Berman Ch29 Crs

Kozier & Erb's
Fundamentals of Nursing
Concepts, Process, and Practice
TENTH EDITION, GLOBAL EDITION
CHAPTER 29
Vital Signs
Copyright © 2016
Kozier & Erb's Fundamentals of Nursing, Tenth Edition, Global Edition
Pearson Education Limited
Audrey Berman | Shirlee Snyder | Geralyn Frandsen
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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 were within normal
range, what would the nurse do next?
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Question 1 Choices
a. Wait 15 minutes and retake it.

b. Check what the client's temperature was the last
time.
c. Retake it using a different thermometer.
d. Chart the temperature; it is normal.
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Question 1 Answer
a. Wait 15 minutes and retake it.

b. Check what the client's temperature was
the last time.
c. Retake it using a different thermometer.
d. Chart the temperature; it is normal.
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Question 1 Rationales
a. Depending on that finding, you might want to

retake it in a few minutes (no need to wait 15
minutes).
b. 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.
continued on next slide

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c. There is no need to take temperature again with

another thermometer to see if the initial
thermometer was functioning properly.
d. Chart after determining that the temperature
has been measured properly.
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Question 2
Which client meets the criteria for

selection of the apical site for assessment
of the pulse rather than a radial pulse?
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Question 2 Choices
a. A client who is in shock

b. A client whose pulse changes with body position
changes
c. A client with an arrhythmia
d. A client who had surgery less than 24 hours ago
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Question 2 Answer
a. A client who is in shock

b. A client whose pulse changes with body position
changes
c. A client with an arrhythmia
d. A client who had surgery less than 24 hours ago
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a. For clients in shock, use the carotid or femoral

pulse.
b. The radial pulse is adequate for determining
change in orthostatic heart rate.
c. 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.
d. The radial pulse is appropriate for routine
postoperative vital sign checks for clients with
regular pulses.
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Question 3
It would be appropriate to delegate the

taking of vital signs of which client to
unlicensed assistive personnel?
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Question 3 Choices
a. A patient being prepared for elective facial

surgery with a history of stable hypertension.
b. A patient receiving a blood transfusion with a
history of transfusion reactions.
c. A client recently started on a new antiarrhythmic
agent.
d. A patient who is admitted frequently with
asthma attacks.
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Question 3 Answer
a. A patient being prepared for elective facial

surgery with a history of stable
hypertension.
b. A patient receiving a blood transfusion with a
history of transfusion reactions.
c. A client recently started on a new antiarrhythmic
agent.
d. A patient who is admitted frequently with
asthma attacks.
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a. 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.
b. This client is unstable and vital signs
measurement cannot be delegated.

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c. 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.
d. This client is unstable and vital signs
measurement cannot be delegated.
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Question 4
A nursing diagnosis of Ineffective

Peripheral Tissue Perfusion would be
validated by which one of the following?
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Question 4 Choices
a. Bounding radial pulse

b. Irregular apical pulse
c. Carotid pulse stronger on the left side than the
right
d. Absent posterior tibial and pedal pulses
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Question 4 Answer
a. Bounding radial pulse

b. Irregular apical pulse
c. Carotid pulse stronger on the left side than the
right
d. Absent posterior tibial and pedal pulses
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a. Abounding radial pulse is more indicative that

perfusion exists.
b. Apical pulses are central and not peripheral.
c. Carotid pulses are central and not peripheral.
d. 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.
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Question 5
The nurse reports that the client has

dyspnea when ambulating. The nurse is
most likely to have assessed which of the
following?
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Question 5 Choices
a. Shallow respirations
b. Wheezing
c. Shortness of breath
d. Coughing up blood
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Question 5 Answer
a. Shallow respirations
b. Wheezing
c. Shortness of breath
d. Coughing up blood
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a. Shallow respirations are seen in tachypnea

(rapid breathing).
b. Wheezing is a high-pitched breathing sound that
may or may not occur with dyspnea.
c. 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.

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d. The medical term for coughing up blood is

hemoptysis and is unrelated to dyspnea.
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Kozier & Erb's

The client's temperature at 8:00 AM

a. Wait 15 minutes and retake it.

a. Wait 15 minutes and retake it.

a. Depending on that finding, you might want to

continued on next slide

c. There is no need to take temperature again with

Which client meets the criteria for

a. A client who is in shock

a. A client who is in shock

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

It would be appropriate to delegate the

a. A patient being prepared for elective facial

a. A patient being prepared for elective facial

a. Correct. Vital signs measurement may be

continued on next slide

c. In addition to the client being unstable, UAP are

A nursing diagnosis of Ineffective

a. Bounding radial pulse

a. Bounding radial pulse

a. Abounding radial pulse is more indicative that

The nurse reports that the client has

a. Shallow respirations are seen in tachypnea

continued on next slide

d. The medical term for coughing up blood is

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