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Showing 19 questions, Sign in for moreAn 85-year-old client has had a stroke resulting in right-sided facial drooping, difficulty swallowing, and the inability to move self or maintain position unaided. The nurse determines that which sites are most appropriate for taking the temperature? Select all that apply
For a client with a previous blood pressure of 138/74 mmHg and pulse of 64 beats/min, approximately how long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading?
According to the JNC’s seventh report, a BP reading of 144/96 would be considered ______.
A healthy adult patient tells the nurse that he obtained his blood pressure in “one of those quick machines in the mall” and was alarmed that it was 152/7B. He immediately repeated the measurement, and the value was 158/80. His normal BP value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/72? Select all that apply
The client’s temperature at 8:00 am using an oral electronic thermometer is 3F.1°C (97.2°F). If the respiration, pulse, and blood pressure were within normal range, what would the nurse do next?
It would be appropriate to delegate the taking of vital signs of which client to unlicensed assistive personnel?
A 69-year-old woman is admitted with dizziness, confusion, and dyspnea. Which vital sign should not be delegated to trained ancillary personnel?
Prioritize your nursing interventions based on the vital signs.
A client is admitted with a head injury and may develop neurogenic fever. Which nursing diagnosis would be most appropriate for this client?
A nurse assesses an oral temperature for a patient as 38.5°C (10A.3°F). What term would the nurse use to report this temperature?
A patient complains of severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessment?
A 52-year-old woman is admitted with pneumonia, dyspnea, and discomfort in her left chest when taking deep breaths. She has smoked for 35 years and recently lost over D.5 kg (10 lb). She is started on intravenous antibiotics, high protein shakes, and 2 L O2 via nasal cannula. Her vital signs at the start of treatment are HR 112, BP 138/82, RR 22, tympanic temperature 37.9°C (100.2°F), and oxygen saturation 94%. Which of the vital signs taken 4 hours later reflect a positive outcome of the treatment interventions? Select all that apply
Which number marks the location where the nurse would auscultate the point of maximal impulse (PMI)?
During admission of an obese patient with heart failure the assistive personnel (AP) reports to the nurse that the blood pressure (BP) is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? Select all that apply
A patient with heart failure is one-day postoperative for major abdominal surgery. When the nurse and the assistive personnel raise the head of the bed to sit the patient on the side of the bed before ambulation, the patient immediately complains of dizziness and nausea. What are your immediate actions? Select all that apply
It is important to have the appropriate cuff size when taking the blood pressure. What error may result from a cuff that is too large or too small?
A patient has intravenous fluids infusing in the right arm. When taking a blood pressure on this patient, what would the nurse do in this situation?
A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient?
A student nurse is learning to assess blood pressure. What does the blood pressure measure?
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