Download Vital Signs Assessment: Identifying Clients Requiring Nurse Intervention and more Exams Nursing in PDF only on Docsity!
ATI ENGAGE FUNDAMENTALS: VITAL
SIGNS
A nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct? A. Pulse 52/min B. Respiratory rate 24 C. SaO2 97% right index finger, room air D. Blood pressure 132/86 mm Hg - correct answer C. SaO2 97% right index finger, room air The nurse should identify that this documentation is thorough and complete and does not require any additional information. The information provided includes the measurement, the site used, and that the client is not on oxygen. A nurse is planning care for a group of clients and is delegating to the assistive personnel (AP) to take the clients' vital signs. For which of the following clients should the nurse obtain the vital signs rather than the AP? A. A client who just received the fourth dose of an antibiotic for an infection B. A client who has heart failure and is scheduled for discharge later in the day C. A client who is 24 hr postoperative and is visiting with friends D. A client who was recently admitted and reports chest pain - correct answer D. A client who was recently admitted and reports chest pain The nurse should identify that a new onset of chest pain is an acute change in condition. The nurse should not delegate this task to the AP. Once the client is stable, the nurse can delegate subsequent measurement of vital signs to an AP. A nurse is caring for a client who has an increase in cardiac output. Which of the following findings should the nurse expect? A. Increase in blood pressure B. Decrease in respiratory rate C. Decrease in heart rate
D. Increase in stroke volume - correct answer A. Increase in blood pressure The nurse should identify that an increase in cardiac output causes an increase in the client's blood pressure. Cardiac output is the amount of blood pumped by the ventricles in 1 min. A nurse is contributing to the plan of care for a client who has hypertension. Which of the following interventions should the nurse recommend? (Select all that apply). A. Provide the client with low-sodium meals and snacks. B. Encourage the client to participate in physical activity each day. C. Instruct the client in the use of relaxation techniques. D. Inform the client of the importance of abstaining from using products that contain nicotine. E. Encourage the client to increase their fluid intake to 2 L per day. - correct answer A. Provide the client with low-sodium meals and snacks B. Encourage the client to participate in physical activity each day. C. Instruct the client in the use of relaxation techniques. D. Inform the client of the importance of abstaining from using products that contain nicotine. A diet high in sodium can cause an increase in blood pressure. Therefore, the nurse should provide the client with foods and fluids that are low in sodium. The nurse should also provide information to the client on which foods and fluids are high in sodium and should be avoided. Daily physical exercise can decrease blood pressure. The nurse should encourage the client to participate in physical activity each day as they are physically able. Relaxation techniques decrease stress, lower the heart rate, and decrease blood pressure. The nurse should instruct the client in the use of relaxation techniques, such as guided imagery, to assist in managing hypertension. Nicotine is a stimulant, which increases heart rate and blood pressure. Nicotine also causes vasoconstriction, increasing blood pressure. The nurse should provide information to the client about these effects and encourage the client to avoid products
D. It is not necessary to record electronic blood pressure measurements. - correct answer B. Recording vital signs provides critical information regarding a client's condition. Vital signs, including blood pressure, temperature, pulse, respiratory rate, and SaO2, reflect the client's currect health status and will vary according to changes in the client's health condition, such as infection, stress, pain, or bleeding and should be recorded accurately and in a timely manner. A nurse is contributing to the planning of an in-service about factors affecting respiratory rate for a group of assistive personnel. Which of the following information should the nurse recommend be included? A. Fever can increase a client's respiratory rate. B. Opioid analgesics can increase a client's respiratory rate. C. Pain can decrease a client's respiratory rate. D. Anxiety can decrease a client's respiratory rate. - correct answer A. Fever can increase a client's respiratory rate. The nurse should include that an increased body temperature can cause an increase in a client's respiratory rate. Other factors that can increase respiratory rate include physical exertion, chronic lung disease, and anxiety. A nurse is assisting in the planning of an in-service for a group of newly hired assistive personnel (AP) about body temperature. Which of the following information should the nurse recommend be included? A. Wait 5 min after a client has consumed a hot drink to obtain an oral temperature. B. Place a tape or patch thermometer over a client's spatula. C. A tympanic thermometer reflects a client's body surface temperature. D. A temporal probe thermometer uses infrared scanning to determine a client's temperature. - correct answer D. A temporal probe thermometer uses infrared scanning to determine a client's temperature. The nurse should instruct the AP that a temporal artery thermometer uses infrared scanning to determine the body's core temperature. The thermometer probe is placed in the center of the forehead, swiped laterally toward the hairline, then touched to the skin behind the client's earlobe.
A nurse is contributing to the plan of care for a client who has a temperature of 39.1 °C (102.4 °F). Which of the following interventions should the nurse include? A. Sponge the client's skin with isopropyl alcohol. B. Slightly increase the temperature of the client's room. C. Offer the client hot beverages every 60 min. D. Administer an antipyretic medication. - correct answer D. Administer an antipyretic medication. The nurse should administer an antipyretic medication, such as acetaminophen or ibuprofen, as prescribed to decrease body temperature. Other interventions to decrease body temperature include removing excess clothing and blankets, bathing the client in a tepid bath, and removing hats or caps from the client's head. A nurse is contributing to the plan of care for a client who is experiencing tachycardia. Which of the following interventions should the nurse plan to recommend? A. Instruct the client to increase exercise. B. Instruct the client to consume no more than four caffeinated beverages per day. C. Encourage the client to practice relaxation techniques each day. D. Encourage the client to engage in pattern paced breathing by panting. - correct answer C. Encourage the client to practice relaxation techniques each day. Tachycardia can be caused by stress or anxiety. The nurse should encourage the client to participate in relaxation techniques such as guided imagery, meditation, or yoga as these can decrease heart rate and blood pressure. A nurse is planning care for a group of clients. For which of the following clients should the nurse direct an assistive personnel (AP) to obtain a rectal temperature? A. A toddler who has diarrhea B. A client who is 1 day postoperative following a hemorrhoidectomy and receiving pain medications via PCA pump C. An infant who is receiving intravenous fluids D. A client who is diaphoretic and frequently chewing ice to relieve dry mouth - correct answer D. A client who is diaphoretic and frequently chewing ice to relieve dry mouth.
C. Place the stethoscope over the 4th intercostal space to the left of the sternum. D. Palpate the infant's sternum for the presence of a murmur. - correct answer C. Place the stethoscope over the 4th intercostal space to the left of the sternum. The nurse should auscultate the apical pulse over the apex of the heart, which is located in the 4th intercostal space to the left of the sternum in infants and children less than 7 years of age. A nurse obtains a client's electronic blood pressure reading of 188/96 mm Hg. Which of the following actions should the nurse take next? A. Obtain a manual blood pressure reading from the client. B. Notify the charge nurse of the client's blood pressure reading. C. Reinforce client education on measures to decrease blood pressure. D. Reinforce client teaching regarding medications to control blood pressure. - correct answer A. Obtain a manual blood pressure reading from the client. Evidence-based practice dictates that if a client's blood pressure is not within the expected reference range when it is taken with an electronic blood pressure machine, then the nurse should recheck the blood pressure by obtaining a manual blood pressure reading to ensure accuracy. A nurse is reviewing the recent vital signs of a group of clients. Which of the following clients should the nurse see first? A. A 45-year-old client who is postoperative and has a BP of 130/82 mm Hg B. A 28-year-old client who runs marathons and has a heart rate of 54/min C. A 52-year-old client who has an SaO2 of 92% D. A 78-year-old client who has a temperature of 35.9°C (96.6°F) - correct answer C. A 52- year-old client who has an SaO2 of 92% Using the airway, breathing, circulation approach to client care, the nurse should identify that the priority finding is the low SaO2. SaO2 is the indicator of the amount of oxygen transported to body tissues and the expected reference range is greater than 95%. Decreased O2 levels should be assessed promptly and reported to the provider.
A nurse is preparing to obtain a young client's apical pulse. In which of the following locations should the nurse place their stethoscope to auscultate the client's pulse? A. Apex of the heart B. Right side of sternum C. 4th intercostal space D. Midclavicular line below right clavicle - correct answer A. Apex of the heart The nurse should identify that the apical pulse is auscultated over the apex of the client's heart for a client who is older than 7 years of age. This is located between the 5th intercostal space to the left of the client's sternum. A nurse is caring for a client who has a heart rate of 118/min. Which of the following actions should the nurse take to improve the client's heart rate? A. Encourage the client to reduce intake of caffeinated soft drinks. B. Inform the client to ambulate in the hallway for 10 min prior to taking vital signs. C. Increase the room temperature and add blankets to warm the client. D. Withhold the client's antianxiety medication. - correct answer A. Encourage the client to reduce intake of caffeinated soft drinks. In an adult client, a heart rate greater than 100/min is known as tachycardia. Tachycardia can be due to exercise, anxiety, certain medications, or use of caffeine or nicotine. It can also be caused by an abnormality in the electrical system of the heart. The nurse should encourage the client to limit their intake of caffeinated soft drinks to decrease the incidence of tachycardia. A nurse is reinforcing teaching with a group of assistive personnel (AP) about techniques used to obtain BP. For which of the following clients should the nurse to instruct the AP to obtain an electronic BP measurement? A. A client who has a BP lower than the expected reference range B. A school-age child C. A client recovering from extensive abdominal surgery D. A client who has stabilized BP measurements - correct answer D. A client who has stabilized BP measurements
C. "Expect clients who have a brainstem injury to exhibit rapid respirations." D. "Clients who are experiencing acute pain will have slow, deep respirations." - correct answer B. "Count the respiratory rate for 1 minute for clients who have a respiratory infection." The charge nurse should include that the nurse should count the respiratory rate for 1 min for clients who have a respiratory infection. For clients who are healthy, the nurse can count the rate for 15 seconds and multiply by 4 to determine the rate per minute. A nurse is reviewing the vital signs for a group of clients. Which of the following clients should the nurse identify as exhibiting tachycardia? A. An infant who has an apical pulse rate of 132/min B. A preschooler who has an apical pulse rate of 108/min C. A young adult who has an apical pulse rate of 104/min D. An older adult who has an apical pulse rate of 96/min - correct answer C. A young adult who has an apical pulse rate of 104/min The nurse should identify that a pulse rate of 104/min is above the expected reference range of 60 to 100/min for a young adult. Therefore, this client is exhibiting tachycardia. The nurse should allow the client to rest in a comfortable position and recheck the apical pulse rate. If it remains elevated, the nurse should notify the provider. A nurse is discussing the physiology of blood pressure with a group of assistive personnel. Which of the following information should the nurse include? A. Diastolic blood pressure reflects the pressure exerted during contraction of the heart. B. Blood pressure is measured and documented in millimeters of mercury. C. Blood pressure decreases when the blood viscosity increases. D. Systolic blood pressure reflects the pressure when the heart is relaxed. - correct answer B. Blood pressure is measured and documented in millimeters of mercury. Blood pressure is measured in millimeters of mercury (mm Hg) and is expressed as a fraction. The pressure is measured with a sphygmomanometer. A nurse is reviewing the vital signs for a group of clients to determine the effectiveness of interventions. Which of the following findings indicate an intervention was effective?
A. An adult client who received medication for pain 30 min ago now has a respiratory rate of 18/min. B. A school-age child who received two units of packed red blood cells now has a BP of 76/54 mm Hg. C. A toddler who received an antibiotic injection now has a heart rate of 148/min while sleeping in their parent's arms. D. An older adult client who received an antipyretic medication 1 hr ago now has a temperature of 38.7° C (101.6° F). - correct answer A. An adult client who received medication for pain 30 min ago now has a respiratory rate of 18/min. An adult client who has a respiratory rate of 18/min is within the expected reference range of 12 to 20/min. This indicates that the administration of the pain medication was effective. Tachypnea, an increased respiratory rate, is an expected finding for clients experiencing pain, anxiety, or increased physical activity. A nurse is providing care to a client who has an apical pulse rate of 54/min and is experiencing dizziness. Which of the following is the nurse's priority action? A. Teach the client how to take their pulse so they can keep the provider informed of variations. B. Inform the client to ask for assistance with getting out of bed. C. Educate the client on medications, including therapeutic effects and potential adverse effects. D. Ensure the client has been taking medications as prescribed. - correct answer B. Inform the client to ask for assistance with getting out of bed. Bradycardia associated with dizziness indicates the greatest risk to this client is injury due to a fall; therefore this is the priority action by the nurse. A nurse is reviewing blood flow through the heart with a group of assistive personnel. The nurse should identify that blood flows to which of the following parts of the heart as it leaves the right ventricle? A. Tricuspid valve B. Pulmonary artery C. Right atrium D. Vena cava - correct answer B. Pulmonary artery
A nurse is evaluating the effectiveness of interventions provided to a client who has an SaO2 below the expected reference range. Which of the following manifestations requires follow up by the nurse? A. Eupnea B. Dyspnea C. Heart rate of 84/min D. SaO2 of 96% - correct answer B. Dyspnea A low SaO2 indicates the body's tissues and cells are not receiving enough oxygen and can be related to several causes including hypothermia, decreased cardiac output, or lung disease. Clients who have an SaO2 below the expected reference range of 95% to 100% can exhibit shortness of breath and difficulty breathing, or dyspnea. This indicates the interventions provided by the nurse have not been successful and require further evaluation and notification of the provider. A nurse on a pediatric unit is reviewing the medical records for a group of clients. Which of the following clients has a vital sign outside the expected reference range and requires intervention? A. A 1-month-old infant who has a respiratory rate of 58/min B. A 3-year-old preschooler who has an apical pulse rate of 144/min C. An 8-year-old child who has a respiratory rate of 25/min D. An 18-month-old toddler who has an apical pulse rate of 120/min - correct answer B. A 3-year-old preschooler who has an apical pulse rate of 144/min The nurse should identify that an apical pulse rate of 144/min is above the expected reference range of 75 to 129/min for a preschooler. This finding requires intervention by the nurse. A charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. Identify the order of the steps the nurse should include. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) A. Apply the sensor probe on the chose site. B. Select the site for obtaining the measurement. C. Confirm the pulse rate displayed on the oximeter by palpating the radial pulse.
D. Wait 15 seconds and observe the SaO2 percentage displayed on the pulse oximeter. - correct answer B. Select the site for obtaining the measurement. A. Apply the sensor probe on the chose site. C. Confirm the pulse rate displayed on the oximeter by palpating the radial pulse. D. Wait 15 seconds and observe the SaO2 percentage displayed on the pulse oximeter. The nurse should identify the site from which to obtain the measurement, such as the finger, wrist, foot, or earlobe. The nurse should check the capillary refill time to ensure adequate perfusion. If the capillary refill time is not less than 2 seconds, the nurse should select another site to ensure an accurate measurement. Next, the nurse should apply the sensor probe to the selected site and instruct the client not to move. Once the pulse rate is displayed on the oximeter, the nurse should palpate the client's radial pulse to confirm the reading. If the pulse rate palpated does not match the pulse rate displayed on the oximeter, the nurse should choose a new site for the measurement and recheck the pulses. If the radial pulse and pulse rate displayed on the oximeter are the same, the nurse should wait approximately 15 to 30 seconds, until a consistent SaO2 and pulse rate are displayed. Lastly, the nurse should remove the probe and document the measurement in the client's medical record. A nurse is assisting with the in-service for a group of nurses about cardiac output. Which of the following statements should the nurse make? A. "Cardiac output is the amount of blood flow through the heart in 1 minute." B. "Cardiac output is the amount of blood ejected from the atria." C. "Cardiac output is the ability of the muscle fibers in the ventricles to stretch." D. "Cardiac output is the resistance of the ventricles to pump blood through the heart." - correct answer A. "Cardiac output is the amount of blood flow through the heart in 1 minute." The nurse should identify that cardiac output is the amount of blood pumped by the ventricles through the heart within 1 min. A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. Which of the following statements should the nurse include? A. "Convection is the loss of body heat when a client is in contact with a cooler surface."
A peripheral pulse strength of +4 is described as bounding and is considered an unexpected finding. The nurse should check further and report the findings to the provider. A pulse strength of +2 is considered an expected finding. A nurse is reinforcing teaching with a group of newly licensed nurses about vital sign measurements. Which of the following factors should the nurse include in the teaching? A. Anxiety can cause a decrease in respiratory rate. B. Body temperature is typically lower in older adults. C. Caffeine can cause a temporary decrease in pulse rate in adolescents. D. Blood pressure slightly decreases immediately following the use of nicotine. - correct answer B. Body temperature is typically lower in older adults. The nurse should identify that body temperature is generally slightly lower in older adults than in younger adults and children. A nurse is evaluating the effectiveness of interventions used to address clients' vital signs that were outside of the expected reference ranges. Which of the following findings indicate the intervention was effective? A. An older adult client who has pneumonia and a respiratory rate of 26/min after a position change B. An adolescent who is postoperative and has an SaO2 of 93% after receiving an opioid analgesic C. A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm Hg after using an inhaler D. An older adult client who has an infection and a pulse rate of 110/min after using relaxation techniques - correct answer C. A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm Hg after using an inhaler The nurse should identify that a blood pressure of 116/72 mm Hg is within the expected reference range for a young adult. The expected systolic blood pressure should be less than 120 mm Hg and the diastolic blood pressure should be less than 80 mm Hg. Therefore, the intervention of using an inhaler was effective. A charge nurse in a clinic is preparing an in-service about blood pressure measurements for a group of staff members. Which of the following information should the nurse include?
A. A client is diagnosed with an elevated blood pressure when the measurement is greater than 130/80 mm Hg. B. A client is experiencing a hypertensive crisis when their blood pressure is greater than 150/90 mm Hg. C. A client who has a blood pressure of 128/86 mm Hg has stage I hypertension. D. A client who has a blood pressure of 162/102 mm Hg has stage II hypertension. - correct answer D. A client who has a blood pressure of 162/102 mm Hg has stage II hypertension. The charge nurse should include that a blood pressure of 162/102 mm Hg meets the diagnostic criteria for stage II hypertension. With Stage II hypertension, the systolic BP must be greater than 140 mm Hg and the diastolic BP must be greater than 90 mm Hg. A nurse is observing an assistive personnel (AP) who is obtaining a blood pressure reading from a client. Which of the following actions by the AP requires follow up by the nurse? A. The AP uses a cuff width that is 40% of the circumference of the client's arm. B. The AP provides support for the client's arm while taking the BP. C. The AP waits to take the client's BP 45 min after the client ambulates in the hallway. D. The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second. - correct answer D. The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second. Releasing the pressure at a rate of 5 mm Hg per second is too fast. The recommended rate is 2 mm Hg per second. Releasing the valve too quickly could prevent the AP from noting the correct reading and too slowly can cause additional discomfort to the client. A nurse working on a medical-surgical unit is caring for a group of clients. Which of the following clients' vital signs should the nurse identify is outside the expected reference range and notify the provider? A. A client who has an apical pulse rate of 120/min B. A client who has a blood pressure of 100/74 mm Hg C. A client who has an apical pulse rate of 84/min D. A client who has a blood pressure of 110/68 mm Hg - correct answer A. A client who has an apical pulse rate of 120/min
C. Decrease in respiratory rate D. Increase in preload - correct answer A. Decrease in contractility The nurse should identify that a decrease in contractility of the client's heart is a contributing factor to hypotension. Contractility is the ability of the heart muscle to contract effectively. A charge nurse is evaluating a newly licensed nurse's documentation of vital signs for several clients. Which of the following documentation should the charge nurse identify as being incomplete? A.Radial pulse regular at 84/min B. Respirations observed as even, nonlabored at 20/min with client in supine position C. BP 124/82 mm Hg, lying in bed D. Temporal temperature 36.9° C (98.4° F) - correct answer C. BP 124/82 mm Hg, lying in bed The charge nurse should identify that this documentation is incomplete because it does not include the site from where the blood pressure was obtained. A nurse is caring for a client who has an increase in cardiac afterload. Which of the following findings should the nurse expect? A. Increase in blood pressure B. Increase in respiratory rate C. Decrease in cardiac output D. Decrease in preload - correct answer A. Increase in blood pressure The nurse should identify that a client who has an increase in afterload increases the risk for hypertension. Afterload is the resistance of the ventricle to pump the heart muscle and eject blood into the client's bloodstream during systole. A nurse is evaluating the effectiveness of interventions provided to a client who was admitted for decreased peripheral circulation. Which of the following findings should the nurse report to the RN? A. Pulse deficit of 0
B. Left radial pulse is nonpalpable C. Peripheral pulse +2 bilateral D. Brachial pulses are symmetrical - correct answer B. Left radial pulse is nonpalpable Peripheral pulses that are nonpalpable require further intervention by the nurse. The nurse should use a Doppler ultrasound stethoscope to auscultate the pulse. The nurse should also determine if the client has other manifestations of impaired circulation, such as cool, pale skin. The nurse should notify the provider of any unexpected findings. A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. Which of the following statements should the charge nurse make? A. "The first step in checking for orthostatic hypotension is obtaining a client's blood pressure while they are standing." B. "An increase of 5 millimeters of mercury in the diastolic pressure with a position change indicates orthostatic hypotension." C. "A decrease of 20 millimeters of mercury in the systolic pressure with a position change indicates orthostatic hypotension." D. "Wait 5 minutes to check the client's blood pressure after each position change." - correct answer C. "A decrease of 20 millimeters of mercury in the systolic pressure with a position change indicates orthostatic hypotension." The charge nurse should include that a decrease of at least 20 mm Hg in the systolic pressure with a position change indicates orthostatic hypotension. A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart? A. Atrioventricular (AV) node B. Left ventricle C. Sinoatrial (SA) node D. Right ventricle - correct answer C. Sinoatrial (SA) node The SA node is the pacemaker of the heart. It consists of a small group of special cells in the right atrium which initiates electrical impulses that travel to the AV node and sets the rate of the contraction of the ventricles.
