Question 1

The nurse is reviewing tasks to assign to unlicensed assistive personnel (UAP). Which task should the nurse complete?&#10;A) Monitor client's vital signs and oxygen saturation every 4 hours.&#10;B) Measure client's blood pressure after administration of routine daily antihypertensive medication.&#10;C) Monitor vital signs of client who complained of chest pain, requiring three doses of nitroglycerin to resolve, earlier in the shift.&#10;D) Measure vital signs on client who had a stroke 3 years ago and is admitted for urinary tract infection.

Accepted Answer

1. The client who is unstable secondary to chest pain should be assessed by the nurse, and this should not be assigned to the UAP. The other clients' vital signs could be measured by the UAP, but the nurse should instruct the UAP regarding exactly what values should be reported immediately.
2. The client who is unstable secondary to chest pain should be assessed by the nurse, and this should not be assigned to the UAP. The other clients' vital signs could be measured by the UAP, but the nurse should instruct the UAP regarding exactly what values should be reported immediately.
3. The client who is unstable secondary to chest pain should be assessed by the nurse, and this should not be assigned to the UAP. The other clients' vital signs could be measured by the UAP, but the nurse should instruct the UAP regarding exactly what values should be reported immediately.
4. The client who is unstable secondary to chest pain should be assessed by the nurse, and this should not be assigned to the UAP. The other clients' vital signs could be measured by the UAP, but the nurse should instruct the UAP regarding exactly what values should be reported immediately.

Question 2

A 2-month-old infant has a temperature of 104.2&#176;F axillary. Which route should the nurse use to validate this measurement?&#10;A) Tympanic&#10;B) Oral&#10;C) Axillary&#10;D) Rectal

Accepted Answer

1. Although rectal temperature measurement may be discouraged for routine use in infants, when the temperature is very high and it is important to get the most accurate reading, the rectal route is best. Oral and tympanic temperatures are generally not considered accurate in infants, and axillary readings are not as accurate as rectal readings.
2. Although rectal temperature measurement may be discouraged for routine use in infants, when the temperature is very high and it is important to get the most accurate reading, the rectal route is best. Oral and tympanic temperatures are generally not considered accurate in infants, and axillary readings are not as accurate as rectal readings.
3. Although rectal temperature measurement may be discouraged for routine use in infants, when the temperature is very high and it is important to get the most accurate reading, the rectal route is best. Oral and tympanic temperatures are generally not considered accurate in infants, and axillary readings are not as accurate as rectal readings.
4. Although rectal temperature measurement may be discouraged for routine use in infants, when the temperature is very high and it is important to get the most accurate reading, the rectal route is best. Oral and tympanic temperatures are generally not considered accurate in infants, and axillary readings are not as accurate as rectal readings.

Question 3

The nurse is caring for a client who is experiencing acute hemorrhagic shock. The client's blood pressure is 60/28 mmHg. How will the nurse assess this client's pulse?&#10;A) Measure the radial pulse for 1 minute.&#10;B) Measure the brachial pulse for 1 minute.&#10;C) Measure the radial pulse for 30 seconds and multiply by 2.&#10;D) Measure the client's apical pulse for 1 minute.

Accepted Answer

1. In all likelihood, a client whose blood pressure is this low and who is in shock will not have a radial or brachial pulse because perfusion will be significantly diminished. The most accurate pulse assessment will be obtained centrally, and the nurse can either auscultate apical pulsation or palpate carotid pulsation. Care should be taken not to ever palpate both carotid arteries at the same time.
2. In all likelihood, a client whose blood pressure is this low and who is in shock will not have a radial or brachial pulse because perfusion will be significantly diminished. The most accurate pulse assessment will be obtained centrally, and the nurse can either auscultate apical pulsation or palpate carotid pulsation. Care should be taken not to ever palpate both carotid arteries at the same time.
3. In all likelihood, a client whose blood pressure is this low and who is in shock will not have a radial or brachial pulse because perfusion will be significantly diminished. The most accurate pulse assessment will be obtained centrally, and the nurse can either auscultate apical pulsation or palpate carotid pulsation. Care should be taken not to ever palpate both carotid arteries at the same time.
4. In all likelihood, a client whose blood pressure is this low and who is in shock will not have a radial or brachial pulse because perfusion will be significantly diminished. The most accurate pulse assessment will be obtained centrally, and the nurse can either auscultate apical pulsation or palpate carotid pulsation. Care should be taken not to ever palpate both carotid arteries at the same time.

Question 4

The clinic nurse measures the client's blood pressure and obtains a reading of 144/82 mmHg. The client's baseline blood pressure has been normal. For what factors would the nurse assess the client based on the current blood pressure reading? Select all that apply.

A) Diet
B) Medication history
C) Activity
D) History of recent symptoms of hypertension
E) Recent stress factors the client has experienced

Accepted Answer

1. The client's diet should be assessed because foods high in sodium could elevate the systolic pressure mildly. The nurse should also assess the client's medication history and activity, as these can impact blood pressure. There is not likely to be a history of symptoms of hypertension, because borderline hypertension usually does not cause symptoms. The client's exposure to stress such as financial pressures and family issues can cause an elevation in systolic pressure.
2. The client's diet should be assessed because foods high in sodium could elevate the systolic pressure mildly. The nurse should also assess the client's medication history and activity, as these can impact blood pressure. There is not likely to be a history of symptoms of hypertension, because borderline hypertension usually does not cause symptoms. The client's exposure to stress such as financial pressures and family issues can cause an elevation in systolic pressure.
3. The client's diet should be assessed because foods high in sodium could elevate the systolic pressure mildly. The nurse should also assess the client's medication history and activity, as these can impact blood pressure. There is not likely to be a history of symptoms of hypertension, because borderline hypertension usually does not cause symptoms. The client's exposure to stress such as financial pressures and family issues can cause an elevation in systolic pressure.
4. The client's diet should be assessed because foods high in sodium could elevate the systolic pressure mildly. The nurse should also assess the client's medication history and activity, as these can impact blood pressure. There is not likely to be a history of symptoms of hypertension, because borderline hypertension usually does not cause symptoms. The client's exposure to stress such as financial pressures and family issues can cause an elevation in systolic pressure.
5. The client's diet should be assessed because foods high in sodium could elevate the systolic pressure mildly. The nurse should also assess the client's medication history and activity, as these can impact blood pressure. There is not likely to be a history of symptoms of hypertension, because borderline hypertension usually does not cause symptoms. The client's exposure to stress such as financial pressures and family issues can cause an elevation in systolic pressure.

Question 5

The nurse assesses vital signs on four clients. Which client would be the first priority for the nurse to assess based on the vital signs?&#10;A) 98.6&#176;F; 88; 16; 134/88 mmHg&#10;B) 98.2&#176;F; 60; 12; 92/64 mmHg&#10;C) 100.8&#176;F; 102; 18; 136/84 mmHg&#10;D) 98.7&#176;F; 96; 14; 156/102 mmHg

Accepted Answer

1. Although the client in option 3 reflects a low-grade temperature with resulting mild tachycardia, the client in option 4 has a dangerously high blood pressure, which would be the nurse's highest priority. Options 1 and 2 reflect vital signs within normal range.
2. Although the client in option 3 reflects a low-grade temperature with resulting mild tachycardia, the client in option 4 has a dangerously high blood pressure, which would be the nurse's highest priority. Options 1 and 2 reflect vital signs within normal range.
3. Although the client in option 3 reflects a low-grade temperature with resulting mild tachycardia, the client in option 4 has a dangerously high blood pressure, which would be the nurse's highest priority. Options 1 and 2 reflect vital signs within normal range.
4. Although the client in option 3 reflects a low-grade temperature with resulting mild tachycardia, the client in option 4 has a dangerously high blood pressure, which would be the nurse's highest priority. Options 1 and 2 reflect vital signs within normal range.

Question 6

The nurse is admitting a client who plays professional football. The nurse assesses vital signs and records the following measurements: 98.6°F; 48; 10; 88/54 mmHg. The client says he "feels fine" and denies any symptoms. Which action by the nurse is the priority?

A) Notify the health care provider.
B) Encourage fluids.
C) Document the client's vital signs and continue the admission history.
D) Place client in the Trendelenburg position.

Accepted Answer

1. Clients in excellent physical condition will often run a lower heart rate and respiratory rate because the cardiac muscle is strong and requires fewer contractions to maintain an adequate cardiac output. There would be no need to intervene for this client.
2. Clients in excellent physical condition will often run a lower heart rate and respiratory rate because the cardiac muscle is strong and requires fewer contractions to maintain an adequate cardiac output. There would be no need to intervene for this client.
3. Clients in excellent physical condition will often run a lower heart rate and respiratory rate because the cardiac muscle is strong and requires fewer contractions to maintain an adequate cardiac output. There would be no need to intervene for this client.
4. Clients in excellent physical condition will often run a lower heart rate and respiratory rate because the cardiac muscle is strong and requires fewer contractions to maintain an adequate cardiac output. There would be no need to intervene for this client.

Question 7

Which adult vital signs would the nurse need to report immediately?&#10;A) 99.2&#176;F; 100; 20; 138/88 mmHg&#10;B) 100.2&#176;F; 88; 18; 128/72 mmHg&#10;C) 97.4&#176;F; 96; 28; 142/82 mmHg&#10;D) 98&#176;F; 64; 14; 88/60 mmHg

Accepted Answer

1. The client with these vital signs-97.4°F; 96; 28; 142/82 mmHg-has a rapid respiratory rate and a high normal heart rate, which could be secondary to respiratory distress and anxiety related to hypoxemia, so it should be reported to the health care provider immediately. The client with these vital signs-98°F; 64; 14; 88/60 mmHg-needs further assessment of symptoms to determine if a problem exists, but vital signs are close to normal values, so the nurse would not be the most concerned with these measurements. The clients with these vital signs-99.2°F; 100; 20; 138/88 mmHg and 100.2°F; 88; 18; 128/72 mmHg-both have mild fevers. The nurse would need to report the temperature of 100.2°F to the health care provider, but there is no urgency.
2. The client with these vital signs-97.4°F; 96; 28; 142/82 mmHg-has a rapid respiratory rate and a high normal heart rate, which could be secondary to respiratory distress and anxiety related to hypoxemia, so it should be reported to the health care provider immediately. The client with these vital signs-98°F; 64; 14; 88/60 mmHg-needs further assessment of symptoms to determine if a problem exists, but vital signs are close to normal values, so the nurse would not be the most concerned with these measurements. The clients with these vital signs-99.2°F; 100; 20; 138/88 mmHg and 100.2°F; 88; 18; 128/72 mmHg-both have mild fevers. The nurse would need to report the temperature of 100.2°F to the health care provider, but there is no urgency.
3. The client with these vital signs-97.4°F; 96; 28; 142/82 mmHg-has a rapid respiratory rate and a high normal heart rate, which could be secondary to respiratory distress and anxiety related to hypoxemia, so it should be reported to the health care provider immediately. The client with these vital signs-98°F; 64; 14; 88/60 mmHg-needs further assessment of symptoms to determine if a problem exists, but vital signs are close to normal values, so the nurse would not be the most concerned with these measurements. The clients with these vital signs-99.2°F; 100; 20; 138/88 mmHg and 100.2°F; 88; 18; 128/72 mmHg-both have mild fevers. The nurse would need to report the temperature of 100.2°F to the health care provider, but there is no urgency.
4. The client with these vital signs-97.4°F; 96; 28; 142/82 mmHg-has a rapid respiratory rate and a high normal heart rate, which could be secondary to respiratory distress and anxiety related to hypoxemia, so it should be reported to the health care provider immediately. The client with these vital signs-98°F; 64; 14; 88/60 mmHg-needs further assessment of symptoms to determine if a problem exists, but vital signs are close to normal values, so the nurse would not be the most concerned with these measurements. The clients with these vital signs-99.2°F; 100; 20; 138/88 mmHg and 100.2°F; 88; 18; 128/72 mmHg-both have mild fevers. The nurse would need to report the temperature of 100.2°F to the health care provider, but there is no urgency.

Question 8

The nurse is caring for a client with vital signs 97.2°F; 112; 48; 104/86 mmHg; and oxygen saturation is 76%. Place the nursing actions in order of their priority for this client.
Response 1. Assess the client.
Response 2. Reduce client anxiety.
Response 3. Notify the health care provider.
Response 4. Obtain assistance from another nurse or member of the team.
Response 5. Administer oxygen.

Accepted Answer

The answer of The nurse is caring for a client...

Deck 3: Vital Signs