Exam 20: Measuring Vital Signs

The nurse is teaching a client how to use a portable blood pressure device to monitor his blood pressure at home.It would be most important for the nurse to:

The nurse palpates a radial pulse on her 80-year-old patient and notes that it feels irregular.What is the most appropriate method to count this patient's pulse?

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

The nurse is caring for a patient with a history of postural hypotension.She obtains a blood pressure reading on her patient of 130/80 lying and 100/60 standing.What is the most appropriate nursing diagnosis for this patient?

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?

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

Comparing the changes in vital signs as a person ages,which statement(s)is/are correct? Select all that apply.

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 (38.5°C),heart rate 76 beats/min,respiratory rate 14 breaths/min,and blood pressure 120/66 mm Hg.Which should the nurse's first intervention be at this time?

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?

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

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 his BP." What is the most appropriate response by the nurse?

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

A postsurgical patient has just returned from the recovery room to the surgical unit.After the first hour on the unit,what is the likely schedule for measuring the patient's vital signs?

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

The nurse obtains the following vital signs on an adult patient: T.100.6°F BP 100/60,HR 110,respirations 36.What is the first action by the nurse?

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

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

The nurse volunteers to work at the annual summer 20-mile marathon in her community.In planning for the event,the nurse knows that which of the following nursing diagnoses is most important to include in the plan?

Which of the following procedure techniques has the most effect on the accuracy of an apical pulse count?

The nurse enters the client's room and before he can take vital signs,he hears a piercing,high-pitched sound coming from the client when he breathes.The nurse's initial next best action is to: