Ch 18 Vitals

Question 1

The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as

Answer 1

Orthopnea

Dyspneic people can often breathe more easily in an upright position, a condition known as orthopnea, because sitting or standing allows gravity to lower organs from the abdominal cavity away from the diaphragm.

Question 2

Bradypnea

Answer 2

decrease in respiratory rate. Tachypnea is an increased respiratory rate

Question 3

Apnea

Answer 3

refers to periods during which there is no breathing

Question 4

auscultatory gap

Answer 4

period during which sound disappears. Can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff sound technique

Question 5

After preparation, the nurse inserts a rectal thermometer into an adult client’s rectum. To ensure an accurate reading, the nurse inserts the thermometer to which depth?

Answer 5

To ensure an accurate reading, a rectal thermometer is inserted into an adult’s rectum to a depth of 1.5 in (3.75 cm). The depth for a child is 1 in (2.5 cm).

Question 6

Stroke Volume

Answer 6

Stroke Volume (mL) X (HR/bpm)

Question 7

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure?

Answer 7

Measuring the blood pressure helps to assess the efficiency of the client’s circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood

Question 8

Pulse Pressure

Answer 8

Systolic - Dystolic

Question 9

Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?

Answer 9

When the stroke volume decreases, such as when blood volume is decreased because of hemorrhage, the heart rate increases to try to maintain the same cardiac output.

Question 10

Which condition will lead to an increase in cardiac output?

Answer 10

Cardiac output increases during exercise and decreases during sleep. When cardiac output is decreased, blood pressure falls. Hemorrhage and dehydration can result in decreased cardiac output and decreased blood pressure.

Question 11

The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse’s priority action in this situation?

Answer 11

Remove the thermometer and assess the blood pressure and heart rate

Vagal nerve stimulation may occur when obtaining a rectal temperature. Vagal nerve stimulation can cause the pulse and blood pressure to drop significantly, causing the client to feel lightheaded; therefore, the thermometer should be removed immediately and the pulse and blood pressure assessed.

Question 12

A nurse is assessing the respirations of a 60-year-old female client and finds that the client’s breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation?

Answer 12

Auscultate the lung sounds and count respirations

If the respirations are too shallow to count it is easier to count respirations by auscultating the lung sounds. The nurse should auscultate lung sounds and count respirations for 30 seconds, then multiply by 2 to calculate the respiratory rate per minute. If the respiratory rate is irregular, the nurse should count for a full minut

Question 13

A nurse has been asked to record a client’s body temperature every hour using a digital thermometer. After recording the temperature, the nurse has to clean the thermometer. Which measure should the nurse follow to clean the thermometer?

Answer 13

A digital thermometer is cleaned by wiping the thermometer with isopropyl alcohol. Disposable plastic sheaths can be used to cover the probe with each use as an alternative sanitary measure.

Question 14

The nurse is preparing to measure a 3-year-old child’s vital signs. Which strategies should the nurse use to obtain accurate readings with minimal disruption? Select all that apply

Answer 14

Allow the child to remain on the parent’s lap while measuring vital signs.

Allow the child to hold the blood pressure cuff and stethoscope before the measurement.
Before beginning measurement of the child’s vital signs, demonstrate the techniques on a d

Question 15

Upon auscultation of a client’s heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/min. The nurse notifies the physician because the client is exhibiting signs of:

Answer 15

An irregular pattern of heartbeats is called a dysrhythmia

Question 16

Normal Temps for Oral, Rectal and Axillary

Answer 16

The normal range for an oral temperature is 37°C (98.6°F), rectal temperature is 37.5°C (99.5°F), an axillary temperature is 36.5°C (97.7°F), and a tympanic temperature is 37.5°C (99.5°F).

Question 17

A nurse is caring for a middle-age client who looks worried and flares his nostrils when breathing. The client reports difficulty in breathing, even when he walks to the bathroom. Which breathing disorder is most appropriate to describe the client’s condition?

Answer 17

Clients with dyspnea usually appear anxious and worried. The nostrils flare as they fight to fill the lungs with air. Dyspnea is almost always accompanied by a rapid respiratory rate because clients work to improve the efficiency of their breathing

Question 18

Rectal temp

Answer 18

During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant

Question 19

The nurse has just received the beginning-of-shift report about assigned clients. Based on the following vital signs, which client should the nurse plan to assess first?

Answer 19

The 2-year-old client whose respiratory rate is 16 breaths/min

Normal respiratory rate for a child 1 to 3 years of age is 20 to 40 breaths/min

Question 20

A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, +3, and equal in radial, popliteal, and dorsalis pedis. What does the number +3 represent?

Answer 20

Pulse amplitude describes the quality of the pulse in terms of its fullness, ranging from absent (0) to bounding (+3)

Question 21

Pulse Rates

Answer 21

measured in beats per minute

Question 22

Pulse Rhythm

Answer 22

pattern of the pulsations and the pauses between the

Question 23

A nurse is preparing to assess a client’s temperature and finds the client to be perspiring profusely. Which method would be least appropriate for the nurse to use to assess this client’s temperature?

Answer 23

Diaphoresis causes skin cooling which may cause a false low reading with a temporal artery thermometer. Another method, such as oral, tympanic membrane, or rectal, should be used

Question 24

The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?

Answer 24

The apex of the heart is found after palpating between the fifth and sixth ribs, then moving the stethoscope to the left midclavicular line. The apical rate is typically assessed for 1 minute. Each “lub-dub” sound counts as one beat

Question 25

A nursing student is manually taking the client’s blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff?

Answer 25

inflating cuff to 30 mm Hg above reading where brachial pulse disappeared ensures accurate assessment of systolic blood pressure.

Question 26

Which describes diastolic blood pressure?

Answer 26

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.

Question 27

A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?

Answer 27

“Dizziness when you change position can occur when fluid volume in the body is decreased.”

Dehydration is a cause for orthostatic hypotension, which causes temporary drop in BP when rising from a reclining position

Question 28

The nurse is assessing a client’s blood pressure and is having difficulty hearing Korotkoff sounds. What is the most appropriate nursing action?

Answer 28

Korotkoff sounds result from the vibrations of blood within the arterial wall and changes in blood flow. These sounds occur in phases and correlate with blood pressure measurement. They can be increased by asking the client to make a fist after cuff inflation.

Question 29

A nurse is assessing a newborn at the health care facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be most appropriate?

Answer 29

“It is because of the immature ability to regulate temperature in general.”

The nurse should explain to the mother that newborns have unstable body temperatures because their thermoregulatory mechanisms are immature.

Question 30

After preparation, the nurse inserts a rectal thermometer into an adult client’s rectum. To ensure an accurate reading, the nurse inserts the thermometer to which depth?

Answer 30

To ensure an accurate reading, a rectal thermometer is inserted into an adult’s rectum to a depth of 1.5 in (3.75 cm). The depth for a child is 1 in (2.5 cm).

Question 31

Reasons for Low BP

Answer 31

Low blood volume, such as occurs with hemorrhage, causes hypotension

Question 32

Reasons for Elevated BP

Answer 32

High blood viscosity and decreased elasticity of the arteriole walls

strong pumping action of the heart may not affect the blood pressure, or it may cause the blood pressure to increase

Question 33

A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, +3, and equal in radial, popliteal, and dorsalis pedis. What does the number +3 represent?

Answer 33

Pulse amplitude

Pulse amplitude describes the quality of the pulse in terms of its fullness, ranging from absent (0) to bounding (+3). P

Question 34

The nurse is checking the client’s temperature. The client feels warm to touch. However, the client’s temperature is 98.8°F (37.1°C). Which statement could explain this?

Answer 34

The client is covered with a couple of thick blankets.

Question 35

Hemmorhaging EQUALS

Answer 35

Increased PR

Question 36

Nurse T. has auscultated Mr. Weinstein’s apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein’s apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem?

Answer 36

Peripheral vascular disease

A pulse deficit indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated, a finding that is congruent with peripheral vascular disease

Question 37

The arterial blood gases for a client in shock demonstrate increased carbon dioxide and decreased oxygen. What type of respirations would the nurse expect to assess based on these findings?

Answer 37

Any condition causing an increase in carbon dioxide and a decrease in oxygen in the blood tends to increase the rate and depth of respirations. An increase in carbon dioxide is the most powerful respiratory stimulant.

Question 38

Noisy and difficult respirations

Answer 38

Indicative of a respiratory alteration.

Question 39

Shallow and Slow respirations

Answer 39

associated with a client who has had narcotics

Question 40

Absent and infrequent respirations

Answer 40

referred at agonal and the client is near death.

Question 41

Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/min. What does this indicate?

Answer 41

Not all of the heartbeats are reaching the periphery.

A difference between the apical and radial pulse rates is the pulse deficit, and signals that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated. It is not normal to a have a pulse deficit and it should be documented.

Question 42

Pulses

Answer 42

A feeble, weak, or thready pulse describes a pulse that is difficult to feel or, once felt, is obliterated easily with slight pressure. A normal pulse is described as strong when it can be felt with mild pressure over the artery. A pulse is considered rapid when the beats exceed 100 bpm, which is not the case here. A bounding or full pulse produces a pronounced pulsation that does not easily disappear with pressure. A strong pulse is felt with a very mild pressure over the artery

Question 43

Cardiac Output

Answer 43

Average cardiac output in a resting client is 5.5 L/min. Cardiac output is the product of stroke volume or the amount of blood pumped by each ventricle with each heartbeat and the heart rate. The average cardiac output in a resting person is not 6.5 L/min, 7.5 L/min, or 8.5 L/min. A stroke volume of 70 mL and a heart rate of 72 beats per minute result in a cardiac output of 5 L/min.

Question 44

Which describes diastolic blood pressure?

Answer 44

occurs when ventricular relaxation happens, and blood pressure is due to elastic recoil of the vessels.

Question 45

Which statement is true regarding the autonomic nervous system and its effect on the rate of a person’s pulse?

Answer 45

Sympathetic nervous system activation occurs in response to a variety of stimuli, including changes in intravascular volume.
The sympathetic nervous system activation occurs in response to various stimuli, including pain, anxiety, exercise, fever, and changes in intravascular volume.

Question 46

Stimulation of parasympathetic system

Answer 46

results in a decrease in pulse rate

Question 47

Which factor is not known to cause false blood pressure readings?

Answer 47

Client should be in a warm, comfortable environment to get accurate readings