Question

Please, answer these questions

1. The nurse is informing a group of unlicensed assistive personnel (UAP) about when it is appropriate for a vital sign assessment to be completed in an acute care facility. What responses would be correct? Select all that apply.

At the beginning and end of each nurse’s shift

Upon admission to a clinical facility

When the client’s status changes

When there is time available in the day

More frequently after a procedure or surgery

2. Which vital signs are considered normal? Select all that apply.

Diastolic blood pressure of 91 mm Hg Apical pulse of 76 beats/min

Systolic blood pressure of 145 mm Hg

Respiratory rate of 22 breaths/min

Rectal temperature of 99.1°F (37.3°C)

3. The nurse assists the client to the restroom. Upon returning to bed, the client says he has a throbbing headache and feels chilled. Which priority vital signs should be evaluated? Select all that apply.

Radial pulse

Respiratory rate

Tympanic temperature

Apical pulse

Blood pressure

Answer 1

Ans)1) At the beginning and end of each nurse’s shift

Upon admission to a clinical facility

When the client’s status changes

More frequently after a procedure or surgery

Explaination:

- Vital signs monitoring must be done in all the above-mentioned options as it is important:

They determine which treatment protocols to follow, provide critical information needed to make life-saving decisions, and confirm feedback on treatments performed.

2) Respiratory rate of 22 breaths/min

Rectal temperature of 99.1°F (37.3°C)

Explaination:

- Normal blood pressure systolic under 140 mmHg and diastolic under 90 mmHg

High blood pressure systolic over 140 mmHg and/or diastolic over 90 mmHg. Here in option: systolic is 145 mmHg & diastolic is 91 mmHg

- Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute. But, Respiration rate under 12 or over 25 breaths per minute while resting is considered abnormal.

- Rectal temperature: newborn 97.9–100.4°F (36.6–38°C) adults 97.1–99.2°F (36.2–37.3°C)

3) Radial pulse

Respiratory rate

Blood pressure

Explaination:

- Vital signs monitoing is essential to monitor if patient is having thrombing headache and feeling chilled.

- Vital signs are often considered to be the baseline indicators of a patient's health status.