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. Applying the ice bag for 30 minutes at a time is a recommended duration for cold therapy. This helps prevent potential tissue damage from prolonged exposure to cold temperatures.
B. Placing the bag directly on the skin is not recommended, as it can cause frostbite or skin damage. A barrier, such as a thin towel or cloth, should be placed between the ice bag and the skin.
C. Allowing room for some air inside the bag is important to allow the ice to conform to the shape of the injured area. However, the bag should not be overfilled with air.
D. Reapplying the bag 30 minutes after removing it is a good practice, as it allows time for the tissues to warm up before reapplying the cold therapy.

A. Request a prescription for an indwelling urinary catheter. B. Take the client to the bathroom every 2 hr. C. Remind the client to tell the nurse when he has to urinate. D. Use adult diapers to prevent frequent clothing changes.

Correct Answer is B

Explanation

A. Requesting a prescription for an indwelling urinary catheter should be considered a last resort. Catheters come with risks of infection and other complications, so they should only be used when other interventions have failed.
B. Taking the client to the bathroom every 2 hours is a proactive approach to managing urinary incontinence in older adults with dementia. This helps ensure that the client has regular opportunities to empty their bladder, reducing the likelihood of accidents.
C. Reminding the client to tell the nurse when he has to urinate may not be effective in clients with dementia, as they may have difficulty recognizing or communicating their need to urinate.
D. Using adult diapers should also be considered a last resort and should not be the primary intervention. While they can provide a temporary solution, they do not address the underlying issue and can contribute to skin problems if not changed frequently.

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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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Correct Answer is A

Explanation

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Explanation

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