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. To determine the heart rate from a rhythm strip, you can count the number of R-R intervals in a set time frame (typically 6 seconds) and multiply by 10 to convert to beats per minute. If the rhythm is regular, you can also use the 300 method by dividing 300 by the number of large squares between R waves. In this case, the rate is calculated to be 90 beats per minute.
B. A heart rate of 110 beats per minute would be classified as tachycardia and is not supported by the observed intervals.
C. A heart rate of 73 beats per minute would be a normal resting heart rate but does not match the calculation from the rhythm strip.
D. A heart rate of 50 beats per minute would indicate bradycardia, which is not reflected in this rhythm strip.
Correct Answer is A
Explanation
A. Vitamin D deficiency is a modifiable risk factor because it can be addressed through dietary changes, supplements, and increased sun exposure.
B. A small-boned, thin frame is considered a nonmodifiable risk factor as it is a genetic characteristic that cannot be changed.
C. A personal history of fractures is also a nonmodifiable risk factor, as past fractures indicate an increased risk for future fractures and cannot be altered.
D. Age is a nonmodifiable risk factor, as it is an intrinsic characteristic that cannot be changed.