Question 1

The nurse has assigned nursing assistive personnel to obtain the blood pressures on the unit's clients.Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate communication of the BP readings?

Accepted Answer

The nurse is responsible for assessing the impact of changes in blood pressure and so must be promptly made aware of each client's reading,not merely the values that the assistive personnel believes to be high.The questions asked may reflect a need for further instruction,but the issues are not as critical as the need to report all readings for the nurse to evaluate.

Question 2

The nurse is assessing an elderly client's blood pressure during a routine visit.When asked,the client volunteers that when he took his pressure at home yesterday it was 126/72 mm Hg.The nurse determines that the client's pressure today is 134/70 mm Hg.The nurse recognizes that the most likely cause of the elevation is:

Accepted Answer

Blood pressure measurements taken at the client's place of employment or in a health care provider's office are higher than those taken at the client's home.The remaining options may be a factor but they are not the most likely.

Question 3

The nurse has asked the assistive personnel to take the blood pressure of a client who experienced a left mastectomy 3 days ago.Which of the following statements by the assistive personnel shows the best understanding regarding the appropriate assessment technique for this particular client?

Accepted Answer

Avoid applying the cuff to the extremity when intravenous fluids are infusing;an arteriovenous shunt or fistula is present;breast or axillary surgery has been performed on that side;or the extremity has been traumatized,diseased,or requires a cast or bulky bandage.The answer reflects an understanding that the right arm is the extremity of choice for monitoring this client's blood pressure.

Question 4

The nurse appropriately instructs trained ancillary personnel to use an electronic blood pressure cuff to take the blood pressure of which of the following clients?

Accepted Answer

Blood pressure less than 90 mm Hg systolic,irregular heart rate,peripheral vascular obstruction (e.g. ,clots,narrowed vessels),shivering,seizures,excessive tremors,and inability to cooperate are reasons to avoid using an electronic BP monitor.The answer reflects the client whose BP is most stable and best assessable via electronic BP monitor.

Question 5

The nurse is using a manual cuff to assess the blood pressure of a client experiencing hypertension.To best ensure accommodation for a possible auscultatory gap,the nurse should use which of the following as a guide for inflating the cuff appropriately?

Accepted Answer

The examiner needs to be certain to inflate the cuff high enough to hear the true systolic pressure before the auscultatory gap.Palpation of the radial artery helps to determine how high to inflate the cuff.The examiner inflates the cuff 30 mm Hg above the pressure at which the radial pulse was palpated.Taking the blood pressure in various positions will not help eliminate the possible loss of auditory sound between the systolic and diastolic sounds.While asking the client and/or reviewing the chart may provide information concerning the client's pressure,these options are not the recommended method for minimizing the effect of the auditory gap on the assessment process.

Question 6

An individual contacts the emergency department of the local hospital to ask what to do for a skiing partner who appears to be suffering from hypothermia.The victim is alert and able to respond to questions.The nurse instructs the individual who has called to have the victim:

Accepted Answer

A conscious client benefits from drinking hot liquids such as soup.Alcohol should be avoided.
Caffeinated fluids should be avoided.Extremities should be warmed gradually.Tissue damage could occur if placed under hot water.The entire body should be warmed,such as by putting heating pads next to the head and neck that lose heat the quickest.

Question 7

The nurse measures the blood pressure in the leg due to the fact that the client has bilateral casts on the upper extremities.The nurse palpates the pulse before the measurement at the:

Accepted Answer

The popliteal artery,palpable behind the knee in the popliteal space,is the site for auscultation when taking the blood pressure in the leg.The inner side of the ankle,top of the foot,and inguinal ligament are not the correct sites for assessment.

Question 8

The nurse has assigned nursing assistive personnel to obtain the blood pressures on the unit's clients.Which of the following statements made by the assistive personnel shows the best understanding regarding appropriate communication of the BP readings?

Accepted Answer

The nurse is responsible for assessing the impact of changes in blood pressure and so must be aware of each client's reading,not merely the values that the assistive personnel believes to be high.Asking the client to share what their BP is routinely and/or retaking a questionable reading is appropriate but not directly related to effective communication of the findings.

Question 9

Upon entering the room,the nurse notes that the client has an irregular respiratory rate,with periods of apnea and increases in respiration,followed by a reversal of the pattern.The nurse reports this respiratory assessment as:

Accepted Answer

Cheyne-Stokes respirations are characterized by an irregular respiratory rate with alternating periods of apnea and hyperventilation.The respiratory cycle begins with slow,shallow breaths that gradually increase to an abnormal rate and depth.The pattern then reverses,breathing slows and becomes shallow,and the pattern climaxes in apnea before respiration resumes.Biot's respirations are abnormally shallow for two to three breaths followed by an irregular period of apnea.Kussmaul's respirations are abnormally deep,regular,and increased in rate.Hyperpneic respirations are labored,increased in depth,and increased in rate (>20 breaths/min);they normally occur during exercise.

Question 10

The nurse has assigned nursing assistive personnel to obtain the temperatures on the unit's clients.Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate temperature monitoring orally?

Accepted Answer

When taking oral temperature,wait 20 to 30 min before measuring temperature if the client has smoked or ingested hot or cold liquids or foods.The nurse needs to reinforce this information so that the assessment will occur before breakfast or to allow enough time to pass after breakfast so as not to affect the readings.The options containing a question reflect a need for knowledge but do not have priority over an obvious indication of possible poor assessment technique.The nurse needs to evaluate the readings and so should be sure to give the assistive personnel guidance as to what readings are "running high."

Question 11

Which of the following sites is best suited for measuring oxygen saturation (pulse oximetry)?

Accepted Answer

Determine most appropriate client-specific site (e.g. ,finger,earlobe)for sensor probe placement by measuring capillary refill.If capillary refill is greater than 3 seconds,select an alternate site.Sites should be free of moisture and tremors,and the nail should be free of polish (no artificial nails).

Question 12

The nurse has assessed a client's blood pressure (BP)using the left thigh because of bilateral upper arm casts.The client's precasting left arm BP was 108/70 mm Hg.The nurse expects the present BP reading to be:

Accepted Answer

Systolic pressure in the legs is usually higher by 10 to 40 mm Hg than in the brachial artery,but the diastolic pressure is the same.

Question 13

A spouse assists the nurse evaluating the measurement of the client's blood pressure.The nurse feels additional teaching is required if the spouse is observed:

Accepted Answer

The client's blood pressure should not be measured after the client has exercised,smoked,or ingested caffeine.The client should wait 30 minutes before assessment of the blood pressure.
The cuff should be deflated at a rate of 2 mm Hg per second.When possible,the client should be sitting in a chair.The blood pressure should be assessed at the same time each day.

Question 14

The nurse appropriately instructs trained ancillary personnel to avoid using an electronic blood pressure cuff to take the blood pressure of which of the following clients?

Accepted Answer

Blood pressure less than 90 mm Hg systolic,irregular heart rate,peripheral vascular obstruction (e.g. ,clots,narrowed vessels),shivering,seizures,excessive tremors,and the inability to cooperate are reasons to avoid using an electronic BP monitor.The client's Parkinson's disease causes tremors,so a manual cuff should be used when assessing this client's BP.

Question 15

The nurse has assigned the vital signs of the elderly clients residing in the facility's assisted living unit to the nursing assistant.Which of the following statements made by the ancillary personnel requires immediate correction by the RN?

Accepted Answer

RAT: The temperature of older adults is at the lower end of the normal temperature range,36° to 36.8° C (96.9° to 98.3° F)orally and 36.6° to 37.2° C (98° to 99° F)rectally.Therefore temperatures considered within normal range sometimes reflect a fever in an older adult.The normal range for blood pressure is the same for older adults and younger people,while older adults depend more on accessory abdominal muscles during respiration than on weaker thoracic muscles,so observing the rise and fall of the abdomen would not be inappropriate.Once elevated,the pulse rate of an older adult takes longer to return to normal resting rate,so waiting 30 minutes would not be inappropriate.

Question 16

The nurse is assessing a client's blood pressure to establish a baseline.The pressure in the right arm is 12 mm Hg lower than that in the left arm.The nurse most appropriately realizes that these data:

Accepted Answer

During the initial assessment,obtain and record the blood pressure in both arms.Normally there is a difference of 5 to 10 mm Hg between the arms (Lane and others,2002).In subsequent assessments,measure the blood pressure in the arm with the higher pressure.Pressure differences greater than 10 mm Hg indicate vascular problems and are reported to the health care provider or nurse in charge.Reporting the assessment findings is the most appropriate outcome.

Question 17

The client's apical pulse will be taken by a student.According to the nurse the stethoscope should be placed along the left clavicular line at the:

Accepted Answer

An apical pulse should be assessed at the client's PMI.The PMI is located at the fourth to fifth intercostal space at the left midclavicular line.Second to third intercostals space is not the correct placement for auscultating a client's apical pulse.The PMI is higher and more medial in children under 8 years old,thus the third to fourth is incorrect.The client is not identified as being a child.
Fifth to sixth is not the correct placement for auscultating a client's apical pulse.

Question 18

The nurse recognizes that which of the following clients present at the annual July 4th marathon is at greatest risk for hyperthermia and the resulting heatstroke?

Accepted Answer

Clients at risk include those who are very young or very old and those who have cardiovascular disease,hypothyroidism,diabetes,or alcoholism.Also at risk are those who take medications that decrease the body's ability to lose heat (e.g. ,phenothiazines,anticholinergics,diuretics,amphetamines,and beta-adrenergic receptor antagonists)and those who exercise or work strenuously (e.g. ,athletes,construction workers,and farmers).While all the options represent risk factors,the degree of exercise,medical history,and age are greatest for the 16-year-old client with diabetes.

Question 19

The nurse recognizes that which of the following clients present at the annual July 4th marathon is showing the most compelling signs of hyperthermia and the resulting heatstroke?

Accepted Answer

Signs and symptoms of heatstroke include giddiness,confusion,delirium,excess thirst,nausea,muscle cramps,visual disturbances,and even incontinence.Vital signs reveal a body temperature sometimes as high as 45° C (113° F)with an increase in heart rate and lowering of blood pressure.The most important sign of heatstroke is hot,dry skin.Victims of heatstroke do not sweat because of severe electrolyte loss and hypothalamic malfunction.If the condition progresses,the client with heatstroke becomes unconscious with fixed,unreactive pupils.Permanent neurological damage occurs unless cooling measures are rapidly started.

Question 20

The nurse enters the room to measure the client's pulse rate.The nurse recognizes that the client's rate may be increased as a result of:

Accepted Answer

Fever and heat may increase a client's pulse rate.Digoxin is a negative chronotropic drug;it will decrease the client's pulse rate.A conditioned athlete who participates in long-term exercise will have a lower heart rate at rest.Unrelieved severe pain increases parasympathetic stimulation;decreasing the heart rate.

Quiz 32: Vital Signs