Vital Signs

A nurse receives information during shift report that a patient is afebrile. What action will the nurse take in response?

• Checking the MAR for prescribed antipyretic medication

• Reporting the finding to the primary care provider

• No action is necessary; this is a normal reading

• Taking the patient’s temperature using a different method

A nurse is caring for a newborn with hypothermia. What action does the nurse take to prevent heat loss from convection?

• Wrapping the newborn in a blanket

• Placing the newborn on a warmed surface

• Reducing the temperature in the room

• Increasing the temperature in the room

Answer explanation

A charge nurse working on a medical-surgical unit stops the AP from taking rectal temperatures on patients with which problems? Select all that apply.

• Pancreatitis

• Thrombocytopenia

• Leukemia

• Bradycardia

• Pneumonia

Answer explanation

The rectal site should not be used in newborns, children with diarrhea, and in patients who have undergone rectal or vaginal surgery.

Inserting a rectal thermometer can stimulate the vagus nerve causing or worsening bradycardia; this route may be contraindicated in certain cardiac patients. The rectal route is also contraindicated in patients who have neutropenia (low white blood cell counts, such as in leukemia or those receiving chemotherapy), thrombocytopenia (low platelet counts), and certain neurologic disorders.

During assessment of vital signs, a patient reports severe abdominal pain. Which pain-related changes in vital signs may be present? Select all that apply.

• Respiratory rate of 24

• Increased respiratory depth

• Blood pressure 154/86

• Body temperature 98.8°F

• Pulse rate of 102

A nurse enters a room and finds a patient who is unable to catch their breath, has a respiratory rate of 28, and is using accessory muscles to breathe. What intervention will the nurse use to relieve dyspnea?

• Remove pillows from under the head

• Raise the head of the bed

• Elevate the foot of the bed

• Reassess the respiratory rate

A nurse has assessed an older adult for orthostatic hypotension as shown in the electronic health record (EHR). What action will the nurse take?

Electronic health record (EHR): 0800

BP lying 124/76

BP sitting 118/74

BP standing 98/58

• Administer medication to increase blood pressure

• Return the patient to bed and place them in Fowler position

• Suggest that in the future the patient “dangle” for a few minutes before standing

• Encourage the patient to rise from a sitting position quickly to improve blood flow

A nurse is caring for a postoperative patient who experienced hypovolemic shock necessitating transfer to the ICU. The nurse manager reviews the medical record and suspects which situation contributed to the emergency?

Electronic health record (EHR)

2:00 PM T 99.2, P 88, RR 16, BP 106/54

2:15 PM T 99.6, P 94, RR 16, BP 100/52

2:30 PM T 99.4, P 110, RR 18, BP 96/50

2:45 PM T 99.2, P 120, RR 20, BP 84/48

 

• Using an inappropriate format to document the vital signs

• Failing to report tachycardia and hypotension to the provider

• Not following the postoperative vital sign protocol

• Failing to reflect a pain assessment in the documentation

A patient has a blood pressure reading of 130/90 mm Hg during a clinic visit. What recommendation for follow-up will the nurse make?

• Follow-up measurements of blood pressure

• Change in dietary intake

• No action, because the nurse considers this reading is due to anxiety

• Immediate treatment by a health care provider

A nurse participating in community blood pressure screening tells the patient their blood pressure is 120/80 mm Hg. When the patient asks what the numbers mean, what information does the nurse provide?

• Rhythmic distention of the arterial walls from increased pressure due to surges of blood with ventricular contraction

• Difference between the pressure on arterial walls with ventricular contraction and relaxation

• Normal blood pressure

• Systolic pressure represents ventricular contraction causing high pressure on arterial walls; the bottom number or diastolic pressure reflects ventricular relaxation with a lower pressure on the arteries

The nurse must assess a patient’s blood pressure using a thigh cuff, due to presence of a right antecubital IV and a left arm dialysis access. Which of these arteries will the nurse use for auscultation?

• Brachial

• Carotid

• Popliteal

• Radial