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Question 1 of 1
1. Question
While caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/20, pulse 120, respirations 36, temperature 100.8°F. The nurse’s initial action should be to:
Correct
Answer A is correct.
Rationale: The client is exhibiting a widened pulse pressure, tachycardia, and tachypnea. The next action after obtaining these vital signs is to notify the doctor for additional orders. Rechecking the vital signs, as in answer B, is wasting time. The doctor may order arterial blood gases and an ECG.
Incorrect
Answer A is correct.
Rationale: The client is exhibiting a widened pulse pressure, tachycardia, and tachypnea. The next action after obtaining these vital signs is to notify the doctor for additional orders. Rechecking the vital signs, as in answer B, is wasting time. The doctor may order arterial blood gases and an ECG.
Assessing Vital signs:
Assessing vital signs includes measuring temperature, blood pressure, pulse rate, and respiration.
Temperature:
Temperature change can result from:
cardiovascular inflammation or infection (higher than normal temperature)
increased metabolism, which heightens cardiac workload (higher than normal temperature)
poor perfusion and certain metabolic disorders such as hypothyroidism (lower than normal temperature).
Blood pressure:
According to the American Heart Association (AHA), three successive readings of blood pressure above 140/90 mm Hg indicate hypertension. However, emotional stress caused by physical examination may elevate blood pressure. If the patient’s blood pressure is high, allow him to relax for several minutes and then measure again to rule out stress.
