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Questions and Answers
Based on the temperature change of a client whose heart rate would be how many beats/min?
Based on the temperature change of a client whose heart rate would be how many beats/min?
112
What action would be most important for the nurse after a surgical procedure on the left leg?
What action would be most important for the nurse after a surgical procedure on the left leg?
Compare the left pedal pulse with the right pedal pulse.
What nursing intervention would be appropriate after hearing rhonchi when auscultating a client's lungs?
What nursing intervention would be appropriate after hearing rhonchi when auscultating a client's lungs?
Ask the client to take a deep breath and cough.
Which set of vital signs are all within normal limits for patients at rest?
Which set of vital signs are all within normal limits for patients at rest?
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Which client situation should be reported to the primary care provider?
Which client situation should be reported to the primary care provider?
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What is the nurse's next best action for a 1-day postoperative client with a temperature of 36.8°C?
What is the nurse's next best action for a 1-day postoperative client with a temperature of 36.8°C?
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Which site should the nurse use to obtain a pulse rate prior to administering digitalis?
Which site should the nurse use to obtain a pulse rate prior to administering digitalis?
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Based on the expected relationship between temperature and respiratory rate, which respiratory rate would the nurse expect?
Based on the expected relationship between temperature and respiratory rate, which respiratory rate would the nurse expect?
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Which client would probably have a higher than normal respiratory rate?
Which client would probably have a higher than normal respiratory rate?
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For which adult client should the nurse make follow-up observations and monitor the vital signs closely?
For which adult client should the nurse make follow-up observations and monitor the vital signs closely?
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What is the best response by the nurse to a client who thinks their stable vital signs mean they are cured?
What is the best response by the nurse to a client who thinks their stable vital signs mean they are cured?
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Which parameter would the nurse document as a 7/10 after assessing the client's fifth vital sign?
Which parameter would the nurse document as a 7/10 after assessing the client's fifth vital sign?
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What should the nurse do to obtain a good estimate of the core temperature for a client with an axillary temperature of 100.8°F?
What should the nurse do to obtain a good estimate of the core temperature for a client with an axillary temperature of 100.8°F?
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What is the nurse's best initial action for a 42-year-old client with a rectal temperature of 39.2°C?
What is the nurse's best initial action for a 42-year-old client with a rectal temperature of 39.2°C?
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Which action is most important for the nurse when teaching a client to use a portable blood pressure device?
Which action is most important for the nurse when teaching a client to use a portable blood pressure device?
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What should be the nurse's first intervention after reassessing a client with vital signs that include an oral temperature of 103.2°F?
What should be the nurse's first intervention after reassessing a client with vital signs that include an oral temperature of 103.2°F?
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Which temperature would be expected during the night for a healthy, young adult client?
Which temperature would be expected during the night for a healthy, young adult client?
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Which instruction is most important when dressing an infant in cold weather?
Which instruction is most important when dressing an infant in cold weather?
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What is the most important action for the nurse when evaluating a client's BP for hypertension?
What is the most important action for the nurse when evaluating a client's BP for hypertension?
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What is the best initial action for the nurse upon hearing a high-pitched sound while taking vital signs?
What is the best initial action for the nurse upon hearing a high-pitched sound while taking vital signs?
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What statement indicates a client understands education regarding hypertension prevention and management?
What statement indicates a client understands education regarding hypertension prevention and management?
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For which patient is it most important to obtain an apical-radial pulse and calculate the pulse deficit?
For which patient is it most important to obtain an apical-radial pulse and calculate the pulse deficit?
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Which procedure technique affects the accuracy of an irregular apical pulse count?
Which procedure technique affects the accuracy of an irregular apical pulse count?
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Which assessment data best supports a report of severe pain in an adult client?
Which assessment data best supports a report of severe pain in an adult client?
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What is the appropriate action for a nurse when a client experiences dizziness upon standing?
What is the appropriate action for a nurse when a client experiences dizziness upon standing?
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What is the first action by the nurse after obtaining a BP reading of 160/90 mm Hg from a cardiac patient?
What is the first action by the nurse after obtaining a BP reading of 160/90 mm Hg from a cardiac patient?
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What is the first action by the nurse after obtaining vital signs: T 100.6°F, BP 100/60 mm Hg, HR 110 beats/min, RR 36 breaths/min?
What is the first action by the nurse after obtaining vital signs: T 100.6°F, BP 100/60 mm Hg, HR 110 beats/min, RR 36 breaths/min?
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What is the likely schedule for measuring vital signs in a skilled nursing center?
What is the likely schedule for measuring vital signs in a skilled nursing center?
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What is the most appropriate response when a CNA states, 'I just took the BP' after the nurse requests another reading?
What is the most appropriate response when a CNA states, 'I just took the BP' after the nurse requests another reading?
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Which vital sign is most critical to monitor for a critically ill patient with a severe midbrain injury?
Which vital sign is most critical to monitor for a critically ill patient with a severe midbrain injury?
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What assessment finding will alert the nurse that a runner is experiencing heat exhaustion?
What assessment finding will alert the nurse that a runner is experiencing heat exhaustion?
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What is the most appropriate nursing action after documenting a patient's radial pulse rate as irregular?
What is the most appropriate nursing action after documenting a patient's radial pulse rate as irregular?
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What is the appropriate method to count an irregular radial pulse in an 80-year-old patient?
What is the appropriate method to count an irregular radial pulse in an 80-year-old patient?
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What is the highest priority nursing diagnosis for a patient with a history of postural hypotension?
What is the highest priority nursing diagnosis for a patient with a history of postural hypotension?
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What must be followed to prevent a decrease in heart rate when palpating a patient's carotid pulse?
What must be followed to prevent a decrease in heart rate when palpating a patient's carotid pulse?
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What is the appropriate action by the nurse after noting respirations at 56 breaths/min in a newborn infant?
What is the appropriate action by the nurse after noting respirations at 56 breaths/min in a newborn infant?
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What clinical data should the nurse document after administering acetaminophen for a postoperative patient with a temperature of 102°F?
What clinical data should the nurse document after administering acetaminophen for a postoperative patient with a temperature of 102°F?
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Which blood pressure readings has a pulse pressure within normal limits? (Select all that apply)
Which blood pressure readings has a pulse pressure within normal limits? (Select all that apply)
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Which interventions would be appropriate for a client who has a fever? (Select all that apply)
Which interventions would be appropriate for a client who has a fever? (Select all that apply)
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Comparing the changes in vital signs as a person ages, which statements are correct? (Select all that apply)
Comparing the changes in vital signs as a person ages, which statements are correct? (Select all that apply)
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Which of these steps in taking a blood pressure are correct? (Select all that apply)
Which of these steps in taking a blood pressure are correct? (Select all that apply)
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When assessing the quality of a client's pedal pulses, what is the nurse assessing? (Select all that apply)
When assessing the quality of a client's pedal pulses, what is the nurse assessing? (Select all that apply)
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Which nursing interventions are appropriate for a patient admitted with dehydration and a temperature of 101.5°F? (Select all that apply)
Which nursing interventions are appropriate for a patient admitted with dehydration and a temperature of 101.5°F? (Select all that apply)
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Which signs and symptoms associated with heat stroke should the nurse be most alert to for a 70-year-old homeless man admitted with heat stroke? (Select all that apply)
Which signs and symptoms associated with heat stroke should the nurse be most alert to for a 70-year-old homeless man admitted with heat stroke? (Select all that apply)
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Study Notes
Vital Signs Assessment
- Normal vital sign ranges: Oral temperature 97°F to 100°F, heart rate 60-100 beats/min, respiratory rate 12-20 breaths/min, blood pressure 90/60 to 120/80 mm Hg.
- Elevated temperature can indicate fever; for instance, a temperature rise from 99.3°F to 102.3°F typically leads to an increased heart rate, forecasting 112 beats/min.
- Changes in vital signs post-surgery, like comparing pedal pulses on either leg, are critical to check for circulatory issues.
Nursing Interventions
- In the presence of lung rhonchi, encouraging deep breathing and coughing may improve lung function before reassessment.
- Monitoring is essential postoperatively; report significant changes like decreased blood pressure after standing.
- Accurate pain assessment is critical; a score of 7/10 indicates the presence of significant pain needing intervention.
Temperature Measurement
- Axillary temperature readings should be validated with rectal measurements for precision in fever assessments.
- A typical core body temperature for a healthy young adult at night can be as low as 97.2°F.
- In pediatric care, particularly in infants, proper dressing includes a cap to conserve body heat.
Blood Pressure Monitoring
- For hypertension assessment, consistency is vital; observe patterns instead of isolated readings.
- In patients with potential heart issues, apical-radial pulse checks help identify discrepancies in pulse rates.
Emergency Situations
- Immediate airway assessment is crucial when abnormal sounds are noted during breathing, indicating potential obstruction.
- Signs of heat exhaustion include excessive sweating (diaphoresis) and require rapid cooling measures.
Patient Education and Follow-Up
- Clients should understand that stable vital signs do not equate to overall health recovery; continued monitoring is critical.
- For home care, clients should demonstrate appropriate techniques when learning to measure blood pressure.
Documentation and Communication
- Accurate documentation includes recording symptoms like fever and actions taken, such as medication administration.
- Collaboration with healthcare teams involves notifying providers of significant vital sign changes or patient symptoms.
Pediatric Considerations
- Newborns' vital signs require careful documentation; notable respiratory rates like 56 breaths/min can be normal.
- Understanding hydration importance, especially in older adults or those with a fever, guides nursing interventions such as fluid replacement.
Aging and Vital Signs
- As people age, blood pressure tends to rise while respiratory rates decrease, highlighting the need for tailored assessments in older populations.
Interventions for Fever Management
- Appropriate fever management includes providing fluids and external cooling methods, like ice packs.
- Regular monitoring of vital signs in patients with fever or dehydration is critical for detecting worsening conditions.
Assessment Techniques
- Correct blood pressure measurement involves properly fitting cuffs and ensuring the client's posture is correct (e.g. sitting with feet flat).
- Assessing pedal pulses includes evaluating strength and symmetry, indicators of peripheral circulation health.
Studying That Suits You
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Description
Test your knowledge on vital signs assessment in nursing with this Chapter 20 quiz. Each question will challenge your understanding of how to interpret changes in vital signs, crucial for effective patient care. Get ready to apply your nursing skills and knowledge in practical scenarios.
