An 84-year-old client with diabetes is admitted for insulin ...

[CQXA]

An 84-year-old client with diabetes is admitted for insulin regulation. Which of the following blood pressure, pulse, and respiration measurements, respectively, is considered to be within the expected limits for a client of this age?
 
  1. BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/min
  2. BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min
  3. BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min
  4. BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min

Question 2

A nurse administers pain medication for a client complaining of pain. The nurse first assesses vital signs and finds them to be as follows: blood pressure, 134/92 mm Hg; pulse, 90 beats per minute; respirations, 26 breaths per minute.
 
  The nurse's most appropriate action is to:
  1. Give the medication
  2. Ask if the client is anxious
  3. Check the client's dressing for bleeding
  4. Recheck the client's vital signs in 30 minutes

[kaylee05]

Answer to Question 1

ANS: 1
These measurements are within the expected limits for an older client. An adult's average blood pressure is 120/80 mm Hg. The systolic pressure may increase with age, but the blood pressure should not exceed 140/90 mm Hg. The range for an adult's pulse is 60-100 beats/min. The ex-pected respiratory rate is 16-25 breaths/min. BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min; BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min; and BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min are not within the expected limits for a client of this age.

Answer to Question 2

ANS: 1
The client's vital signs are consistent with the client being in pain. It would be safe and appropri-ate for the nurse to give the pain medication. Asking if the client is anxious is not the most ap-propriate action. The client is not demonstrating signs of shock (e.g., decreased blood pressure, increased pulse). The most appropriate action is for the nurse to administer pain medication. Re-checking would not be the most appropriate action. The nurse should medicate the client for pain.