Which of the following interventions should the nurse plan to recommend? D. An 18-month-old toddler who has an apical pulse rate of 120/min. B. D. Decrease in preload. Continue to inflate the blood-pressure cuff 30 mm Hg more. S2 is produced when the, When preparing to measure the vital signs of a patient, you should recognize that which of the following will affect the methods that you will use? The nurse should use clinical judgment when evaluating vital signs and wait 15 to 30 min following exercise. 2005 - 2023 WebMD LLC, an Internet Brands company. For example, if you have a two-year-old and use a temporal artery thermometer, you may get a reading of 101 degrees Fahrenheit. 4. The nurse should identify that an apical pulse rate of 66/min is within the expected reference range of 60 to 100/min for an older adult client. Increase in respiratory rate Peripheral pulses that are nonpalpable require further intervention by the nurse. 3) Instruct patient to close the lips around the probe and to keep mouth closed until temp has been measured. A. E. An adult client who had tachycardia 1 hr ago due to postoperative pain and has an apical pulse rate of 106/min. B. A 45-year-old client who is postoperative and has a BP of 130/82 mm Hg 7)Remove the blood-pressure cuff, perform hand hygiene, and document your findings. Design: A prospective repeated measures (induction, emergence, and postanesthesia care unit) design was used. B. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart? 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 charge nurse is reviewing the expected reference range of blood pressure in adult clients with a newly licensed nurse. B. B. A. Apex of the heart Place the sensor flush on the patient's forehead. a passive process that involves the diaphragm moving up, the external intercostal muscles relaxing, and the chest cavity returning to its normal resting state. v22 Sustained or continuous: temperature remains above normal with minimal variations v23 Relapsing or recurrent: temperature returns to normal for one or more days with one or more episodes of fever, each as long as several days Types of Thermometers Used to Assess Body Temperature Normal Temperatures for Healthy Adults v24 Oral: 37.0C, 98.6 . data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAKAAAAB4CAYAAAB1ovlvAAAAAXNSR0IArs4c6QAAAw5JREFUeF7t181pWwEUhNFnF+MK1IjXrsJtWVu7HbsNa6VAICGb/EwYPCCOtrrci8774KG76 . Wait 30 seconds. B. C. Encourage the client to practice relaxation techniques each day. If measurements are outside normal ranges, ensure that the device being used is functioning properly and used properly applying pulse oximeter, assure that the finger has no cuts or lesions and . B. Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall. To obtain the best reading, place the oximeter sensor on a vascular area of the body. A nurse is caring for a client who has a heart rate of 120/min. Which of the following actions should the nurse take to improve the client's heart rate? Which of the following information should the nurse recommend be included? A client who has a BP lower than the expected reference range In addition to gender and age, exercise, medications, decreased oxygen saturation, blood loss, and body temperature can all influence a patient's pulse rate. It can also be caused by an abnormality in the electrical system of the heart. Range is from 96.8-100.4 is acceptable. Temporal Temperature Measurement Method 1) Provide privacy 2) Remove protective cap and wipe lens of device with alcohol swab Which of the following findings indicate the intervention was effective? A peripheral pulse strength of +4 is described as bounding and is considered an unexpected finding. 1) Provide privacy Blood pressure is measured and documented in millimeters of mercury. B. C. A client recovering from extensive abdominal surgery The nurse should document the findings in the client's medical record and notify the provider if a pulse deficit is present. Design: . Our MCQ book is the key to achieving exam success and advancing your career. The nurse should encourage the client to limit their intake of caffeinated soft drinks to decrease the incidence of tachycardia. Temporal temperatures are close to rectal, but they are nearly 0.5 degrees Celsius higher than oral, and 1 degree Celsius higher than axillary temperatures. Smart Grocery Shopping When You Have Diabetes, Surprising Things You Didn't Know About Dogs and Cats. Which of the following statements should the nurse include in the teaching? Many of today's oxygen-dependent organisms could not have survived in the Archean atmosphere. Another indicator of a patient's health status is pulse oximetry. Select the site for obtaining the measurement. If the capillary refill time is not less than 2 seconds, the nurse should select another site to ensure an accurate measurement. Tachypnea, an increased respiratory rate, is an expected finding for clients experiencing pain, anxiety, or increased physical activity. -Any signs or symptoms of pain A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. A. B. A. D. "Clients who are experiencing acute pain will have slow, deep respirations.". 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. -The site where you measured the blood pressure The nurse should identify that a client who has an increase in afterload increases the risk for hypertension. -Your nursing interventions ("antipyretic given") You have assessed a 45-year-old patient's vital signs. Plaster cast care advice Keep your arm or leg raised on a soft surface, such as a pillow, for as long as possible in the first few days.. Do this for about five to 10 minutes or until the itch subsides. "The body lowers body temperature through sweating." Blood pressure is measured and documented in millimeters of mercury. 60-100 BPM. A nurse is reviewing the vital signs for a group of clients to determine the effectiveness of interventions. The nurse should also determine if the client has other manifestations of impaired circulation, such as cool, pale skin. D. Vena cava. 2) Apply light pressure with the pads of the fingers in the groove along the radial or thumb side of the patients inner wrist. Testimonials; FAQ; Windows. C. An infant who is receiving intravenous fluids exchange of oxygen and carbon dioxide between atmosphere and the cells of the body. Rectal thermometer devices met accuracy criterion of remaining within 0.5 C of core temperature 95% of the time. 5) Discard disposable cover and document results. This number is the patient's diastolic blood pressure. Patients who have tachycardia might experience dyspnea, fatigue, chest pain, palpitations, and edema. For a healthy adult is between 95% and 100%. Accuracy: Research has demonstrated that the TAT The client's auscultated apical pulse was 106/min and the palpated radial pulse was 93/min. Instruct the client to bear down like they are having a bowel movement. 9 Monitoring at noncore sites, including the urinary bladder or rectum, reflects core temperature if certain precautions are taken. a. increases the flow of auxin down the shoot, c. produces a plant that will grow taller, d. produces a plant that will grow fuller. usually slightly faster in woman and more rapid in infants and children. A charge nurse is evaluating a newly licensed nurse's documentation of vital signs for several clients. D. "Cardiac output is the resistance of the ventricles to pump blood through the heart.". This study asks if a temporal artery temperature (TAT) measure can supplant the RT measure. Conditions such as congestive heart failure (CHF), hemorrhage, shock, dehydration, and anemia can all speed up the heart rate. A. "Conduction is the loss of body heat when sweat dries from a client's skin." D. Withhold the client's antianxiety medication. 5. 2)The second sound is a whooshing sound, A term used when systolic pressure drops more than 20 mm Hg or the pulse increases by 20 beats per minute or more when the patient moves from a recumbent to a standing position, - Considered a 5th vital sign The expected systolic blood pressure should be less than 120 mm Hg and the diastolic blood pressure should be less than 80 mm Hg. A nurse is observing an assistive personnel (AP) obtain vital signs from an adult client. C. The AP gently presses down with the pads of two to three fingers over the radial pulse site. Which of the following clients' vital signs indicate that interventions were effective? Here is how to take a forehead temperature: Follow the instructions on the package to know how and where to slide or aim the sensor across the forehead to get the most accurate measurement. Your temporal temperature is usually 0.5 to 1 degree Fahrenheit lower than your oral temperature. The nurse should identify that a young adult client who has a radial pulse rate of 56/min is exhibiting bradycardia. Vital signs are when you take measurements of the body's basuc functions such as temperature, respiration, blood pressure, and pulse.-Hand hygiene -Gloves/PPE if needed -Thermometer -Watch -Stethoscope -Blood pressure cuff-Fever . C. "A decrease of 20 millimeters of mercury in the systolic pressure with a position change indicates orthostatic hypotension." B. When using pharmacological agents, the medication should be prescribed and administered on a regular schedule rather than on an as-needed basis. Lastly, the nurse should remove the probe and document the measurement in the client's medical record. We use cookies to personalize and improve your experience on our site. Oxygen saturation reflects the amount of oxygen being delivered to body tissues. C. BP 124/82 mm Hg, lying in bed A. C. Educate the client on medications, including therapeutic effects and potential adverse effects. Pull the client pinna's up and back C. Document client temperature with "AX" next to the value D. Slide the A nurse is reviewing the vital signs of four clients. B. fat larry james cause of death top d1 women's golf colleges calculating a clients net fluid intake ati nursing skill Posted on August 7, 2022 Author bank owned homes hillsborough county, fl Continue to deflate the blood-pressure cuff slowly, noting the number at which the sound disappears. B. C. An 11-year-old child who has a respiratory rate of 34/min A nurse is assisting in the planning of an in-service for a group of newly hired assistive personnel (AP) about body temperature. "Count the respiratory rate for 1 minute for clients who have a respiratory infection." Your fever is generally considered safe up to 104 degrees Fahrenheit. "Convection is the loss of body heat when a client is in contact with a cooler surface." 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