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 A
Explanation
A. Ventricular tachycardia: Ventricular tachycardia (VT) is identified by a regular, fast rhythm with wide QRS complexes, typically without visible P waves. This rhythm often appears as consecutive, large, uniform waves, which is consistent with what is seen in the diagram.
B. Asystole: Asystole is characterized by a flat line, indicating no electrical activity, which is not present in this strip.
C. Normal sinus rhythm: Normal sinus rhythm would show identifiable P waves, a normal QRS complex, and a regular rate, which are not observed here.
D. Ventricular fibrillation: Ventricular fibrillation appears as chaotic, irregular waveforms with no clear QRS complexes or organization, which does not match the rhythm shown.
Correct Answer is B
Explanation
A. The palm is not the best part of the hand to assess lymph nodes, as it lacks the sensitivity needed for palpation.
B. The parts of the fingers, particularly the pads of the fingers, are used to assess lymph node size. This allows for a more precise and sensitive examination of the lymph nodes.
C. The dorsal side of the hand is not typically used for palpation because it is less sensitive.
D. The ulnar surface of the hand is not commonly used for this purpose, as the fingertips provide better tactile sensation for assessing lymph node size.