ATI - Vital Signs Pretest

C. A respiratory rate of 30/min A respiratory rate of 30/min is above the normal range and indicates a respiratory problem that requires immediate attention. An adult breathing at that rate might be experiencing shortness of breath or dyspnea and, without intervention, this could become a life-threatening situation.

B. The pulse pressure The difference between the systolic and diastolic pressures is the pulse pressure; if the patient's blood pressure is 130/85 mm Hg, the pulse pressure is 45/min. Pulse pressure can be a predictor of heart problems, especially in older adults. For example, an elevated pulse pressure usually reflects stiffness and reduced elasticity of the aorta, most often due to hypertension or atherosclerosis.

D. at the fifth intercostal space at the left midclavicular line To locate the point of maximal impulse, first locate the angle of Louis - a bony prominence just below the suprasternal notch. Slide your fingers down each side of the angle of Louis to locate the second intercostal space. Gently move your fingers down the left side of the sternum to the fifth intercostal space and laterally to the left midclavicular line. You have found the PMI.

A. have the head of the bed elevated 45 to 60 degrees This is a comfortable position for most patients and it allows full ventilatory movement. Also, any type of discomfort can increase respiratory rate.

B. using a cuff of the appropriate size for the patient Using the wrong cuff size for the patient will result in an erroneous reading. A cuff that is too small will result in a reading that is falsely high while a cuff that is too big will record a false low. One way to select a cuff is to make sure that the width of the cuff is 40% of the arm circumference where the cuff will be wrapped. The bladder (inside the cuff) should surround 80% of the arm circumference.

C. semilunar valves close The second heart sound, S2, is generated by the closure of the semilunar vales (the aortic and pulmonic valves) and signals the start of diastole. S2 is the "dub" heard in the normal "lub-dub" sound.

C. Gently pulling the pinna back and upward This position helps straighten the ear canal and provides optimal access to the tympanic membrane. Good contact with sufficient tympanic membrane is essential for an accurate tympanic temperature measurement.

-Patient is 60 pounds overweight It is likely that a patient who is 60 pounds (27.3 kilograms) overweight would have a larger-than-average upper-arm circumference. If so, you would have to use a large blood-pressure cuff (instead of a regular-sized cuff) to assure an accurate blood-pressure reading. -Patient is reporting a "stuffy" nose A patient who has nasal congestion might resort to "mouth breathing," which would alter a temperature measurement obtained orally. This condition would also require that you assess the patient's respiration for a full 60 seconds. -Patient is taking digoxin (Lanoxin) The presence of a cardiovascular problem that warrants pharmacological digoxin therapy would require that you assess the patient's apical pulse for a full 60 seconds. -The patient had a mastectomy 2 years ago Lymphatic drainage might be altered in the affected arm post mastectomy. The application of pressure from the assessment of blood pressure could result in a painful condition called lymphedema.

D. observe the patient's chest movements while appearing to assess his pulse You are most likely to observe the true respiratory pattern (rate, rhythm, and depth) when the patient is unaware that he is being assessed. When patients know their respiration is being observed, it is common for them to alter their respiratory pattern either voluntarily or involuntarily.

A. observe the degree of chest-wall movement during inspiration and expiration You determine the depth of respiration subjectively by evaluating how much chest-wall movement you can observe. The movement is generated by the movements of the diaphragm and intercostal muscles as the patient breathes. With shallow respiration, for example, you will observe very little movement. Deep respiration involves full expansion of the lungs, which is usually quite visible.

D. insert the probe about an inch and a half into the patient's anus An insertion depth of 1.5 inches (3.5 centimeters) ensures sufficient exposure of the probe to the blood vessels in the rectal wall. Positioning the probe against the blood vessels enables it to measure heat maximally and accurately.

A. in the posterior lingual pocket lateral to the midline The heat produced by superficial blood vessels in the right and the left posterior sublingual pocket is what generates an accurate oral temperature reading. Inserting the probe "sideways" into the back of the area under the tongue on the left or the right will access this area.

A. an elevated pulse rate A fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate.

D. You might not hear a fifth Korotkoff sound Most clinicians consider the fifth Korotkoff sound, which is actually the disappearance of sound, an adult patient's diastolic blood pressure. However, with some patients, there is no distinct fifth sound. You hear sounds all the way to 0 mm Hg. For these patients, you would record the fourth Korotkoff sound as the diastolic blood pressure.