When assessing a client's vital signs, a nursing student has explained each of her next actions prior to assessing the client's temperature, pulse, and blood pressure

Question

However, the nurse has not announced her intention to assess the client's respiratory rate prior to measuring it. Which of the following is a plausible rationale for the nurse's decision?

A) Respirations have both autonomic and voluntary control.
B) The nurse likely assessed the client's respiratory rate simultaneous to heart rate.
C) Temperature, pulse, and blood pressure are more volatile than respiratory rate.
D) Tachypnea is an expected finding among hospitalized individuals.

Answer 1

Ans: A
Because respiratory rate is under both autonomic and voluntary control, making the client conscious of his or her respiratory rate prior to assessment has the potential to affect that accuracy of the assessment. It is not possible to simultaneously assess pulse and respirations. Temperature, pulse, and blood pressure are not necessarily more volatile than respiratory rate. Tachypnea is not an expected finding.