N5451 Skills Lab Video Quizzes - Module 2 Vital Signs
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Course
N5451
Institution
N5451
N5451 Skills Lab Video Quizzes - Module 2 Vital Signs The nurse is planning to take a client's temperature orally. The nurse enters the room and observes the client drinking a cup of coffee. Which action would be most appropriate? Assess the client's temperature about 30 minutes after the client ...
N5451 Skills Lab Video Quizzes - Module 2 Vital Signs
The nurse is planning to take a client's temperature orally. The nurse enters the room
and observes the client drinking a cup of coffee. Which action would be most
appropriate?
Assess the client's temperature about 30 minutes after the client has finished drinking
the coffee. Because the client was drinking coffee, the nurse should wait 30 minutes
before taking an oral temperature because of the possible direct influence of the coffee
on the client's temperature. Taking the oral temperature sooner would lead to inaccurate
results. A rectal temperature is uncomfortable for a client and should only be used in
specific situations, where the oral or other sites would be inappropriate.
The nurse would use which part of the hand when assessing the radial pulse?
Pads of first, second, and third fingers To assess the radial pulse, the nurse uses the
pads of the index, second and third fingers of the hand. These three fingers help
determine the volume, rate and rhythm of the pulse. The thumb of the hand should not
be used, because it has its own pulse. The palm of the hand does not have enough
sensitivity to determine volume and rhythm. Because of the sensitivity of the fingertips,
they can interfere with an accurate measurement of the pulse.
The nurse estimates a client's systolic pressure to be 150 mm Hg. When obtaining the
client's blood pressure measurement with a sphygmomanometer, the nurse would
inflate the cuff to which pressure?
180 mm Hg When measuring a client's blood pressure, the nurse inflates the cuff to a
pressure 30 mm Hg above the estimated systolic pressure. Doing so ensures a period
before hearing the first sound that corresponds to the systolic pressure and prevents
misinterpreting phase II sounds as phase I sounds. The pressures below 180 mm Hg
would all be too low.
When preparing to obtain vital signs on a client, which action would the nurse perform
first?
Perform hand hygiene. When performing any skill, including measuring vital signs, the
first step is to perform hand hygiene. Next, the nurse would confirm the client's identity,
ensure privacy by closing the curtain and/or door to the room, and put on nonsterile
gloves (if appropriate).
A nurse is measuring a client's blood pressure in the right arm and is having difficulty
auscultating the sounds. Which would be least appropriate for the nurse to do?
Apply less pressure with the stethoscope. Difficulty auscultating blood pressure sounds
may be related to equipment, environmental noise, or inaccurate placement of the
, stethoscope. Appropriate actions would include applying firmer pressure to the
stethoscope when it is placed at the brachial artery, rechecking the brachial artery pulse
to ensure the proper placement of the stethoscope, checking to make sure that all
equipment is functioning properly, making sure that the room is quiet, and trying the
measurement on the opposite extremity.
The nurse is providing care to a client who has had a left modified radical mastectomy 2
days ago. The woman also has an intravenous line inserted in the right antecubital
space. Which would be most appropriate when assessing this client's blood pressure?
Use either the client's right or left thigh to obtain the blood pressure. If a client has a
mastectomy or catheters in the extremity, the blood pressure should not be measured in
the affected extremity because of risk for lymphedema secondary to the mastectomy,
and the risk of tissue and vessel injury or catheter damage secondary to the catheter
placement. Since this client has an intravenous line in the right arm and had the
mastectomy on the left, neither upper extremity would be appropriate to use. Instead the
nurse should obtain a thigh blood pressure using either lower extremity. There is no
need to notify the health care provider to obtain the blood pressure through an arterial
device.
A nurse is having difficulty observing the rise and fall of a client's chest when assessing
respirations. Which action would be most appropriate?
Put the stethoscope at the apical site and watch its movement. If the rise and fall of the
client's chest is difficult to observe the nurse should place the stethoscope at the apical
site and then observe the rise and fall of the chest or watch the stethoscope move up
and down. Documenting the rate as unattainable is inappropriate. Having the client
breathe deeply will alter the actual respiratory rate of the client. Asking the client if he or
she is having trouble breathing is inappropriate because doing so may lead the client to
experience undue anxiety and fear.
A nurse is measuring a client's blood pressure using an electronic device. What is
important for the nurse to do to ensure accurate results?
Check to make sure the client's heart rate is regular. Various factors such as an
irregular heart rate, excessive client movement, and environmental noise can interfere
with the accuracy of the readings obtained with an electronic blood pressure device.
Therefore, the nurse should make sure that the client's heart rate is regular and take
steps to minimize client movement and external noise. In addition, it is important that
the cuff be applied to the arm so that no clothing interferes with its placement.
What is most important for the nurse to do when using an automatic electronic device to
obtain serial blood pressure readings?
Check that the cuff is deflated completely after the reading. With serial blood pressure
readings, typically the cuff of the automatic electronic device remains in place. The
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