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besides high blood pressure values, what other signs and symptoms may the nurse observe if hypertension is present?
A) Unexplained pain and hyperactivity
B) Headache, flushing of the face, and nosebleed
C) Dizziness, mental confusion, and mottled extremities
D) Restlessness and dusky or cyanotic skin that is cool to the touch
Which of the following vlues for vital signs would the nurse address first?
A) Heart rate = 72 beats per minute
B) Respiration rate = 28 breaths per minute
C) Blood pressure = 160/86
D) Oxygen saturation by pulse oximetry = 89%
E) Temperature = 37.2° C (99° F), tympanic
An 82-year-old widower brought via ambulance is admitted to the emergency department with complaints of shortness of
breath, anorexia, and malaise. He recently visited his health care provider and was put on an antibiotic for pneumonia. The client indicates that he also takes a diuretic and a beta blocker, which helps his "high blood." Which vital sign value would take priority in initiating care?
A) Respiration rate = 20 breaths per minute
B) Oxygen saturation by pulse oximetry = 92%
C) Blood pressure = 138/84
D) Temperature = 39° C (102° F), tympanic
The client, who has been on bed rest for 2 days, asks to get out of bed to go to the bathroom. He has new orders for "up ad lib." What action should the nurse take?
A) Give him some slippers and tell him where the bathroom is located.
B) Ask the nursing assistant to assist him to the bathroom.
C) Obtain orthostatic blood pressure measurements.
D) Tell him it is not a good idea and provide a urinal.
Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 36.1° C (97° F). The client's remaining vital signs are in the normally acceptable range. What should the nurse do next?
A) Check the client's temperature history.
B) Document the results; temperature is normal.
C) Recheck the temperature every 15 minutes until it is normal.
D) Get another thermometer; the temperature is obviously an error.
The nurse decides to take an apical pulse instead of a radial pulse. Which of the following client conditions influenced the nurse's decision?
A) The client is in shock.
B) The client has an arrhythmia.
C) The client underwent surgery 18 hours earlier.
D) The client showed a response to orthostatic changes.
The nurse is to measure vital signs as part of the preparation for a test. The client is talking with a visiting pastor. How should the nurse handle measuring the rate of respiration?
A) Count respirations during the time the client is not talking to the visitor.
B) Wait at the client's bedside until the visit is over and then count respirations.
C) Tell the client it is very important to end the conversation so the nurse can count respirations.
D) Document the respiration rate as "deferred" and measure the rate later, since the talking client is obviously not in respiratory distress.
Delegation of some tasks may become one of the decisions the nurse will make while on duty. For which of the following clients would it be most appropriate for unlicensed assistive personnel to measure the client's vital signs?
A) A client who recently started taking an antiarrhythmic medication
B) A client with a history of transfusion reactions who is receiving a blood transfusion
C) A client who has frequently been admitted to the unit with asthma attacks
D) A client who is being admitted for elective surgery who has a history of stable hypertension
The client has an oral temperature of 39.2° C (102.6° F). What are the most appropriate nursing interventions?
A) Provide an alcohol sponge bath and monitor laboratory results.
B) Remove excess clothing, provide a tepid sponge bath, and administer an analgesic.
C) Provide fluids and nutrition, keep the client's room warm, and administer an analgesic.
D) Reduce external coverings and keep clothing and bed linens dry; administer antipyretics as ordered.
The hypothalamus controls body temperature. The anterior hypothalamus controls heat loss, and the posterior hypothalamus controls heat production. What heat conservation mechanisms will the posterior hypothalamus initiate when it senses that the client's body temperature is lower than comfortable?
A) Vasodilation and redistribution of blood to surface vessels
B) Sweating, vasodilation, and redistribution of blood to surface vessels
C) Vasoconstriction, sweating, and reduction of blood flow to extremities
D) Vasoconstriction, reduction of blood flow to extremities, and shivering
The nurse's documentation indicates that a client has a pulse deficit of 14 beats. The pulse deficit is measured by:
A) Subtracting 60 (bradycardia) from the client's pulse rate and reporting the difference
B) Subtracting the client's pulse rate from 100 (tachycardia) and reporting the difference
C) Assessing the apical pulse and the radial pulse for the same minute and subtracting the difference
D) Assessing the apical pulse and 30 minutes later assessing the carotid pulse and subtracting the difference
The nurse observes that a client's breathing pattern represents Cheyne-Stokes respiration. Which statement best describes the Cheyne-Stokes pattern?
A) Respirations cease for several seconds.
B) Respirations are abnormally shallow for two to three breaths followed by irregular periods of apnea.
C) Respirations are labored, with an increase in depth and rate (more than 20 breaths per minute); the condition occurs normally during exercise.
D) Respiration rate and depth are irregular, with alternating periods of apnea and hyperventilation; the cycle begins with slow breaths and climaxes in apnea.
The nurse finds that the systolic blood pressure of an adult client is 88 mm Hg. What are the appropriate nursing interventions?
A) Check other vital signs.
B) Recheck the blood pressure and give the client orange juice.
C) Recheck the blood pressure after ambulating the client safely.
D) Recheck the blood pressure, make sure the client is safe, and report the findings.
52 year old woman admitted with dyspnea and discomfort in her left chest with deep breaths. SHe smoked for 35 years and recently lost over 10 pounds. What vital sign should not be delegated to a nursing assistant:
b) radial pulse
c) respiratory rate
d) oxygen saturation
1, 5, 2, 4, 3
Place the vital signs in order of priority for your nursing interventions:
1) SpO2= 89%
2) BP= 160/86 mmHG
3) Temperature= 37.3 (99.4)
4) HR= 72 BPM
5) RR= 28 BrPM
1, 2, 4, 7
82 yr old admitted via ambulance to ER with shortness of breath, anorexia, and malaise. He recently visited the health care center and is on antibiotic for pneumonia. He is also on a diuretic, beta-adrergic blocker, which helps his "high blood".
He has a temperature of 38.2 (100.8) via temporal artery. What additional assessment data is needed in planning intervention for the patients infection ? (choose all that apply)
2. Skin turgor
3. Smoking history
4. Allergies to antibiotics
5. Recent BM's
6. BP in right arm
7. Client's normal temperature
8. BP in distal extremity
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