minimal bearing on temperature assessment. The client's preferred site for assessment is important, but the nurse ultimately determines the most appropriate site based on nursing knowledge.

The nurse is assessing the blood pressure of a hospitalized client using a Doppler ultrasound device. Which actions are performed correctly? Select all that apply. The nurse places the client in a comfortable lying or sitting position. The nurse centers the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. The nurse wraps the cuff around the limb smoothly and snugly and fastens it. The nurse checks that the needle on the aneroid gauge is within the zero mark. The nurse checks to see that the manometer is in the horizontal position. The nurse opens the valve to the sphygmomanometer once the pulse if found.

The nurse places the client in a comfortable lying or sitting position. The nurse centers the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. The nurse wraps the cuff around the limb smoothly and snugly and fastens it. The nurse checks that the needle on the aneroid gauge is within the zero mark. Explanation: Lying or sitting in a comfortable position allows for a more accurate measurement. Pressure in the cuff applied directly to the artery provides the most accurate readings. A smooth cuff and snug wrapping produce equal pressure and help promote an accurate measurement. A cuff wrapped too loosely results in an inaccurate reading. An aneroid gauge must be at zero when beginning to measure the blood pressure to help in ensuring accuracy. The manometer must be in the vertical position for BP measurement. Once the pulse is found with the Doppler the nurse should close the valve on the sphygmomanometer to allow for inflation of the BP cuff bladder.

A nurse is explaining to a nursing student why blood pressure is a frequently used assessment parameter in a wide variety of care settings. What can be inferred from an assessment of a client's blood pressure? The amount of oxygen available to tissues throughout the body The volume of the venous system relative to the volume of the arterial system The size of the client's heart muscle The resistance that the client's heart must overcome when pumping blood

The resistance that the client's heart must overcome when pumping blood Explanation: Blood pressure is representative of the amount of resistance that the heart must overcome in order to pump blood; increased BP equates with increased resistance, or afterload. Blood pressure is not necessarily indicative of oxygen supply, the relative volumes of the venous and arterial systems or the size of the heart.

Prioritization: Place the following descriptions of the phases of Korotkoff sounds in order from phase I to phase V. A. Characterized by muffled or swishing sounds that may temporarily disappear; also known as the auscultatory gap B. Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery C. The last sound heard before a period of continuous silence, known as the second diastolic pressure D. Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; known as the systolic pressure E. Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; considered to be the first diastolic pressure

d, a, b, e, c. RATIONALE Phase I is characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; the first tapping sound is the systolic pressure. Phase II is characterized by muffled or swishing sounds, which may temporarily disappear, especially in hypertensive people; the disappearance of the sound during the latter part of phase I and during phase II is called the auscultatory gap. Phase III is characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery. Phase IV is characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; in adults, the onset of this phase is considered to be the first diastolic pressure. Phase V is the last sound heard before a period of continuous silence; the pressure at which the last sound is heard is the second diastolic pressure.

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.

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.

The nurse knows that a client who is being taught to perform home blood pressure monitoring (HBPM) understands the teaching plan when he makes which statement about the size of the BP cuff? The cuff should: fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow. fit snug around the upper arm with room to slip a fingertip under the cuff and should be touching the crease of the elbow. fit snug around the upper arm with room to slip three fingertips under the cuff and should be 1 in (2.5 cm) above the crease of the elbow. fit snug around the upper arm with no room to slip a fingertip under the cuff and should be 2 in (5 cm) above the crease of the elbow.

fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow. Explanation: When teaching a client to perform home blood pressure monitoring (HBPM), he or she should be taught that the proper fitting cuff should fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow.

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.

Which term indicates a potentially serious client condition? pyrexia pulse pressure eupnea afebrile

pyrexia Explanation: Pyrexia means an increase above normal in body temperature. Pulse pressure is an objective term related to the pulse. Eupnea means a normal breathing pattern. Afebrile means that the body temperature is not elevated.