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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?

A.

Temperature

B.

Respirations

C.

Blood pressure

D.

Heart rate

Answer and Explanation

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.

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