VITAL SIGNS

eva boje-jugador,rn
Learning Outcomes

1. Describe factors that affect the vital signs

and accurate measurement of them.
2. Identify the variations in normal body
temperature, pulse, respirations, and
blood pressure that occur from infancy to
old age.
3. Compare methods of measuring body
temperature.

Copyright 2008 by Pearson

Learning Outcomes

4. Describe appropriate nursing care for

alterations in body temperature.
5. Identify nine sites used to assess the
pulse and state the reasons for their
use.
6. List the characteristics that should be
included when assessing pulses.
7. Explain how to measure the apical
pulse and the apical-radial pulse.
Learning Outcomes

8. Describe the mechanics of breathing and

the mechanisms that control respirations.
9. Identify the components of a respiratory
assessment.
10. Differentiate systolic from diastolic blood
pressure.
11. Describe five phases of Korotkoff’s
sounds.

Copyright 2008 by Pearson

Learning Outcomes

12. Describe methods and sites used to

measure blood pressure.
13. Discuss measurement of blood
oxygenation using pulse oximetry.
14. Identify when it is appropriate to
delegate measurement of vital signs
to unlicensed assistive personnel.
Vital Signs
• Monitor functions of the body
• Should be a thoughtful, scientific
assessment
When to Assess Vital Signs?
• On admission
• Change in client’s health
status
• Client reports symptoms
such as chest pain,
feeling hot, or faint
• Pre and post
surgery/invasive
procedure
Copyright 2008 by Pearson
When to Assess Vital Signs?
• Pre and post
medication
administration that
could affect CV
system
• Pre and post nursing
intervention that could
affect vital signs
Guidelines for Taking Vital Signs
1. The Nurse caring for the client
measures vital signs
2. Equipment is functional and
appropriate
3. The Nurse knows the normal range
for all Vital Signs
4. The Nurse knows the client’s Medical
History and Therapies and
Medications prescribed
Guidelines for Taking Vital Signs

5. The Nurse knows the client’s normal

range of Vital Signs
6. The Nurse controls or minimizes
environmental factors that may affect
vital signs
7. The Nurse and Physician decide the
frequency of vital signs assessment
on the basis of the client’s condition
Guidelines for Taking Vital Signs

8. The Nurse analyzes the result of vital

signs measurement
9. The Nurse uses an organized,
systematic approach when taking
vital signs
10. The Nurse verifies and
communicates significant changes in
vital signs
Body Temperature

 The balance between the heat

produced by the body and the heat
lost from the body

KINDS:
1. Core Temp. – temp of the deep
tissue of the body
2. Surface Temp. – temp of the skin,
subcutaneous tissue and fat
Factors Affecting Body’s Heat
Production
 Basal Metabolic Rate (BMR) – the
rate of energy utilization in the body
required to maintain essential
activities such as breathing…
 Muscle Activity
 Thyroxine Output – Chemical Thermogenesis
 Epinephrine, Norepinephrine &
Sympathetic Stimulation
 Fever
Heat Loss Processes
1. Radiation
- the transfer of heat from the
surface of one object to the
surface of another without
contact between the two objects,
mostly in the form of infrared
rays
Heat Loss Processes

2. Conduction
- the transfer of heat from one
object to another in direct
contact

3. Convection
- dispersion of heat by air
currents
Heat Loss Processes

4. Evaporation
- continuous vaporization of
moisture from the skin, oral
mucous, respiratory tract
(insensible heat loss)
Regulation of Body Temperature

3 Main Parts
> Sensors or Sensory
Receptors in the shell and in
the core
> Hypothalamic integrator
> Effector System that adjust
the production and loss of heat
Factors Affecting Body Temperature
• Age
• Diurnal variations (circadian rhythms)
Factors Affecting Body Temperature

• Exercise
• Hormones
• Stress
• Environment
Alterations in Body Temperature

PYREXIA – a body temperature

above the usual range
- aka Hyperthermia/ fever
HYPERPYREXIA – very high fever
FEBRILE – A client who has fever
AFEBRILE – a client who has no
fever
Figure 29-4 Terms used to describe alterations in body temperature (oral measurements) and ranges in Celsius
(centigrade) and Fahrenheit scales.
Types of FEVER
4 TYPES:
1. INTERMITTENT
- temp alternates at regular intervals
between periods of fever and periods
of normal or subnormal
2. REMITTENT
- a wide range of temperature
fluctuations occurs over the 24-hour
period, all of which are above normal
Types of FEVER
4 TYPES:
3. RELAPSING
- short febrile periods of a few days
are interspersed with periods of 1-2
days of normal temperature
4. CONSTANT
- body temperature fluctuates
minimally but always remains above
normal
Exceptions:
Fever Spike
- a temperature that rises to fever level
rapidly following a normal temperature
and returns to normal after few hours
Heat Exhaustion
– result of excessive heat & dehydration
Heat Stroke
- result of prolonged exercise in hot
weather
Clinical Manifestations of Fever:
ONSET (Cold or Chill Phase)
Increased Heart Rate
 Increased Respiratory Rate and Depth
 Shivering
 Pallid, Cold skin
 Complaints of feeling cold
 Cyanotic Nail beds
 Gooseflesh appearance of the skin
 Cessation of sweating
Clinical Manifestations of Fever:
COURSE
(PlateauPhase) Drowsiness,
Absence of chills Restlessness,
Skin that feels warm Delirium or
Convulsion
 Photosensitivity
 Herpetic lesions of
 Glassy-eyed appearance the mouth
 Increased pulse and Loss of appetite
Respiratory rate  Malaise, weakness
Increased thirst & aching muscles
Mild to severe
Clinical Manifestations of Fever:
DEFERVESCENCE
(Fever abatement/flush Phase)
Skin that appears flushed and feels warm
 Sweating
 Decreased Shivering
Possible Dehydration
Hypothermia
- A core body temperature below the
lower limit of normal

3Physiologic Mechanism:
1. Excessive heat loss
2. Inadequate heat production to
counteract heat loss
3. Impaired hypothalamic
thermoregulation
Clinical Manifestations of
Hypothermia
 Decreased: Body Temp., Pulse & Respirations
 Severe shivering (initially)
 Feelings of cold and chills
 Pale, cool, waxy skin
 Frostbite
 Hypotension
 Decreased urinary output
 Lack of muscle coordination
 Disorientation
 Drowsiness progressing to coma
 Nursing Interventions
for Clients with Fever
Monitoring V/S
Assess skin color and temperature
 Monitor WBC Count, Hematocrit value
and other pertinent laboratory results for
indications of infection or dehydration
Remove excess blankets when the client
feels warm, but provide extra warmth
when the client feels chilled
 Nursing Interventions
for Clients with Fever
Provide adequate Nutrition and Fluids to
meet the increased metabolic demands
and prevent dehydration
 Measure Intake and Output
Reduce physical activity to limit heat
production, especially during the flush
stage
 Nursing Interventions
for Clients with Fever
Administer Antipyretics as ordered
Provide oral hygiene to keep the mucus
membrane moist
Provide a TSB to increase heat loss
through:
CONDUCTION
Provide dry clothing and bed linens
 Nursing Interventions
for Clients with Hypothermia
Provide a warm environment
Provide dry clothing
Apply warm blankets
Keep limbs close to the body
Cover the client’s scalp with a cap or
turban
Supply warm oral or intravenous fluid
 Apply warming pads
 Assessing Body Temperature
Most Common Sites of
Measuring Body Temperature:
Oral -- Accessible and Convenient
Rectal -- Reliable Measurement

Axillary -- Safe and Non-invasive

Tympanic Membrane -- Readily Accessible,
Reflects Core Temp.,
Very Fast
Skin/Temporal Artery -- Safe & Non-invasive
Very Fast
 Assessing Body Temperature
Most Common Sites of
Measuring Body Temperature:
Oral
Consider:
**When taking cold or hot fluids or smoking
 Rectal
Consider:
**C/I for patients with MI, rectal surgery, diarrhea,
immunosuppressed, clotting disorders or significant
hemorrhoids
 Assessing Body Temperature
Most Common Sites of
Measuring Body Temperature:
 Axilla
**Accessible and safe
 Tympanic Membrane
**Frequent site for estimating core temperature
**Uncomfortable and risk of membrane injury or
perforation
 Types of Thermometers

Figure 29-10 Axillary thermometer placement.

 Types of Thermometers

Figure 29-5 An electronic thermometer. Note the probe and probe cover.
 Types of Thermometers

Figure 29-11 Pull the pinna of the ear back and up for placement of a tympanic
thermometer in a child over 3 years of age, back and down for children under age 3.
 Types of Thermometers

Figure 29-8 An infrared (tympanic) thermometer used to measure the tympanic

membrane temperature.
 Types of Thermometers

Figure 29-9 A temporal artery thermometer.

 Types of Thermometers

Figure 29-7 A temperature-sensitive skin tape.

 Types of Thermometers

Figure 29-6 A chemical thermometer showing a reading of 99.2°F.

 Temperature Scales
2 Scales:
1. degrees Celsius (Centigrade)
2. degrees Fahrenheit
CONVERSION
a. °F  °C
°C = (Fahrenheit Temp-32) X 5/9
example: °C = (100°F-32) X 5/9 = 37.8
100°F = 37.8°C
b. °C  °F
°F = (Celsius Temp X 9/5) + 32
example: °F = (40°C X 9/5) + 32 = 104
40°C = 104°F
Temperature: Lifespan Considerations

Infants Unstable
Newborns must be
kept warm to prevent
hypothermia
Children Tympanic or temporal
artery sites preferred

Elders Tends to be lower than

that of middle-aged
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Clients at Risk for Hypothermia
People who participate in cold weather sport
Infants and children whose thermoregulatory
systems are immature
Elderly people who have insufficient food,
clothing
 People who have neurologic deficits and are unable
to identify or respond to cold
 Alcoholics who have extreme heat loss secondary to
vasodilation
 “street people” who lack adequate clothing and
shelter
Clients at Risk for Hyperthermia
People who have infection
 Debilitated clients who are vulnerable to
infection
 People with diseases processes of the CNS
that may impair thermoregulation
People who have head trauma causing
increased ICP
Neonates who have ineffective
thermoregulation
 Nursing Diagnosis
1. High Risk for Altered Body Temperature R/T
- Illness or Trauma affecting temperature regulation
- Medication causing vasoconstriction, vasodilation,
altered metabolic state or sedation
- Inactivity or vigorous activity

2.Hyperthermia R/T
- exposure to excessively hot environment
- Increased Metabolic Rate
- Dehydration
 Nursing Diagnosis
1. Hypothermia R/T
- exposure to excessively cool environment
- Debilitating illness or trauma
- Lack of adequate clothing or shelter

2.Ineffective Thermoregulation R/T

- Decreased Basal Metabolism secondary to aging
- Trauma or illness
 PULSE

 A wave of blood created by contraction

of the LEFT VENTRICLE of the Heart
 PULSE
Compliance of the Arteries
- ability to contract and expand

Cardiac Output
- the volume of blood pump into the arteries by the
heart
- equals the result of the Stroke Volume (SV) times the
Heart Rate (HR) per minute
- ex: CO = SVxHR [ 65ml x 70bpm = 4.55L ]
*In normal adult at rest, the heart pumps 5L of blood/min
 PULSE

Peripheral Pulse
- pulse located away from the heart

Apical Pulse
– central pulse, located at the apex
of the heart
- aka point of maximal impulse
(PMI)
Factors Affecting PULSE
• Age
• Gender
• Exercise
• Fever
• Medications
• Hypovolemia
• Stress
• Position changes
• Pathology
PULSE Sites
1. Temporal
2. Carotid
3. Apical
4. Brachial
5. Radial
6. Femoral
7. Popliteal
8. Posterior
Tibial
9. Dorsalis
Pedis (Pedal)
Reasons for using Specific Sites
 Readily Accessible
 To determine circulation to 1. Temporal
the lower leg 2. Carotid
 Used when radial pulse not 3. Apical
accessible 4. Brachial
 for infants and children to 5. Radial
3yo 6. Femoral
 Used to measure BP; 7. Popliteal
cardiac arrest for infants 8. Posterior
Tibial
 Det. Circulation to the brain;
9. Dorsalis
cardiac arrest for adults Pedis
 Det. Circulation to a Leg; (Pedal)
cardiac arrest or shock
Figure 29-13 Location of the apical pulse for a child under 4 years,
a child 4 to 6 years, and an adult.
Assessing the Pulse
 Palpation or Auscultation
 Middle 3 fingers are used with moderate
pressure
Nurse should determine:
 Any medication that could affect the HR
 If client has been physically active
 Baseline data about normal HR
 Whether client need to assume a
particular position
Measuring Apical Pulse

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Assessing the Pulse
Data Collection:
(Characteristics of Pulse)
 Rate
 Rhythm
 Volume
 Arterial wall elasticity
 Presence/absence of bilateral
equality
Apical-Radial Pulse

• Locate apical and radial sites

• Two nurse method:
– Decide on starting time
– Nurse counting radial says “start”
– Both count for 60 seconds
– Nurse counting radial says “stop”
– Radial can never be greater than apical

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Assessing the Pulse

 Tachycardia – excessively fast HR

 Bradycardia – Slow, less than 60bpm in
adult
Pulse Rhythm – pattern and interval of the
beats
 Dysrhythmia/arrhythmia – pulse rate
with irregular rhythm
Assessing the Pulse

Pulse Volume – the force of blood with

each beat; aka pulse strength or
amplitude
- absent to bounding
 Full/Bounding Pulse – obliterated with
difficulty
 Weak/Feeble/Thready Pulse – easily
obliterated
Pulse: Lifespan Considerations

Infants Newborns may have

heart murmurs that are
not pathological
Children The apex of the heart is
normally located in the
fourth intercostal space in
young children; fifth
intercostal space in
children 7 years old and
older
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Figure 29-14 A Doppler ultrasound stethoscope (DUS).
Figure 29-24 Fingertip oximeter sensor (adult).
Figure 29-25 Fingertip oximeter sensor (cordless). (Courtesy of Nonin Medical, Inc.)
Figure 29-26 Fingertip oximeter sensor (child). (Courtesy of Nonin Medical, Inc.)
Respiration
 the act of Breathing
Inhalation/Inspiration
- intake of air into the lungs
Exhalation/Expiration
- breathing out
Ventilation – used to refer to the movement
of air in and out of the lungs
Respiration
2 Types of Breathing:

1. Costal (Thoraxic) Breathing

- involves the external intercostal
muscles and other accessory
muscles.
- observed by the movement of the
chest upward & outward
Respiration
2 Types of Breathing:

2. Diaphragmatic (Abdominal)
Breathing
- involves the contraction and the
relaxation of the diaphragm
- observed by the movement of the
abdomen
Inhalation
• Diaphragm contracts
(flattens)
• Ribs move upward
and outward
• Sternum moves
outward
• Enlarging the size of
the thorax

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Figure 29-15 Respiratory inhalation. Lateral view Figure 29-16 Respiratory exhalation. Lateral view
Figure 29-15 Respiratory inhalation. Anterior view. Figure 29-16 (Respiratory exhalation. Anterior view.
Exhalation
• Diaphragm relaxes
• Ribs move downward
and inward
• Sternum moves
inward
• Decreasing the size
of the thorax

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Respiratory Control Mechanisms

• Respiratory
centers
– Medulla
oblongata
– Pons

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AssessingRespiration
IMPORTANT
Baseline data:
 Client’s normal breathing pattern
 Influence of the client’s health problems
on respirations
 Medications or therapies that might
affect the respirations
 Relationship of the client’s respiration to
cardiovascular functions
 AssessingRespiration
WHAT TO ASSESS?
 Rate
 Depth
 Rhythm
 Quality and
effectiveness

EUPNEA – breathing
that is normal in
rate and depth
Factors Affecting Respirations
• Exercise
• Stress
• Environmental
temperature
• Medications

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Factors Affecting Respirations

Tidal Volume – the amount of air

taken in during a normal inspiration
and expiration
- 500ml of air
- Position also affects the amount
of air that can be inhaled

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Altered Breathing Patterns and Sounds
BREATHING PATTERNS
RATE
Tachypnea – quick, shallow breaths
Bradypnea – abnormally slow breathing
Apnea – cessation of breathing
VOLUME
Hyperventilation – overexpansion of the
lungs, charac. by rapid and deep breaths
Hypoventilation – underexpansion of the
lungs, charac by shallow respirations
Altered Breathing Patterns and Sounds
BREATHING PATTERNS
RHYTHM
Cheyne-Stokes Breathing – rhythmic waxing
and waning of respirations, from very deep to
very shallow breathing and temporary apnea
EASE OR EFFORT
Dyspnea – difficult and labored breathing
during which the client has a persistent,
unsatisfied need for air & feels distressed
Orthopnea – ability to breath only in upright
Altered Breathing Patterns and Sounds
BREATH SOUNDS
AUDIBLE Š AMPLIFICATION
Stridor – a shrill, harsh sound heard during
inspiration with laryngeal obstruction
Stertor – snoring, usually due to partial
obstruction of the upper airway
Wheeze– continuous, high-pitched musical
squeak or whistling sound occurring on
expiration & sometimes on inspiration when air
moves thru a narrowed or partially obstructed
airway
Altered Breathing Patterns and Sounds
BREATH SOUNDS
AUDIBLE Š AMPLIFICATION
 Bubbling – gurgling sounds heard as air passes
through moist secretions in the respiratory tract
CHEST MOVEMENTS
 Intercostal Retraction– indrawing between the ribs
 Substernal Retractions – indrawing beneath the
breastbone
 Suprasternal Retractions – indrawing above the
clavicles
Altered Breathing Patterns and Sounds

BREATH SOUNDS
SECRETIONS AND COUGHING
 Hemoptysis – presence of blood in the sputum
 Productive cough – a cough accompanied by
expectorated secretions
 Nonproductive cough – a dry, harsh cough
without secretions
Respirations: Lifespan Considerations

Infants Some newborns

display “periodic
breathing”
Children Diaphragmatic
breathers
Elders Anatomic and
physiologic changes
cause
Copyright respiratory
2008 by Pearson Education, Inc. system
 Blood Pressure
- A measure of the pressure exerted by the
blood as it flows to the arteries
- Measured in millimeters of mercury
(mmHg)

2Blood Pressure Measures

1. Systolic Pressure- pressure of the blood as a
result of contraction of the ventricles, that is,
the pressure of the height of the blood wave
2. Diastolic Pressure – pressure when the
ventricles are at rest
Systolic and Diastolic Blood Pressure

• Measured in mm Hg

• Recorded as a fraction
e.g. 120/80mmHg

Systolic = 120 and

Diastolic = 80

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Blood Pressure
Pulse Pressure – the difference between
the Systolic pressure and the Diastolic
Pressure
- normal PP is 40mmHg (at rest)
- 100mmHg (exercise)
Pulse Pressure – arteriosclerosis
Pulse Pressure – Severe heart failure
Blood Pressure
IMPORTANT:
Know the client’s
Baseline BP
Determinants of Blood Pressure
A. Pumping Action of the Heart
B. Peripheral Vascular Resistance
C. Blood Volume
Factors Affecting Blood Pressure

 Age
 Exercise
 Stress
 Race
 Gender
 Medications
 Obesity
 Diurnal variations
 Disease process

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Hypertension
A Blood Pressure that is
persistently above normal

Primary Hypertension – Elevated

BP of UNKNOWN Cause
Secondary Hypertension – elevated
BP of KNOWN Cause
Hypertension
Associated Factors:
 Thickening of the arterial wall
 Inelasticity of the arteries
 Lifestyle factors as:
 Cigarette Smoking
 Obesity
 Heavy Alcohol Consumption
 Lack of Physical Exercise
 High Blood Cholesterol levels
 Continued exposure to stress
Hypotension
A Blood Pressure that is below
normal

Orthostatic Hypotension – BP that

falls when the client sits or stands
- result of vasodilation
- medications
IMPORTANT: Prevention of
FALLS
Hypotension
Assessment of Orthostatic Hypotension:
 Place pt. in supine position for 10mins
 Record pt.’s pulse and BP
 Assist pt to slowly sit or stand; support in
case of faintness
 Stat recheck of Pulse and BP in same sites
 Repeat Pulse and BP after 3 minutes
 Record the results
* (+) A rise in pulse of 15-20bpm or a drop in
BP of 20mmHg(SYS) & 10mmHg (DIAS)
ASSESSING Blood Pressure
 ASSESSING Blood Pressure

Figure 29-18 An aneroid sphygmomanometer and cuff.

 ASSESSING Blood Pressure

Figure 29-19 Blood pressure monitors register systolic and diastolic blood pressures and often other vital signs.
 ASSESSING Blood Pressure

Figure 29-20 Three standard cuff sizes: a small cuff for an infant, small child, or frail adult; a normal adult-size cuff;
and a large cuff for measuring the blood pressure on the leg or on the arm of an obese adult.
 ASSESSING Blood Pressure

Figure 29-21 Determining that the bladder of a blood pressure cuff is 40% of the arm circumference or 20% wider
than the diameter of the midpoint of the limb.
ASSESSING Blood Pressure
BLOOD PRESSURE SITES
1. Upper Arm
2. Thigh
> when BP cant be measured in either
arm
> when deemed necessary to compare
BP on both thigh
ASSESSING Blood Pressure
METHODS
1. Direct (Invasive)
2. Indirect
a. Auscultatory Method
B. Palpatory Method
- when korotkoff sound cannot be
heard
Auscultatory Gap – temporary disappearance of
sounds normally heard over the brachial artery
when the cuff pressure is high followed by the
reappearance of sound at a lower level
Korotkoff’s Sounds
Korotkoff’s Sounds
• Phase 1
– First faint, clear
tapping or
thumping sounds
– SYSTOLIC PRESSURE
• Phase 2
– Muffled,
whooshing, or
swishing sound

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Korotkoff’s Sounds
• Phase 3
– Blood flows freely
– Crisper and more intense
sound
– Thumping quality but softer
than in phase 1
• Phase 4
– Muffled and have a soft,
blowing sound
• Phase 5
– Pressure level when the last
sound is heard
– Period of silence
– DIASTOLIC PRESSURE
Blood Pressure: Lifespan Considerations

Infants Arm and thigh

pressures are
equivalent under 1
year of age
Children Thigh pressure is 10
mm Hg higher than
arm
Elders Client’s medication
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Common Errors in Assessing BP
A. Haste
B. Subconcsious basis
 Pulse Oximetry

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 Pulse Oximetry

• Noninvasive
• Estimates arterial blood oxygen
saturation (SpO2)
• Sites – finger (common)
• Normal SpO2 85-100%; < 70%
life threatening
• Detects hypoxemia before
clinical signs and symptoms
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 Pulse Oximetry
• Factors that affect accuracy
include:
– Hemoglobin level
– Circulation
– Activity
– Carbon monoxide poisoning

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 Pulse Oximetry

• Prepare site
• Align LED and photodetector
• Connect and set alarms
• Ensure client safety
• Ensure accuracy

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Delegation of Measurement of Vital Signs

• General considerations prior to

DELEGATION
– Nurse assesses to determine stability
of client
– Measurement is considered to be
routine
– Interpretation rests with the nurse

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Delegating to UAP

• BODY TEMPERATURE
– Routine measurement may be
delegated to UAP
– UAP reports abnormal
temperatures
– Nurse interprets abnormal
temperature and determines
response

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Delegating to UAP

• PULSE
– Radial or brachial pulse may
be delegated to UAP
– Nurse interprets abnormal rates
or rhythms and determines
response
– UAP are generally not
responsible for assessing apical
or one person apical-radial
pulses
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Delegating to UAP

• RESPIRATIONS
– Counting and observing
respirations may be
delegated to UAP
– Nurse interprets
abnormal respirations
and determines response

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Delegating to UAP
• BLOOD PRESSURE
– May be delegated to UAP
– Nurse interprets abnormal readings and
determines response
• OXYGEN SATURATION
– Application of the pulse oximeter sensor and
recording the Sp02 may be delegated to UAP
– Nurse interprets oxygen saturation value and
determines response

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Post Test

• Use your clickers to complete the

following post test.

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 Question 1
The client’s temperature at 8:00 AM using
an oral electronic thermometer is 36.1°C
(97.2°F). If the respiration, pulse, and blood
pressure are within normal range, what
would the nurse do next?

1. Wait 15 minutes and retake it.

2. Check what the client’s temperature was
the last time.
3. Retake it using a different thermometer.
4. Chart the temperature; it is normal.

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 Rationales 1
1. Depending on that finding, you might want to
retake it in a few minutes (no need to wait 15
minutes).
2. Correct. Although the temperature is slightly
lower than expected for the morning, it would be
best to determine the client’s previous temperature
range next. This may be a normal range for this
client.
3. There is no need to take temperature again with
another thermometer to see if the initial
thermometer was functioning properly.
4. Chart after determining that the temperature has
been measured properly.

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 Question 2
Which of the following clients meets the
criteria for selection of the apical site for
assessment of the pulse rather than a
radial pulse?

1. A client is in shock
2. The pulse changes with body position
changes
3. A client with an arrhythmia
4. It is less than 24 hours since a client's
surgical operation
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 Rationales 2

1. For clients in shock, use the carotid or femoral

pulse.
2. The radial pulse is adequate for determining
change in orthostatic heart rate.
3. Correct. The apical rate would confirm the
rate and determine the actual cardiac rhythm
for a client with an abnormal rhythm; a radial
pulse would only reveal the heart rate and
suggest an arrhythmia.
4. The radial pulse is appropriate for routine
postoperative vital sign checks for clients with
regular pulses.
Copyright 2008 by Pearson
 Question 3
It would be appropriate to delegate the taking of
vital signs of which of the following clients to a
UAP?

1. A patient being prepared for elective facial surgery

with a history of stable hypertension.
2. A patient receiving a blood transfusion with a
history of transfusion reactions.
3. A client recently started on a new antiarrhythmic
agent.
4. A patient who is admitted frequently with asthma
attacks.

Copyright 2008 by Pearson

 Rationales 3
1. Correct. Vital signs measurement may be
delegated to UAP if the client is in stable condition,
the findings are expected to be predictable, and
the technique requires no modification. Only the
preoperative client meets these requirements.
2. This client is unstable and vital signs measurement
cannot be delegated.
3. In addition to the client being unstable, UAP are
not delegated to take apical pulse measurements
for the client with an irregular pulse as would be
the case with the client newly started on
antiarrhythmic medication.
4. This client is unstable and vital signs measurement
cannot be delegated.

Copyright 2008 by Pearson

 Question 4
A nursing diagnosis of Ineffective
Peripheral Tissue Perfusion would be
validated by which one of the
following:

1. Bounding radial pulse

2. Irregular apical pulse
3. Carotid pulse stronger on the left side
than the right
4. Absent posterior tibial and pedal
pulses
 Rationales 4
1. Abounding radial pulse is more indicative
that perfusion exists.
2. Apical pulses are central and not
peripheral.
3. Carotid pulses are central and not
peripheral.
4. Correct. The posterior tibial and pedal
pulses in the foot are considered peripheral
and at least one of them should be
palpable in normal individuals.

Copyright 2008 by Pearson

 Question 5
The nurse reports that the client has
dyspnea when ambulating. The nurse
is most likely to have assessed which
of the following?

1. Shallow respirations
2. Wheezing
3. Shortness of breath
4. Coughing up blood

Copyright 2008 by Pearson

 Rationales 5
1. Shallow respirations are seen in tachypnea (rapid
breathing).
2. Wheezing is a high-pitched breathing sound that
may or may not occur with dyspnea.
3. Correct. Dyspnea, difficult or labored breathing, is
commonly related to inadequate oxygenation.
Therefore, the client is likely to experience
shortness of breath, that is, a sense that none of
the breaths provide enough oxygen and an
immediate second breath is needed.
4. The medical term for coughing up blood is
hemoptysis and is unrelated to dyspnea.

Copyright 2008 by Pearson