Vital Signs Post Test

A nurse is obtaining a client's vital signs. The client has a new onset of a new onset of a temp of 39 degrees C (102 degrees F). Which of the following other vital signs should the nurse expect? A. An elevated pulse rate B. A decreased BP C. An elevated BP D. A decreased pulse rate

A. ***A fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate

A nurse is measuring a client's temperature orally. Which of the following actions should the nurse take? A. Place the probe in the posterior lingual pocket lateral to the midline B. Rest the probe on the lower lingual frenulum C. Place the probe centrally on top of the client's tongue D. Rest the probe under the tongue just beyond the client's teeth

A. ***the heat produced by superficial blood vessels in the right and the left posterior sublingual pocket is what generates and accurate oral temperature reading. Inserting the probe "sideways" into the back of the area under the tongue on the left or the right will access this area

A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider? A. Oral temp. 37.8 degrees C (100 degrees F) B. Respiration 30/min C. BP 148/88 mm Hg D. Radial Pulse rate 45 beats/30 seconds

B. ***Respirations of 30/min is above the expected reference range of 12 to 20/min and indicates the need for immediate attention. An adult client who has respirations of 30/min is experiencing shortness of breath, or dyspnea. Without intervention, this can become a life-threatening situation

A nurse is preparing to record the difference between a client's systolic and diastolic BP. Which of the following terms defines this information when documenting? A. Auscultatory gap B. Pulse Pressure C. Orthostatic hypotension D. Pulse deficit

B. ***The difference b/w the systolic and diastolic pressures is the pulse pressure. If the client's blood pressure is 130/85mm HG, the pulse pressure is 45 mm Hg. Pulse pressure can be a predictor of heart conditions, especially in older adults. For example, an elevated pulse pressure usually reflects stiffness and reduced elasticity of the aorta, most often due to hypertension or atherosclerosis.

A nurse is assessing a client's respiration. Which of the following actions should the nurse take? A. Have the client lie flat in bed with their head on a pillow B. Elevate the head of the client's bed 45 to 60 degrees C. Encourage the client to breathe shallowly D. Ask the client to take several deep breaths prior to the assessment

B. ***This is a comfortable position for most clients and it allows full ventilatory movement. Discomfort can increase a client's respiratory rate.

A nurse is preparing to auscultate a client's apical pulse at the point of maximal impulse (PMI). In which of the following locations should the nurse position the stethoscope? A. Over the right midclavicular line B. Over the angle of Louis C. Overt the fifth intercostal space at the left midclavicular line D. Over the suprasternal notch

C. ***To locate the PMI, the nurse should first locate the angle of Louis, a bony prominence just below the suprasternal notch. The nurse should then side their fingers down each side of the angle of Louis to locate the second intercostal space. Next, the nurse should gently move their fingers down the left side of the sternum to the fifth intercostal space and laterally to the left midclavicular line. This is the PMI.

A nurse is preparing to use a tympanic thermometer to acquire a client's temperature. Which of the following actions should the nurse take to ensure an accurate reading? A. Attach the disposable probe cover B. Assess the external ear for redness C. Pull the pinna back and upward gently D. Replace the thermometer in its charger

C. ***Gently pulling the pinna back and upward helps straighten the ear canal and provides optimal access to the tympanic membrane. Good contact with sufficient tympanic membrane is essential for an accurate tympanic temp. measurement

A nurse is auscultating a client' apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs? A. When the atria contracts vigorously B. As the ventricular walls contract C. When the semilunar valves close D. As the mitral valve snaps open

C. ***The second heart sound, S2, is generated by the closure of the aortic and pulmonic valves, or semilunar valves, and signals the start of diastole. S2 is the "dub" heard in the normal "lub-dub" sound.

A nurse is taking an adult client's temperature rectally. Which of the following actions should the nurse take? A. Rotate the probe if any resistance is met as the thermometer is inserted B. Insert the probe to aim at the client's pelvic area C. Dip the probe about 0.58cm (2in) into a tube of lubricant D. Insert the probe about 2.5 cm (1in) into the client's anus

D. ***An insertion depth of 2.5 to 3.5 cm (1 to 1.5 in) for an adult ensures sufficient exposure of the probe to the blood vessels in the rectal wall. Positioning the probe against the blood vessels enables it to measure heat maximally and accurately

A nurse is establishing baseline for a client's respirations. Which of the following actions should the nurse take? A. Instruct the client to breathe in and to exhale out as they normally do B. Count the client's respirations for 15 seconds then multiply by 4 C. Determine if the client has a history of any chronic respiratory problems D. Observe the client's chest movements while appearing to assess their pulse

D. ***The nurse is most likely to observe the true respiratory pattern (rate, rhythm, and depth) when the client is unaware that they are being assessed. When clients know their respiration is being observed, it is common for them to alter their respiratory pattern either voluntarily or involuntarily

A nurse is collecting data about a client's respiratory condition . Which of the following actions should the nurse take to determine the depth of the client's respiration? A. Observe the degree of chest-wall movement during inspiration and expiration B. Count how many breathing cycles are observed per minute C. Notice whether or not expiration takes longer than inspiration D. Measure the precise amount of air the client takes in and breathes out

A. The nurse can determine the depth of respiration subjectively by evaluating how much chest-wall movement is observed. The movement is generated b the movements of the diaphragm and intercostal muscles as the client breathes. With shallow respiration, the nurse will observe very little movement. Deep respiration involves full expansion of the lungs, which is usually quite visible.

A nurse is preparing to measure a client's vital signs. The nurse should identify that which of the following factors will affect the methods that are used? (Select all that apply) A. The client who has a BMI of 35 B. The client has ha nausea for 2 days C. The client is reporting a "stuffy nose" D. The client has been fasting for blood tests E. The client is taking digoxin for an irregular heart rate F. The client had a mastectomy 2 years ago

A., C.,E., F. ***The client who has a BMI of 35 is overweight and has a larger-than-average upper-arm circumference. Therefore, the nurse should use a large blood-pressure cuff, instead of a regular-sized cuff. to ensure an accurate blood-pressure reading. ***The client who has nasal congestion might resort to "mouth breathing," which would alter an oral temperature measurement. A respiration assessment for a full 60 seconds should also be included. ***The presence of a cardiovacular condition that warrants pharmacological digoxin therapy would require an assessment of the client's apical pulse for a full 60 seconds. ***Lymphatic drainage might be altered in the client's affected arm following a mastectomy. The application of pressure from the assessment of blood pressure could result in a painful condition called lymphedema

A nurse is preparing to obtain a client's blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately? A. Obtain the reading in the early morning B. Use a cuff of the appropriate size for the client C. Assist the client to the bathroom to void D. Apply the cuff loosely around the client's arm

B. ***Using the wrong cuff size for the client will result in an erroneous reading . A cuff that is too small will result in a reading that is falsely high and using a cuff that is too big will record a false low. One way to select a cuff is to make sure that the width of the cuff is 40% of the arm circumference where the cuff will be wrapped. The bladder, which is inside the cuff, should surround 80% of the arm circumference.

A nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading correlate to? A. It corresponds to the client's systolic pressure B. It is the second diastolic pressure to record C. It is the loudest of the Korotkoff sounds D. It might not follow with a fifth Korotkoff sound

D. ***Most clinicians consider the fifth Korotkoff sound, which is actually the disappearance of sound, as an adult client's diastolic blood pressure. However, with some clients, there is no distinct fifth sound. You hear sounds all the way to 0 mm Hg. For these clients, the nurse should record the fourth Korotkoff sound as the diastolic BP