Which statement should the nurse question when discussing what is ...

[roselinechinyere27m]

Which statement should the nurse question when discussing what is included when taking vital signs? Select all that apply.
 
  1. You are taking my temperature.
  2. You will be listening to my heart.
  3. You will be measuring what I have eaten.
  4. You will be taking my blood pressure.
  5. You will be listening to my stomach.

Question 2

The nurse is caring for a client with vital signs 97.2 F; 112; 48; 104/86; and oxygen saturation is 76. Place the nursing actions in order of their priority for this client.
 
  Click on the down arrow for each response in the right column and select the correct choice from the list.
  Response 1. Assess the client.
  Response 2. Reduce client anxiety.
  Response 3. Notify the health care provider.
  Response 4. Obtain assistance from another nurse or member of the team.
  Response 5. Administer oxygen.

[mcomstock09]

Answer to Question 1

Correct Answer: 3,5

Temperature, pulse, and blood pressure are all measured when assessing a client's vital signs. Food intake and assessing bowel sounds are not included in a vital signs assessment.

Answer to Question 2

Correct Answer: 5,1,4,3,2

Because of the client's rapid respirations and reduced oxygen saturation, the nurse's first priority would be to administer oxygen to improve oxygenation. After oxygen is applied, the client should be assessed quickly, and the nurse should obtain assistance from another nurse or member of the team who can stay with the client or notify the health care provider. When the health care provider has been notified, or while the health care provider is being notified, the nurse should attempt to allay the client's anxiety, as that otherwise will lead to greater dyspnea.