The nursing assistant brings the nurse the following vital signs for an older adult client: Temperature 97.4ºF (oral), BP 165/70, Pulse Rate 84/min, and Respirations 28
After reviewing the vital signs, the nurse should do which of the following? 1. Continue to monitor the client.
2. Tell the nursing assistant to recheck the temperature.
3. Obtain an order for an antihypertensive.
4. Obtain an order for oxygen therapy.
1
Rationale 1: Normal variations in vital signs occur with aging. Body temperature may be decreased due to a decrease in the thermoregulatory control and loss of subcutaneous fat. The pulse rate remains within the normal range of 60 to 100 BPM. A decrease in vital capacity and inspiratory reserve volume may result in an increased respiratory rate. Because systemic arteries lose elasticity with aging, the heart has greater resistance to pump against, which can result in an increased systolic blood pressure. No interventions are needed at this time.
Rationale 2: The temperature is within a normal range for this client; there is no need to recheck the temperature.
Rationale 3: While the systolic blood pressure reading is higher than the upper limit of normal, one elevated reading of 165 systolic is not an indication for antihypertensive therapy. The nurse should continue to monitor this client's blood pressure and alert the healthcare provider if the systolic blood pressure remains elevated.
Rationale 4: The client's vital signs are within a normal range; there is no indication for oxygen therapy.
You might also like to view...
The nurse is aware that risk factors for the development of pancreatic cancer include: (Select all that apply.)
a. obesity. b. Jewish ethnicity. c. diabetes mellitus. d. hepatitis A. e. smoking.
Which blood component forms the initial plug that helps stop bleeding?
a. Fibrin b. Platelets c. Neutrophils d. Eosinophils
Choose the instructions to an elderly woman with osteoarthritis that best help her maintain normal activities of daily living (ADLs) and complete her usual household chores
a. Try to complete all of your chores before lunch because the pain and soreness is less serious in the morning. b. If you rest in the morning and afternoon, you will be able to complete your chores in the evening with less discomfort. c. Make sure you do warm-up and stretching exercises before you do your chores to maximize your agility. d. Do your chores at a pace that is comforta-ble for you, resting frequently after pe-riods of activity.
A client with a long leg cast is complaining of knee discomfort. Which nonpharmacologic intervention can the nurse use to help this client?
1. Apply ice to the knee over the cast. 2. Rub the knee of the non-casted leg. 3. Apply heat to the knee over the cast. 4. Rub the foot of the casted extremity.