NUR 324 FUNDAMENTALS HESI Vital signs DOWNLOAD for an A+
Vital signs: Orthostatic Changes
The nurse plans to assess Clara for orthostatic vital sign changes.
1.
What action will the nurse take first?
A) Assist Clara to a standing
position. INCORRECT
During orthostatic vital sign measurement the client should be placed in another position.
B) Position Clara in a supine
position. CORRECT
Orthostatic vital signs are measured in each position: lying, sitting, and standing. The client's vital signs
are first assessed in the supine position so that changes that occur when the client sits and stands can
be determined.
C) Elevate the head of Clara's
bed. INCORRECT
The client is assisted to a sitting position after vital signs are first measured in another position.
D) Dangle Clara's feet at the
bedside. INCORRECT
The client is assisted to a sitting position after vital signs are first measured in another position.
The nurse takes the first blood pressure measurement.
2.
After recording the first blood pressure measurement, what action will the nurse take?
A) Count the client's radial pulse
rate. CORRECT
Both the blood pressure and pulse rate are typically measured in each position: lying, sitting, and
standing.
B) Remove the blood pressure
cuff. INCORRECT
After the blood pressure cuff is deflated, it is left in the same position on the same arm for all three
blood pressure readings.
C) Help the client change
positions. INCORRECT
Another action should be taken before assisting the client to change positions.
D) Assess for an auscultatory gap.
,NUR 324 FUNDAMENTALS HESI Vital signs DOWNLOAD for an A+
INCORRECT
Assessment for an auscultatory gap is done while the blood pressure measurement is being taken.
3.
Since Clara has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when Clara
moves from a lying to a standing position?
A) Respiratory rate.
INCORRECT
Respiratory rate is unlikely to be affected by a change in position.
B) Blood pressure.
CORRECT
Fluid volume deficit often causes orthostatic hypotension and tachycardia. Because the client may
experience dizziness with orthostatic hypotension, the nurse should take additional safety precautions
during this assessment.
C) Temperature.
INCORRECT
Temperature is unlikely to be affected by a change in position.
D) Pulse rate.
INCORRECT
The client's pulse rate is likely to increase upon standing in response to a change in another vital sign.
Assessment
In addition to obtaining Clara's vital signs, the nurse performs additional assessments.
4.
For ongoing evaluation of Clara's fluid volume status, it is most important to obtain which assessment
data?
A) Urine color.
INCORRECT
This provides valuable assessment data related to fluid volume, but it is not the most important data for
ongoing evaluation of fluid volume.
B) Capillary refill.
INCORRECT
This provides valuable assessment data regarding adequacy of tissue perfusion, which may be impacted
by fluid volume, but it is not the most important assessment related to fluid volume.
C) Body weight.
CORRECT
, NUR 324 FUNDAMENTALS HESI Vital signs DOWNLOAD for an A+
Daily weights provide the most important data about fluid volume status, so an initial weight upon
admission must be obtained.
D) Skin turgor.
INCORRECT
This provides valuable assessment data related to fluid volume, but it is not the most important data for
ongoing evaluation of fluid volume.
The nurse continues to assess the client and observes that Clara's skin tents when a fold of skin over her
sternum is pinched.
5.
What action should the nurse implement?
A) Confirm this finding by pinching the skin on her
hand. INCORRECT
The elderly frequently experience inelastic skin turgor of the hands, so this is not a valuable indicator of
fluid volume status.
B) Notify the healthcare provider that the client is now retaining
fluid. INCORRECT
Tenting is not a sign of fluid retention.
C) Advise Clara that the fluid deficit seems to be
worsening. INCORRECT
Tenting is an expected finding in a client with fluid volume deficit.
D) Document the presence of inelastic skin
turgor. CORRECT
Skin turgor is best assessed in the elderly by gently pinching a fold of skin over the sternum. Inelastic
turgor is an expected finding in a client with fluid volume deficit. Additional findings may include
weakness, confusion, and tachycardia.
Math
Clara's daughter reports that her mother usually weighs about 150 lbs. and is 5 feet, 4 inches in height.
The nurse weighs Clara and obtains a measurement of 65 kg.
6.
The nurse explains to Clara's daughter that Clara has lost approximately how many pounds?
A) 3.
Vital signs: Orthostatic Changes
The nurse plans to assess Clara for orthostatic vital sign changes.
1.
What action will the nurse take first?
A) Assist Clara to a standing
position. INCORRECT
During orthostatic vital sign measurement the client should be placed in another position.
B) Position Clara in a supine
position. CORRECT
Orthostatic vital signs are measured in each position: lying, sitting, and standing. The client's vital signs
are first assessed in the supine position so that changes that occur when the client sits and stands can
be determined.
C) Elevate the head of Clara's
bed. INCORRECT
The client is assisted to a sitting position after vital signs are first measured in another position.
D) Dangle Clara's feet at the
bedside. INCORRECT
The client is assisted to a sitting position after vital signs are first measured in another position.
The nurse takes the first blood pressure measurement.
2.
After recording the first blood pressure measurement, what action will the nurse take?
A) Count the client's radial pulse
rate. CORRECT
Both the blood pressure and pulse rate are typically measured in each position: lying, sitting, and
standing.
B) Remove the blood pressure
cuff. INCORRECT
After the blood pressure cuff is deflated, it is left in the same position on the same arm for all three
blood pressure readings.
C) Help the client change
positions. INCORRECT
Another action should be taken before assisting the client to change positions.
D) Assess for an auscultatory gap.
,NUR 324 FUNDAMENTALS HESI Vital signs DOWNLOAD for an A+
INCORRECT
Assessment for an auscultatory gap is done while the blood pressure measurement is being taken.
3.
Since Clara has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when Clara
moves from a lying to a standing position?
A) Respiratory rate.
INCORRECT
Respiratory rate is unlikely to be affected by a change in position.
B) Blood pressure.
CORRECT
Fluid volume deficit often causes orthostatic hypotension and tachycardia. Because the client may
experience dizziness with orthostatic hypotension, the nurse should take additional safety precautions
during this assessment.
C) Temperature.
INCORRECT
Temperature is unlikely to be affected by a change in position.
D) Pulse rate.
INCORRECT
The client's pulse rate is likely to increase upon standing in response to a change in another vital sign.
Assessment
In addition to obtaining Clara's vital signs, the nurse performs additional assessments.
4.
For ongoing evaluation of Clara's fluid volume status, it is most important to obtain which assessment
data?
A) Urine color.
INCORRECT
This provides valuable assessment data related to fluid volume, but it is not the most important data for
ongoing evaluation of fluid volume.
B) Capillary refill.
INCORRECT
This provides valuable assessment data regarding adequacy of tissue perfusion, which may be impacted
by fluid volume, but it is not the most important assessment related to fluid volume.
C) Body weight.
CORRECT
, NUR 324 FUNDAMENTALS HESI Vital signs DOWNLOAD for an A+
Daily weights provide the most important data about fluid volume status, so an initial weight upon
admission must be obtained.
D) Skin turgor.
INCORRECT
This provides valuable assessment data related to fluid volume, but it is not the most important data for
ongoing evaluation of fluid volume.
The nurse continues to assess the client and observes that Clara's skin tents when a fold of skin over her
sternum is pinched.
5.
What action should the nurse implement?
A) Confirm this finding by pinching the skin on her
hand. INCORRECT
The elderly frequently experience inelastic skin turgor of the hands, so this is not a valuable indicator of
fluid volume status.
B) Notify the healthcare provider that the client is now retaining
fluid. INCORRECT
Tenting is not a sign of fluid retention.
C) Advise Clara that the fluid deficit seems to be
worsening. INCORRECT
Tenting is an expected finding in a client with fluid volume deficit.
D) Document the presence of inelastic skin
turgor. CORRECT
Skin turgor is best assessed in the elderly by gently pinching a fold of skin over the sternum. Inelastic
turgor is an expected finding in a client with fluid volume deficit. Additional findings may include
weakness, confusion, and tachycardia.
Math
Clara's daughter reports that her mother usually weighs about 150 lbs. and is 5 feet, 4 inches in height.
The nurse weighs Clara and obtains a measurement of 65 kg.
6.
The nurse explains to Clara's daughter that Clara has lost approximately how many pounds?
A) 3.
