Vital signs

Question 1

A nurse is obtaining vital signs from a client. Which of the following findings warrants a report to the provider ?
A. Oral temperature 37.8° C (100° F)
B. Respirations 30/min
C. BP 148/88 mm Hg
D. Radial pulse rate 45 beats/30 seconds

Answer 1

B. Respirations of 30/min

Respirations of 30/min is above the expected reference range of 12 to 20/min and indicates the need for immediate attention. An adult client who has respirations of 30/min is experiencing shortness of breath, or dyspnea. Without intervention, this can become a life-threatening situation.

Question 2

If the body temperature is high the nurse can also expect the ______ to be elevated.

Answer 2

Pulse rate

Question 3

The difference between a client’s systolic and diastolic blood pressure is called the

Answer 3

Pulse pressure

Question 4

Which action should the nurse take to determine the depth of the client’s respiration.?

Answer 4

Observe the degree of chest-wall movement during inspiration and expiration.