Question 1

Which procedure technique has the most effect on the accuracy of an irregular apical pulse count?

Accepted Answer

A) Counting the rate for 1 full minute 
B) Exposing only the left side of the chest 
C) Determining why assessment of apical pulse is indicated 
D) Using the ring finger to palpate the intercostal spaces 
A) Counting the rate for 1 full minute 
B) Exposing only the left side of the chest 
C) Determining why assessment of apical pulse is indicated 
D) Using the ring finger to palpate the intercostal spaces

Question 2

A client who has been hospitalized for an infection states, "The nursing assistant told me my vital signs are all within normal limits; that means I'm cured." Which is the best response by the nurse?

Accepted Answer

A) "The vital signs confirm that your infection is resolved; how do you feel?" 
B) "I'll let your healthcare provider know so that you can be discharged." 
C) "Your vital signs are stable, but there are other things to monitor." 
D) "We still need to keep monitoring your blood pressure for a while." 
A) "The vital signs confirm that your infection is resolved; how do you feel?" 
B) "I'll let your healthcare provider know so that you can be discharged." 
C) "Your vital signs are stable, but there are other things to monitor." 
D) "We still need to keep monitoring your blood pressure for a while."

Question 3

During a clinic interview, a client states he has been experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement?

Accepted Answer

A) Ask the client when in the day dizziness occurs. 
B) Help the client to assume the Trendelenburg position. 
C) Take both heart rate and blood pressure with the client standing. 
D) Measure vital signs with the client supine, sitting, and standing. 
A) Ask the client when in the day dizziness occurs. 
B) Help the client to assume the Trendelenburg position. 
C) Take both heart rate and blood pressure with the client standing. 
D) Measure vital signs with the client supine, sitting, and standing.

Exam 20: Measuring Vital Signs

Which procedure technique has the most effect on the accuracy of an irregular apical pulse count?

A client who has been hospitalized for an infection states, "The nursing assistant told me my vital signs are all within normal limits; that means I'm cured." Which is the best response by the nurse?

During a clinic interview, a client states he has been experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement?

Evolution of Nursing Thought Action

Assessment

Analysisdiagnosis

Planning Outcomes

Planning Interventions

Implementation Evaluation

Theory, Research, Evidence-Based Practice

Life Span: Infancy Through Middle Adulthood

Life Span: Older Adults

Experiencing Health Illness

Stress Adaptation

Psychosocial Health Illness

The Family

Culture Ethnicity

Spirituality

Loss, Grief, Dying

Documenting Reporting

Teaching Learning

Communication Therapeutic Relationships

Health Assessment

Promoting Asepsis Preventing Infection

Promoting Safety

Facilitating Hygiene

Administering Medications

Nutrition

Urinary Elimination

Bowel Elimination

Sensation, Perception, Response

Pain

Physical Activity Immobility

Sexual Health

Sleep Rest

Skin Integrity Wound Healing

Oxygenation

Circulation Perfusion

Fluids, Electrolytes, Acidbase Balance

Perioperative Care

Leading Managing

Nursing Informatics

Promoting Health

Community Home Health Nursing

Ethics Values

Legal Accountability

Holistic Healing

Filters