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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 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.

Correct Answer is A

Explanation

A. Assessing visual acuity directly tests cranial nerve II (the optic nerve), which is responsible for vision.

B. Eliciting the gag reflex tests cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve II.

C. Checking for pupillary response to light primarily assesses the function of cranial nerve II but is more associated with cranial nerve III (oculomotor) since it involves the constriction of the pupil. While relevant, it is not the best standalone action for assessing cranial nerve II specifically.

D. Observing for facial symmetry is associated with cranial nerve VII (facial nerve), not cranial nerve II.

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