Exam 20: Measuring Vital Signs

The nurse caring for a postsurgical patient obtains an oral temperature reading of 103°F.She contacts the surgeon,obtains an order,and administers acetaminophen 650 mg orally.Which clinical information should the nurse document? Select all that apply.

Which of the following sets of vital signs are all within normal limits for patients at rest?

The nurse is assessing vital signs for a client after a surgical procedure on the left leg.IV fluids are infusing.It would be most important for the nurse to:

A client's vital signs 4 hours ago were temperature (oral)101.4°F (38.6°C),heart rate 110 beats/min,respiratory rate 26 breaths/min,and blood pressure 124/78 mm Hg.The temperature is now 99.4°F (37.4°C).Based only on the expected relationship between temperature and respiratory rate,the nurse might best anticipate the client's respiratory rate to be:

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

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?

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

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

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

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?

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

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 alerted to which signs and symptoms associated with heat stroke? Select all that apply.

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

The nurse provides client education regarding hypertension prevention and management.Which of these statements indicates that the client understands the instructions?

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?

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

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 she must be careful that her technique does not cause a/an:

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." The nurse's best response would be which of the following?

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

The nurse documents a patient's radial pulse rate as 120 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?