Exam 20: Measuring Vital Signs

Which of these steps in taking a blood pressure are correct? Select all that apply.

The nurse administers two blood pressure (BP) medications to a patient and asks the certified nurse assistant (CNA) to obtain a BP reading in 30 minutes. The CNA states, "I just took the BP." What is the most appropriate response by the nurse?

The nurse is caring for a patient in a skilled nursing center. What is the likely schedule for measuring the patient's vital signs?

Which nursing interventions are appropriate for a patient who has been admitted with a diagnosis of Dehydration and has a temperature of 101.5°F (38.6°C)? Select all that apply.

Which interventions would be appropriate for a client who has a fever? Select all that apply.

A 70-year-old homeless man is admitted to the emergency department with heat stroke following 3 days of overexposure to outside temperatures. The nurse is most alert to which signs and symptoms associated with heat stroke? Select all that apply.

The nurse obtains a blood pressure (BP) reading of 160/90 mm Hg from a cardiac patient. What is the first action by the nurse?

For which patient would it be most important to obtain an apical-radial pulse and calculate the pulse deficit? A patient who:

The nurse obtains the following vital signs on an adult patient: temperature (T) 100.6°F (38.1°C); blood pressure (BP) 100/60 mm Hg; heart rate (HR) 110 beats/min; respiratory rate (RR) 36 breaths/min. What is the first action by the nurse?

The nurse on a medical-surgical unit palpates a patient's carotid pulse for 30 seconds and obtains a rate of 80 beats/min. The nurse knows in obtaining a patient's carotid pulse, careful technique must be followed to prevent which response?

Which blood pressure reading has a pulse pressure within normal limits? Select all that apply.

A 1-day postoperative client has a temperature of 36.8°C. What is the nurse's next best action?

The nurse hears rhonchi when auscultating a client's lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds?

At last measurement, the client's vital signs were as follows: oral temperature 98°F (36.7°C), heart rate 76 beats/min, respiratory rate 16 breaths/min, and blood pressure (BP) 118/60 mm Hg. Four hours later, the vital signs are as follows: oral temperature 103.2°F (39.6°C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mm Hg. Which should be the nurse's first intervention at this time?

Which client would probably have a higher than normal respiratory rate? A client who has:

When assessing the quality of a client's pedal pulses, what is the nurse assessing? Select all that apply.

The nurse provides client education regarding hypertension prevention and management. Which statement indicates the client understands the instructions?

The nurse assesses the following changes in a client's vital signs. Which client situation should be reported to the primary care provider?

Which assessment data best supports a report of severe pain in an adult client whose baseline vital signs are within an average normal range?

The nurse volunteers to work at the annual summer 20-mile marathon in the community. Which assessment finding will alert the nurse a runner is experiencing heat exhaustion?