Besides high blood pressure values, what other signs and symptoms may the nurse observe if hypertension is present? Show An 82-year-old widower brought via ambulance is admitted to the emergency department with complaints of shortness of breath, anorexia, and malaise. He recently visited his health care provider and was put on an antibiotic for pneumonia. The client indicates that he also takes a diuretic and a beta blocker, which helps his "high blood." Which vital sign value would take priority in initiating care? The client, who has been on bed rest for 2 days, asks to get out of bed to go to the bathroom. He has new orders for "up ad lib." What action should the nurse take? Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 36.1° C (97° F). The client's remaining vital signs are in the normally acceptable range. What should the nurse do next? The nurse decides to take an apical pulse instead of a radial pulse. Which of the following client conditions influenced the nurse's decision? The nurse is to measure vital signs as part of the preparation for a test. The client is talking with a visiting pastor. How should the nurse handle measuring the rate of respiration? Delegation of some tasks may become one of the decisions the nurse will make while on duty. For which of the following clients would it be most appropriate for unlicensed assistive personnel to measure the client's vital signs? The client has an oral temperature of 39.2° C (102.6° F). What are the most appropriate nursing interventions? The hypothalamus controls body temperature. The anterior hypothalamus controls heat loss,
and the posterior hypothalamus controls heat production. What heat conservation mechanisms will the posterior hypothalamus initiate when it senses that the client's body temperature is lower than comfortable? The nurse's documentation indicates that a client has a pulse deficit of 14 beats. The pulse deficit is measured by: A) Subtracting 60 (bradycardia) from the client's pulse rate and reporting the difference The nurse observes that a client's breathing pattern represents Cheyne-Stokes respiration. Which statement best describes the Cheyne-Stokes pattern? The nurse finds that the systolic blood pressure of an adult client is 88 mm Hg. What are the appropriate nursing interventions? 52 year old woman admitted with dyspnea and discomfort in her left chest with deep breaths. SHe smoked for 35 years and recently lost over 10 pounds. What vital sign should not be delegated to a nursing assistant: Place the vital signs in order of priority for your nursing interventions: 82 yr old admitted via ambulance to ER with shortness of breath, anorexia, and malaise. He recently visited the health
care center and is on antibiotic for pneumonia. He is also on a diuretic, beta-adrergic blocker, which helps his "high blood". Which of the following clients would be most at risk of hypothermia? a 14 year old b 25 year old c 40 year old d 76 year old A nurse getting report at the beginning of shift learns that an assigned client has hyperpyrexia. The nurse realizes that this client is experiencing which of the following signs or symptoms? A.. extreme bleeding of the gums B. a very high fever, such as 41°C or 105.8°F C. waxy flexibility of the muscles D. third-degree burns over much of the body You are ready to take the client's oral temperature. You ask this client how long it has been since drinking something hot or cold or smoking. The client admits having just drunk a cup of hot coffee. You will wait how long before taking the temperature? A. 5 minutes B. 10 minutes C. 20 minutes D. 30 minutes In which of the following clients is a rectal temperature most usually contraindicated? A. client who has had a myocardial infarction B. client with Parkinson's disease C. client who is prone to seizures D. client with neuropathology associated with diabetes A When taking a radial pulse for half a minute, the nurse finds it to be irregular. Which of the following would be best for the nurse to do next? A. Take the radial pulse for one minute. B. Check the carotid pulse to see if it is irregular. C. Assess the apical pulse. D. Chart the radial pulse and the irregularities. The nurse wants to check the popliteal pulse. This pulse can be better palpated if the nurse does which of the following things? A. Ask the client to extend the knee. B. Have the client flex the knee. C. Press lightly on the right side of the front of the knee. D. Palpate more deeply than for other pulses. The nurse is taking the client's blood pressure. The physician asks for the pulse pressure. To obtain the pulse pressure, the nurse will have to do which of the following things? A. Obtain a pulse-pressure machine. B. Subtract the diastolic blood pressure from the systolic. C. Subtract the systolic blood pressure from the diastolic. D. Take client's apical pulse and subtract it from systolic. The nurse notices that the client has a hematocrit of 70 percent. This level of hematocrit will most likely affect the vital signs in which of the following ways? A. The blood pressure will be elevated. B. The pulse will be low. C. Temperature will be elevated. D. Blood pressure will be low. A. A nurse assesses an oral temperature for a patient as 38.5°C (101.3°F). What term would the nurse use to report this
temperature? A nurse is assessing vital signs on several hospitalized children. the nurse would plan to use the oral route to assess temperature for which patient? When assessing a temperature rectally, the nurse would use extreme care when inserting the thermometer to prevent which of the following? A insertion of a rectal thermometer may stimulate the vagus nerve, which in turn, would decrease heart rate. This may potentially be harmful for patients with cardiac problems While taking an adult patient's pulse, a nurse finds the rate to be 140 bpm. what should the nurse do next? C. report the rate. A heart rate of 140 bpm in an adult is abnormal and should be reported to the instructor or the nurse in charge of the patient. A patient complains of severe abdominal pain. when assessing the vital signs, the nurse would not be surprised to find what assessment? D. an increase in pulse rate. pulse often increases when someone experiencing pain. pain doesn't affect body temp, and may increase (not decrease) BP. acute pain may increase respiratory rate, but decrease depth Two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 bpm. the nurse would document this difference as which of
the following? Before assessing respirations, the nurse reviews normal rates for adults. which rate would the nurse identify as normal? A patient is having dyspnea. what
would the nurse do first? A. elevate the head of the bed. Elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm greater room for expansion and facilitating lung expansion. A
student nurse is learning to assess BP. What does the BP measure? A. force of blood against atrial walls A nurse knows BP is often higher in older adults based on the understanding that which of the following occurs with aging?
C. decreased elasticity in arterial walls A patient has a BP reading of 130/90 mmHg when visiting a clinic. What would a nurse
recommend to the patient? D. follow-up BP measurements. A single reading of a mildly elevated BP is not significant, but 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. It is important to have the appropriate cuff size when taking the BP. what error may occur when the cuff size is wrong? A patient has intravenous fluids infusing in the
right arm. when taking a BP on this patient, what would the nurse do in this situation? A. take it in the left arm. Which vital signs are routinely measured? Select all that apply. 1. Pulse oximetry & blood pressure 2. Body Temperature 4. Pulse & respiration Heat is lost from the body by which processes? A. Radiation, conduction, convection, evaporation B. Evaporation, convection, crying, conduction C. Convection, conduction, sneezing, radiation D. Radiation, conduction, shivering, evaporation gastrointestinal (GI) tract body area containing the organs of the digestive tract, it extends from the mouth to the anus What should a nurse do if the radial pulse is irregular?What is the nurse's priority action if a patient's radial pulse has an irregular rhythm? Reassess the pulse for 1 full minute. Assess the patient for a pulse deficit. Wait 5 minutes, and then reassess the pulse.
How do you assess an irregular pulse?firmly place the index and middle finger of your right hand on your left wrist, at the base of the thumb (between the wrist and the tendon attached to the thumb) using the second hand on a clock or watch, count the number of beats for 30 seconds, and then double that number to get your heart rate in beats per minute.
What action would take priority if a patient's apical pulse has an irregular rhythm?Which action would take priority if a patient's apical pulse has an irregular rhythm? Reassess the pulse for 1 full minute.
What does it mean if radial pulse is irregular?An abnormally slow, rapid, or irregular pulse may indicate the cardiovascular system's decreased ability to deliver an adequate blood supply to the body. . During cardiovascular collapse, the radial pulse may not be palpable because of decreased blood pressure and decreased perfusion to the distal arteries.
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Which is the best action for the nurse to take when identifying an irregular radial pulse on a client?
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