A nurse is taking an adult client's temperature rectally. Which of of the following actions should the nurse take?
Insert the prob about 1.27 cm (0.5 in) into the client's anus
A nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading correlate to?
It might not follow with the fitfh Korotkoff sound.
A nurse is preparing to auscultate a client's apical pulse a the point of maximal impulse (PMI). In which of the following locations should the nurse position the stethoscope?
Over the fifth intercostal space at the left midclaviclular line.
A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of 39 celsius (102 degrees f). Which of the following other vital signs should the nurse expect?
Elevated pulse rate
A nurse is collecting data about a client's respiratory condition. Which of the following actions should the nurse take to determine the depth of the client's respiration.
Observe the degree of the chest-wall movement during inspiration and expiration.
A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider?
Respirations 30/min
A nurse is preparing to record the difference between a client's systolic and diastolic blood pressure. Which of the following terms defines this information when documenting?
Pulse pressure
A nurse is auscultating a client's apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs?
When the semilunar valves close
A nurse is preparing to obtain a clients blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately?
Use a cuff of the appropriate size for the client
A nurse is assessing a client's respiration. Which of the following actions should the nurse take?
Elevate the head of the clients bed 45 degree to 60 degree.
A nurse is measuring a client's temperature orally. Which of the following actions should the nurse take?
Place the probe in the posterior lingual pocket lateral to there midline.
A nurse is establishing baseline for a client's respirations. Which of the following actions should the nurse take?
Observe the clients chest movements while appearing to assess their pulse.
A nurse is preparing to use a tympanic thermometer to acquire a clients temperature. Which of the following actions actions should the nurse take to ensure an accurate reading?
Pull the pinna back and upward gently
A nurse is preparing to measure a clients vital signs. The nurse should identify that which of the following factors will affect the methods that are used?
1. BMI of 35 2. Stuffy nose 3. irregular hearth rate 4. mastectomy 2 years ago