Vital Signs: ATI Post-Test 2022 with complete solution

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1. When preparing to measure the vital signs of a patient, you should recog- nize that which of the following will affect the methods that you will use? The client who has a BMI of 35. The client ... has had nausea for 2 days. The client is reporting a "stuffy" nose. The client has been fasting for blood tests. The client is taking digoxin for an irregular heart rate. The client had a mastectomy 2 years ago.: The client who has a BMI of 35 is correct. The client who has a BMI of 35 is overweight and has a larger-than-average upper-arm circumference. Therefore, the nurse should use a large blood-pressure cuff, instead of a regular-sized cuff, to ensure an accurate blood-pressure reading. The client has had nausea for 2 days is incorrect. Nausea, while uncomfortable and possibly a manifestation of gastrointestinal pathology, has no direct effect on the nurse assessing the client's vital signs. The client is reporting a "stuffy" nose is correct. The client who has nasal con- gestion might resort to "mouth breathing," which would alter an oral temperature measurement. A respiration assessment for a full 60 seconds should also be included. The client has been fasting for blood tests is incorrect. The lack of food has no direct bearing on checking the client's vital signs. However, recent ingestion of foods of extreme temperatures, hot or cold, can affect the accuracy of an oral temperature measurement. The client is taking digoxin for an irregular heart rate is correct. The presence of a cardiovascular condition that warrants pharmacological digoxin therapy would require an assessment of the client's apical pulse for a full 60 seconds. The client had a mastectomy 2 years ago is correct. Lymphatic drainage might be altered in the client's affected arm following a mastectomy. The application of pressure from the assessment of blood pressure could result in a painful condition called lymphedema. 2. A nurse is obtaining vital signs from a client. Which of the following fingins is the priority for the nurse to report to the provider? Oral temperature 37.8° C (100° F) Respirations 30/min BP 148/88 mm Hg Radial pulse rate 45 beats/30 seconds: Respirations 30/min Respirations of 30/min is above the expected reference range of 12 to 20/min and indicates the need for immediate attention. An adult client who has respirations of 30/min is experiencing shortness of breath, or dyspnea. Without intervention, this can become a life-threatening situation. 3. You are assessing a patients vital signs. the patient has a temperature of 102F which of the following do you expect to find? An elevated pulse rate A decreased blood pressure An elevated blood pressure A decreased pulse rate: 1.an elevated pulse rate [Show More]

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