NUR 29 Chap 20 Vital Signs

The nursing assistant collects a resident’s vital signs (VS). The blood pressure, pulse, and respirations are elevated from the resident’s baseline. What action(s) should the nursing assistant take? Select all that apply.

• Ask another nursing assistant to double-check the blood pressure.

• Determine what activity the resident recently engaged in.

• Retake the VS after the resident rests for several minutes.

• Chart the VS because it is normal to have changes.

• Report the VS and findings to the nurse.

The nursing assistant is caring for a client diagnosed with a bilateral ear infection and recent dental surgery. What method should the nursing assistant employ? Use:

• A lubricated glass rectal thermometer in the Sims position.

• The tympanic thermometer with a soft probe cover.

• The electronic thermometer under the tongue on the unaffected side.

• The temporal artery thermometer swept across the forehead.

How is the spread of infection prevented when using an electronic thermometer?

• The probe is discarded after it is used.

• The probe is stored in a disinfectant-filled case.

• A new probe sheath is used with each measurement.

• Sheath colors are different for rectal and oral probes.

What is meant by the term pulse rhythm?

• The force of the pulse

• A wave of blood through the arteries

• The pattern of the beats and the pauses

• The number of beats that can be felt in 1 minute

The nursing assistant measures respirations that are irregular by:

• counting the number of respirations in 30 seconds and multiplying by 2.

• counting the number of respirations for 1 full minute.

• using a stethoscope to listen to the respirations for 1 minute.

• having another nursing assistant measure as well.

The nursing assistant is caring for a client lying in bed who suddenly develops dyspnea with respirations 28 breaths per minute. What action should the nursing assistant take first?

• Raise the head of the bed.

• Chart the findings.

• Collect the other vital signs.

• Provide comfort measures.

When a blood pressure measurement needs to be repeated to assure an accurate measurement, the nursing assistant will:

• fully deflate the cuff and wait 1 full minute before reinflating it.

• partially deflate and then reinflate the cuff quickly.

When taking a person’s blood pressure, how should the person’s arm be positioned?

• Higher than the heart with the palm facing down

• Lower than the heart with the palm facing down

• Higher than the heart with the palm facing up

• Level with the heart with the palm facing up

The nursing assistant (NA) prepares to take the blood pressure (BP) of a client returning from dialysis. Which action by the NA requires further intervention?

• Waiting 5 minutes for the client to rest after returning to their chair

• Asking the client to keep legs uncrossed and feet flat on the floor

• Placing the cuff below the dialysis access point in the right arm

• Determining the correct size BP cuff to use on the client

The primary reason(s) a nursing assistant regularly weighs a resident is that: (Select all that apply)

• Changes in weight help evaluate the person’s nutritional status.

• A change in weight can be an early sign of several diseases.

• Medication dosage is often determined by a person’s weight.

• Residents are usually very concerned about their weight.

• Obesity is a widespread health problem.