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 C

Explanation

A. Autonomy vs. shame and doubt focuses on developing a sense of independence and autonomy in early childhood (around 1-3 years old). It does not directly involve acceptance of death.
B. Identity vs. role diffusion pertains to adolescence (around 12-18 years old) and involves the development of a sense of self and one's role in society. It does not specifically address the acceptance of death.
C. Integrity vs. despair is the stage that occurs in late adulthood (65 years and older), where individuals reflect on their lives. Acceptance of death is a significant aspect of achieving a sense of integrity during this stage.
D. Generativity vs. stagnation occurs in adulthood (around 40-65 years old) and involves concerns about contributing to the next generation and leaving a legacy. While mortality may be a consideration, it is not the primary task of this stage.

A. Gloves B. Face shield C. Gown D. Mask

Correct Answer is A

Explanation

A. Gloves should be removed first. This is because the gloves are the items most likely to be contaminated. To remove gloves, grasp the outside edge near the wrist and peel them off, turning them inside out as you go.
B. The gown should be removed next. The gown protects the nurse's clothing from contamination. Untie or unfasten the gown, and then carefully remove it, taking care to avoid touching the outside of the gown.
C. Face shields or goggles should be removed next if used. This helps protect the eyes and face. Handle the shield or goggles by the headband or earpieces and remove them without touching the front.
D. Mask should be removed last. The mask helps protect the respiratory system. Untie or unhook the mask from behind the ears or head and discard it.

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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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