Author Question: The nurse has just taken vital signs for a 30-year-old client. Based on the results, the nurse will ... (Read 45 times)

imowrer · **on:** Jul 23, 2018

The nurse has just taken vital signs for a 30-year-old client. Based on the results, the nurse will report the following finding that is out of the expected range for a client of this age:

1. T = 37.4 C
2. P = 110 beats/min
3. R = 20 breaths/min
4. BP = 120/76 mm Hg

Question 2

When using a glass thermometer at home to accurately assess axillary temperature, the nurse should tell the parent of a 1 1/2-year-old child to:

1. Hold the thermometer at the bulb end
2. Cleanse the thermometer in hot water
3. Assess the thermometer for 5 minutes
4. Allow the child to hold the thermometer

smrtceo · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 2
The expected pulse range for an adult is 60-100 beats/min. This client's pulse is elevated at 110 beats/min. This client's temperature is within the normal range of 36 to 38 C for an adult. This client's respiratory rate is within the normal range of 12-20 breaths/min for an adult. This client's blood pressure reading is within the normal range of 120/80 mm Hg for an adult.

Answer to Question 2

ANS: 3
When assessing a client's axillary temperature with a glass thermometer, the thermometer should be left in place for 3 to 5 minutes. The thermometer should be held at the opposite end of the bulb. The thermometer should be covered with a plastic sheath when in use and after used the plastic sheath is discarded. If the thermometer requires cleaning, the nurse should not use hot water, as it could cause the thermometer to break. The parent should hold the thermometer, not the child. A 1 1/2-year-old client may drop the thermometer, creating a mercury spill.