An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 42/min, respiratory rate 14/min, and BP 98/77 mm Hg. Which vital sign should the nurse re-measure?
Temperature
Respirations
Blood pressure
Heart rate
The Correct Answer is D
A. The tympanic temperature of 37.1° C (98.8° F) is within normal limits and does not require re-measurement.
B. The respiratory rate of 14/min is also within the normal range (12-20 breaths per minute).
C. The blood pressure of 98/77 mm Hg is not alarmingly low and does not require immediate re-measurement.
D. A pulse rate of 42/min indicates bradycardia (normal resting heart rate is typically between
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Correct Answer is C
Explanation
A. Metabolic alkalosis is characterized by a high pH and a high HCO3- level; this does not match the provided values.
B. Metabolic acidosis would show a low pH and a low HCO3-, which does not match the findings.
C. The pH is high (7.45) while the Paco2 is low (30 mm Hg), indicating respiratory alkalosis. The low HCO3- could be a compensatory mechanism but does not change the primary interpretation of respiratory alkalosis.
D. Respiratory acidosis would be indicated by a low pH and a high Paco2, which is not the case here.
Correct Answer is B
Explanation
A. Early ventricular repolarization is represented by the T wave, not the P wave.
B. The P wave represents atrial depolarization, which is the electrical activity that triggers the contraction of the atria.
C. Slow repolarization of ventricular Purkinje fibers is represented by the T wave, not the P wave.
D. Ventricular depolarization is represented by the QRS complex, not the P wave.