Exam 7: Vital Signs

The nurse assesses the patient's respirations and notes the patient routinely takes two to three breaths followed by an irregular period of apnea.How does the nurse document this finding?

The patient's oral temperature is 37.1 $\degree$ C (98.78 $\degree$ F) at 1 PM.Which of the following actions should the nurse take next?

The nurse is teaching a family member how to check a teenager's temperature using a tympanic thermometer.Which step is most important for the nurse to include in order to obtain an accurate reading?

The nurse is validating the measurement of an infant's pulse by a nursing student.Which method should the nurse use to obtain the most accurate count?

The nurse is preparing to assess the apical pulse.At which location should the nurse listen to obtain an accurate apical pulse on an adult patient?

The nurse is preparing to obtain a rectal temperature.Nursing care is correct if the nurse inserts the thermometer how far into the rectum of an adult?

The nurse uses a blood pressure (BP) cuff that is too narrow for the arm of a patient with morbid obesity.What problem will the nurse encounter because of the cuff used?

The nurse notes that the patient's tympanic temperature is 37.88 $\degree$ C (100.2 $\degree$ F) at 4 PM on the patient's second postoperative day.What should the nurse do initially?

The patient is unstable, so the nurse is using an electronic blood pressure device to measure blood pressures every 15 minutes.What should the nurse do to verify the accuracy of the electronic blood pressure measurements?

The nurse is caring for a lethargic, 18-year-old patient with a respiratory rate of 32 breaths per minute.What is the first action the nurse should take?

The nurse is preparing to measure the patient's blood pressure with an electronic blood pressure device.Which concept is most important for the nurse to consider?

A patient born without arms needs to have a blood pressure assessment.Which artery should the nurse use to most accurately obtain this measurement?

The nurse is running a blood pressure screening clinic at the community health center.Which action should the nurse implement to obtain an accurate measurement of a patient's blood pressure on an upper extremity?

The nurse needs to measure the adult patient's temperature, but the patient has just finished a cup of coffee.Which is the best type of temperature for the nurse to obtain accurate results efficiently?

The nurse delegates temperature measurement to nursing assistive personnel (NAP).For which patient should the nurse instruct the NAP to use the tympanic thermometer?

The nursing assistant reports the following vital signs for four patients just evaluated.Which patient should the nurse see first?

At what distance above the antecubital fossa does the nurse position a blood pressure (BP) cuff when using the brachial artery to measure BP?

The patient's oral temperature is 39 $\degree$ C (102.2 $\degree$ F).Which conclusion can the nurse make about the patient on the basis of this information?

A patient taking a new cardiac medication suddenly develops an irregular pulse.The nurse plans to obtain an apical-radial pulse.What action by the nurse is best?

While inserting a rectal thermometer, the nurse encounters resistance.What action should the nurse take?