Vital Signs NCLEX Questions

Vital Signs NCLEX Questions ScienceMedicineNursing nellyiscute13 Save Vital Signs Practice for NCLEX Ques...15 terms lizzyohmesPreview Vital Signs NCLEX Questions 28 terms arianna_leigh8 Preview Chapter 12 Vital signs NCLEX questi...21 terms Savannah_Cresap2 Preview ATI Fun 308 term sca When assessing a client’s radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next?Auscultate the apical pulse for 60 sec.The nursing student is selecting a blood pressure cuff prior to obtaining a client's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading?40% of the circumference of the limb to be used.When performing hourly checks, a client reports feeling "different" than earlier in the day. On what schedule will the nurse assess the client's vital signs?immediately A nurse attempts to count the respiratory rate of a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this client?Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.A client who has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong?She should place her three fingers just below the wrist on the outside of the arm with the palm up

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that

the digoxin will:

decrease the apical pulse The nurse is assessing a client with a known cardiac arrhythmia. The nurse should most accurately assess the client's heart rate and rhythm by using which method?Auscultate at the fifth intercostal space at the left mid-clavicular line.When administering beta blocker medications, the health care provider adds an order to hold medication when the client is bradycardic. Which statement explains this order?The client's pulse rate is below 60 beats per minute Which term indicates a potentially serious client condition?pyrexia The nurse is educating a client with heart disease about taking their temperature. Which statement indicates the client requires further education?The axillary route is just as accurate as the oral route." The nurse instructs a parent of young children how to properly use a nonmercury glass thermometer. Which statement made by the parent indicates a need for further instruction?"I will clean the thermometer in the dishwasher." For which client should the nurse use a Doppler ultrasound as part of a vital signs assessment?client whose peripheral pulses are difficult to palpate A nurse is caring for an adult with fever. The nurse determines that which site is most accurate for obtaining the client's core body temperature?rectum The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention?Provide privacy for the patient The nurse is caring for a 5-year-old child who is postoperative after having surgical removal of the tonsils and adenoids. When assessing the client's temperature, which method(s) is appropriate and least invasive for this child? Select all that apply.-using a temporal artery thermometer -using the axillary site

The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular.What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate?The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse The nurse is preparing to administer a medication that the client takes to treat a cardiac arrythmia. Which site should the nurse use to assess pulse in this client?apical While recording the pulse of an infant at 160 beats/min, the parent asks if it is normal for the infant's pulse rate to be so high. Which statement by the nurse best answers the parent's question?"A heart rate of 160 beats/min is normal for a healthy infant." An older adult client monitors their blood pressure at home. Lately the client has been experiencing dizziness and nausea, followed by a headache when arising from lying down for a nap. The client was worried it was their blood pressure and began measuring their blood pressure arising from their nap. The client found that their blood pressure would drop shortly after getting. The client followed up with their health care provider and was diagnosed with orthostatic hypotension. What is the most important concern the nurse will include in the teaching plan?falls risk related to inadequate physiologic response to postural (positional) changes The home care nurse is assessing a 37-year-old client's vital signs at rest. Which finding requires nursing intervention?temporal temperature 100.8º F (38.2º C) The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in

this upright position and documents this condition on the chart as:

orthopnea A nurse is assessing an apical pulse on an older adult client who takes metoprolol daily. The nurse can anticipate that the client's medication will: decrease the apical pulse The nurse is caring for a client who has smoked for more than 20 years and is now experiencing labored respirations. The nurse documents the

client is experiencing:

dyspnea The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse’s priority action in this situation?Remove the thermometer and assess the blood pressure and heart rate.The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?Listen for heart sounds

The nurse discovers during assessment that the client has an altered temperature. Select one caustive factor for each type of heat loss.

Radiation: infrared heat waves

Conduction: the air itself

Evaporation: through sweating

Convection: exposure to a fan

The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats/min. What additional assessment information would be important to obtain because it may account for this assessment finding? Select all that apply.

• The client reports pain of 8 on a scale of 0 to 10
• The client just finished ambulating with physical therapy
• The client has a temperature of 101.8 (38.8C)

The nurse assesses a client admitted with multiple trauma including basilar skull fracture and rhinorrhea (drainage from nose), bilateral otorrhea (drainage from ear), and multiple fractures requiring a full body cast. The client is on a 40% Venturi oxygen mask. What is the best way to evaluate the client’s temperature?Temporal artery Terms (28) Hide definitions