A nurse is reinforcing teaching with a newly licensed nurse about documenting vital signs. Which of the following documentation made by the nurse indicates an understanding of the teaching?

Pulse 82/min, client sitting in a chair

Temperature 36.9°C (98.4°F)

Respirations auscultated, even at 22/min, client supine

Blood pressure 108/68 mm Hg

Answer and Explanation

The Correct Answer is A

Choice A reason: Documenting the pulse as "82/min, client sitting in a chair" is correct and shows an understanding of the teaching. The pulse rate is within the normal range for a resting adult, which is typically between 60 to 100 beats per minute. Additionally, noting the client's position is important as body position can affect pulse rate; sitting can slightly increase the pulse compared to lying down.

Choice B reason: The temperature of "36.9°C (98.4°F)" is within the normal range for body temperature, which is typically between 36.5°C to 37.5°C (97.7°F to 99.5°F). Documenting the temperature in both Celsius and Fahrenheit is a good practice, as it provides clarity and prevents confusion in clinical settings where different systems may be used.

Choice C reason: The documentation of respirations as "auscultated, even at 22/min, client supine" is appropriate. The normal respiratory rate for a healthy adult at rest is between 12 to 20 breaths per minute. Noting that the respirations are even and the client's position is supine is important, as different positions can affect breathing patterns and rates.

Choice D reason: A blood pressure reading of "108/68 mm Hg" falls within the normal range, which is generally considered to be between 90/60 mm Hg and 120/80 mm Hg for adults. Proper documentation of blood pressure includes both systolic and diastolic values, as seen here, which is essential for accurate monitoring and treatment decisions.

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Correct Answer is D

Explanation

Choice A reason: Inspection should be performed first to observe for any visible abnormalities, distention, or movements that could indicate underlying conditions.

Choice B reason: Percussion is used after auscultation to assess the presence of fluid, gas, and to estimate the size of the organs within the abdomen.

Choice C reason: Palpation is typically performed last because it can alter the natural state of the abdomen, potentially causing discomfort and affecting the bowel sounds that are assessed during auscultation.

Choice D reason: Auscultation should be performed before palpation and percussion to avoid altering bowel sounds. It allows the nurse to listen to the natural state of bowel motility and vascular sounds without interference.

A. Pulse 82/min, client sitting in a chair B. Temperature 36.9°C (98.4°F) C. Respirations auscultated, even at 22/min, client supine D. Blood pressure 108/68 mm Hg

Correct Answer is A

Explanation

Choice A reason: This documentation is correct as it includes the pulse rate and the client's position when the measurement was taken, which can affect the reading.

Choice B reason: The temperature is documented with the correct unit of measurement, but it does not specify the method of measurement (oral, axillary, tympanic, etc.), which is important for accurate interpretation.

Choice C reason: Respirations should be observed, not auscultated, and the documentation should include the client's position. The term 'even' is unnecessary and could be confusing.

Choice D reason: The blood pressure reading is correctly documented with both systolic and diastolic values. However, it should also include the client's position and the arm in which the measurement was taken for clarity.

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A nurse is reinforcing teaching with a newly licensed nurse about documenting vital signs. Which of the following documentation made by the nurse indicates an understanding of the teaching?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

For documenting vital signs, the following documentation made by the nurse indicates an understanding of the teaching:

Correct Answer is A

Explanation

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