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
BP
Pulse rate
Respiratory rate
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Education may influence the communication process to a significant extent as an interpersonal variable.
B. Time can affect communication in terms of available time for interaction, but it is not specifically related to interpersonal variables.
C. Perception refers to how individuals interpret and make sense of information. It is a key interpersonal variable that can influence how a message is received and understood.
D. Gender can be an interpersonal variable that affects communication. Different genders may have different communication styles and preferences.
E. Feedback is not considered an interpersonl ariation that can affect communication
Correct Answer is A
Explanation
A. This is the appropriate height to allow the fluid flow by gravity.
B. This is such a short distance and the fluid wouldn't flow as desired.
C. Holding the container at the client's upper hip would not provide the appropriate angle for administering the enema.
D. This choice does not provide specific guidance on the height or angle for administering the enema, which is crucial for the procedure's effectiveness.
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