Exam 20: Measuring Vital Signs

The nurse is caring for a critically ill patient with a severe midbrain injury involving the hypothalamus. Which vital sign is most critical for the nurse to monitor closely for this patient?

The nurse documents a patient's radial pulse rate as 100 beats/min and regular. One hour later, the nurse rechecks the pulse, and it is irregular at 120 beats/min. What is the most appropriate nursing action?

The nurse caring for a postsurgical patient obtains an oral temperature reading of 102°F (38.9°C). The nurse contacts the surgeon, obtains an order, and administers acetaminophen 650 mg orally. Which clinical data should the nurse document? Select all that apply.

A client's axillary temperature is 100.8°F (38.2°C). The nurse realizes that this is outside the normal range for this client and that axillary temperatures do not reflect the core temperature. What should the nurse do to obtain a good estimate of the core temperature?

The nurse is assessing vital signs for a client after a surgical procedure on the left leg. Intravenous (IV) fluids are infusing. Which action would be most important for the nurse to take?

A 42-year-old female client has a rectal temperature reading of 39.2°C (102.6°F). Her blood pressure has decreased from 124/76 to 118/70 mm Hg since taken 4 hours earlier. Her pulse rate has increased from 68 to 78 beats/min. What is the nurse's best initial action?

A client's average normal temperature is 98°F (36.7°C). Which temperature would be expected during the night in this healthy, young adult client who does not have a fever, inflammatory process, or underlying health problems?

Comparing the changes in vital signs as a person ages, which statements are correct? Select all that apply.

The nurse is instructing a client how to appropriately dress an infant in cold weather. Which instruction would be most important for the nurse to include?

After obtaining a full set of vital signs, the nurse assesses the client's fifth vital sign as a 7 on a scale of 1 to 10 (or 7/10). Which parameter would the nurse document as a 7/10?

The client has an order for the drug digitalis, which has the effect of decreasing the heart rate. Which site should the nurse use to obtain a pulse rate prior to administering the medication?

The nurse is caring for a patient with a history of postural hypotension. The nurse obtains a blood pressure (BP) reading of 130/80 mm Hg with the patient lying and 100/60 mm Hg with the patient standing. What is the highest priority nursing diagnosis for this patient?

A client's vital signs at the beginning of the shift are as follows: oral temperature 99.3°F (37°C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four hours later, the client's oral temperature is 102.3°F (39.1°C). Based on the temperature change, the nurse should anticipate the client's heart rate would be how many beats/min?

For which adult client should the nurse make follow-up observations and monitor the vital signs closely? A client whose:

A client's vital signs 4 hours ago were temperature (oral) 101.4 $\degree$ F (38.6 $\degree$ C), heart rate 110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/78 mm Hg. The temperature is now 99.4 $\degree$ F (37.4 $\degree$ C). Based only on the expected relationship between temperature and respiratory rate, which respiratory rate would the nurse expect to find?

Which set of vital signs are all within normal limits for patients at rest?

The nurse enters the client's room and before taking vital signs, the nurse hears a piercing, high-pitched sound coming from the client when breathing. Which best action should the nurse take initially?

The nurse is teaching a client how to use a portable blood pressure device to monitor the blood pressure at home. Which action is most important for the nurse to take?

In evaluating a client's blood pressure (BP) for hypertension, it would be most important for the nurse to take which action?

The nurse is obtaining vital signs on a newborn infant and notes respirations at 56 breaths/min. What is the most appropriate action by the nurse?