Vital signs 1. If you observe your nursing assistant taking a client’s vital signs (blood pressure, temperature, pulse rate, respiratory rate) immediately after breakfast, the nurse instruct the nursing assistant that it is best to: a. Obtain the client’s apical-radial pulse b. Wait 15 minutes to assess the client’s pulse c. Assess the client’s temperature in 30 minutes d. Take the blood pressure with the client lying down 2. Mr Dolfo is admitted in medical ward because of fever, anorexia, and body malaise. What is the nurse best action id the client’s body temperature is 38.9 C and is shivering? a. Offer the client a cup of hot soup b. Cover the client with a light blanket c. Direct a fan in the client’s direction d. Darken the room to provide rest 3. When assessing a client’s radial pulse, the nurse notes that it disappears with very slight pressure. The nurse is most correct in documenting that the pulse is: a. Normal c. Thready b. Weak d. Diminished 4. Before assessing an adult’s blood pressure, the nurse is most correct in selecting a blood pressure cuff with a bladder width that is 40% and the bladder length that encircles at least which percent of the client’s upper arm? a. 40%c. 80% b. 60%d. 100% 5. If the nurse detects that a client has symptoms associated with orthostatic hypotension, the best instruction the nurse can offer the client is to: a. Limit consumption of fluids during the day b. Rise slowly from a lying or sitting position c. Remain in bed throughout care in the health agency d. Ambulate about the health agency at least 4x a day 6. The nurse is checking routine vital signs on four assigned clients. For which client would the nurse measure an apical pulse instead of a radial pulse? a. A client receiving digitalis, a cardiac drug b. A client who will be going to surgery the next morning c. A client who will be discharged to home d. A client who is reporting pain 7. The nurse measures a respiratory rate of 16 respirations per minute for a newly admitted adult client. Which of the following actions should the nurse do next? a. Recheck the measurement in 15 minutes b. Document the measurement on the flow sheet c. Ask another nurse to measure the respiratory rate d. Check the client’s medical record for history of respiratory disease. 8. The nurse gave a client a 325-mg aspirin suppository. The client has diarrhea and is in the bathroom. The best nursing approach as this time would be to: a. Wait 15 minutes after the diarrhea stops and then administer the suppository b. Withhold the suppository and notify the client’s physician. c. Tell the client you’ll give him the suppository when he’s finished in the bathroom d. Substitute 325-g aspirin by mouth 9. A client is to have rectal temperature taken. A glass of thermometer is available at the client’s bedside. The mercury bulb on the insertion end of the thermometer is long and slender. The best action by the nurse is which of the following? a. obtain a thermometer with a short, blunt insertion end b. take the client’s temperature with the available thermometer c. carefully insert the long end of the thermometer after lubricating that end d. put on gloves on before using the thermometer available at the client’s bedside 10. The nurse completing anthropometric measurements for a patient collects which of the following information? a. height and weight c. dietary history b. serum hemoglobin and hematocrit level d. intake and output 11. A 72-year-old was admitted to the hospital for pneumonia. He is receiving oxygen a 6 liters per mask. In obtaining his vital signs, the nurse should all of the following except: a. Take the axillary temperature c. listen to the apical heart ate b. listen to the lungs when counting the respiration d. take an oral temperature 12. In obtaining a blood pressure measurement, the most appropriate nursing action is: This study source was downloaded by 100000869267694 from CourseHero.com on 08-25-2023 05:06:04 GMT -05:00