Vital Sign EOCHQ and ATI Flashcards
The client’s temperature at 8:00 A.M. using an oral electronic thermometer is 36.1°C (97.2°F). If the respiration, pulse, and blood pressure were within normal range, what would the nurse do next?
Check what the client’s temperature was the last time it was taken
Which client meets the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse?
A client with an arrhythmia
When the nurse enters a client’s room to measure routine vital signs, the client is on the phone. What technique should the nurse use to determine the respiratory rate
Since there is no evidence of distress or urgency, postpone the measurement until later.
For a client with a previous blood pressure of 138/74 mmHg and pulse of 64 beats/min, approximately how long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading?
30–45 seconds
It would be appropriate to assign the taking of vital signs of which client to assistive personnel?
A client being prepared for elective facial surgery with a history of stable hypertension.
An 85-year-old client has had a stroke resulting in right-sided facial drooping, difficulty swallowing, and the inability to move self or maintain position unaided. The nurse determines that which sites are most appropriate for taking the temperature? Select all that apply.
Axillary
Tympanic
Temporal artery
A nursing diagnosis of impaired perfusion of peripheral tissue would be validated by which one of the following?
Absent posterior tibial and pedal pulses.
The nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following?
Shortness of breath
What is the primary reason for assessing a clients vital signs?
Establish a baseline when the client reports no specific health related problem
Describe what body temperature is?
The difference between heat produced and heat lost from the body
How is a tympanic temperature documented correctly and is it in the expected reference range?
T = 99.6 F (T) {T = Temporal A= Axillary R= Rectal O= oral}
What is true about assessing a pts pulse?
The pts pulse is palpable bounding of the blood flow in the peripheral artery
What is true when assessing a pts respiration?
Document the RR number/ min regular rhythm and depth
Describe systolic pressure?
The pressure exerted by the blood during the hearts contraction phase
Which category of BP is 166/88 mmHg?
Hypertension stage 2
