Chapter 5, Vital Signs Video Solutions, Clinical Nursing Skills and Techniques

Problem 1

The nurse is assessing the axillary temperature of a confused patient with a fever. Which actions by the nurse will best help provide an accurate measurement? (Select all that apply.)
1 Drying the axilla before placing the thermometer probe
2 Holding the thermometer probe in place
3 Placing the patient in a supine position
4 Checking that the patient has not had anything to eat or drink recently

Suman Saurav Thakur

Numerade Educator

01:16

Problem 2

After checking the tympanic temperature two consecutive times in an 82 -year-old patient, the nurse finds the reading to be several degrees lower than expected. What is the most appropriate nursing action at this time?
1 Obtain a different thermometer
2 Observe for the presence of cerumen
3 Document the temperature assessed
4 Record the average between the two readings

Ma Ednelyn Lim

Numerade Educator

00:49

Problem 3

A patient with abdominal ascites is having his respiratory rate assessed. Which is the best action to obtain the respiratory assessment for this patient?
1 The patient is assessed while flat, supine, and quiet.
2 The patient's head is elevated based on his desire.
3 The nurse tells the patient when to begin breathing for the assessment.
4 The nurse holds the patient's wrist while counting respirations.

Paras Aggarwal

Numerade Educator

01:26

Problem 4

The nurse is preparing to assess a patient's blood pressure. Which statement by the nurse will help promote an accurate reading?
1 "Just relax while I put the cuff on your arm."
2 "This is painless and will take just a minute."
3 "The cuff can go over your thin silk sleeve."
4 "Please uncross your legs while I do this."

Qudsiya Anis

Numerade Educator

05:02

Problem 5

Place in correct order the following sequencing steps for two-step blood pressure measurement using the brachial artery.
a Relocate brachial artery and inflate blood pressure cuff.
b Palpate brachial artery.
c Obtain proper sized cuff.
d Apply deflated cuff above brachial artery.
e Apply bell of stethoscope over artery.
$f$ Release pressure in cuff.
$\mathrm{g}$ Record first and last sounds.
$1. \quad \mathrm{c}, \mathrm{d}, \mathrm{b}, \mathrm{e}, \mathrm{a}, \mathrm{f}, \mathrm{g}$
$2. \quad \mathrm{c}, \mathrm{b}, \mathrm{a}, \mathrm{d}, \mathrm{e}, \mathrm{g}, \mathrm{f}$
3. c, $b, d, a, e, f, g$
$4. \quad \mathrm{~b}, \mathrm{c}, \mathrm{d}, \mathrm{a}, \mathrm{e}, \mathrm{g}, \mathrm{f}$

Suzanne W.

Numerade Educator

01:46

Problem 6

Electronic blood pressure monitoring cannot be used on certain patients. Which of these patients can have an electronic blood pressure monitor?
1 The patient with constant extremity tremors
2 The patient with diabetes mellitus
3 The feverish patient who is shivering
4 The patient with an irregular heart rate

Aparna Shakti

Numerade Educator

02:13

Problem 7

Mr. Marquis is 87 years old and is admitted to your medical unit for pneumonia of 4 days' duration. His temperature is $37.2^{\circ} \mathrm{C}\left(99^{\circ} \mathrm{F}\right)$. The NAP questions why his temperature is so low for a person with an active infection. Your best response is:
1 His body has compensated for the infection by increasing heart rate.
2 He probably had an antipyretic in the assisted-living facility where he lived.
3 He took a cool shower before he was admitted.
4 The baseline temperature of older adults is lower because of loss of subcutaneous fat.

Ren Jie Tuieng

Numerade Educator

01:12

Problem 8

You are checking the vital signs of a 75 -year-old patient. The radial pulse is irregular, and about every fourth beat is different. The patient offers no complaints. What is your next action?
1 Report the findings to the health care provider immediately.
2 Obtain a blood pressure.
3 Obtain an apical heart rate.
4 Notify the nurse in charge.

Yujie Wang

College of San Mateo

01:04

Problem 9

Which of the following nursing interventions is/are correct when determining a pulse deficit? (Select all that apply.)
1 Counting for 30 seconds and multiplying by 2
2 Starting to count after the peripheral first beat is heard
3 Using a peripheral artery and apical pulse
4 Counting simultaneously with another health care provider

Anitha Mary

Numerade Educator

01:40

Problem 10

Which of the following blood pressures would classify as prehypertension? (Select all that apply.)
$1 \quad 118 / 78$
$2 \quad 126 / 82$
$3 \quad 130 / 80$
$4 \quad 132 / 94$

Qudsiya Anis

Numerade Educator