An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

Temperature

Pulse rate

Respiratory rate

Answer and Explanation

The Correct Answer is B

A.   The reported tympanic temperature of 37.1°C (98.8°F) is within normal range.
B.   The blood pressure (BP) reading of 98/58 mm Hg indicates a relatively low diastolic pressure. Diastolic pressure is an important indicator of perfusion to vital organs, especially the coronary arteries and the brain. It's crucial to ensure that this reading is accurate.
C.   The reported pulse rate of 92/min falls within the normal range for an adult at rest.
D.   The reported respiratory rate of 18/min is within the normal range for an adult at rest.

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Correct Answer is A

Explanation

A. This is the correct method for identifying the client before administering medication.
Asking for the client's full name and date of birth is a standard and effective way to ensure that the right medication is given to the right person.
B. Depending solely on a family member to verify the client's identity is not considered a reliable method. While involving family members can be helpful in certain situations, the primary responsibility lies with the nurse to directly confirm the client's identity.
C. Verifying the client's room number is not a sufficient method of client identification.
Room numbers can change, and it's possible for clients to be moved, so relying on this alone is not considered safe practice.
D. Checking the client's name on the medication administration record (MAR) is an important step in medication administration, but it is not the initial method of identifying the client. It's used to confirm that the right medication is being administered to the right person after the client's identity has been established through direct interaction and confirmation.

A. Observe client's respiratory status. B. Monitor intake and output every 8 hr. C. Elevate the head of the client's bed 30° to 45°. D. Check residual volume every 4 to 6 hr.

Correct Answer is A

Explanation

A. Observing the client's respiratory status is the priority action because a decreased level of consciousness can potentially lead to compromised airway and respiratory function. It's crucial to monitor for signs of respiratory distress or compromise, such as changes in respiratory rate, depth, and effort.
B. Monitoring intake and output every 8 hr is an important nursing responsibility, but it is not the top priority when the client's respiratory status is in question.
C. Elevating the head of the client's bed 30° to 45° is a standard practice to prevent aspiration and promote optimal digestion during enteral feedings. While important, it is not the immediate priority in this situation.
D. Checking residual volume every 4 to 6 hr is a part of enteral feeding management, but it is not the priority when the client's respiratory status is a concern.

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An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

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