The client sits in the chair and has a new, irregular tachyarrhythmia (arrhythmia greater than 100 beats/min)

Question

Rank the equipment used to measure vital signs in order of importance for monitoring this client, beginning with equipment used to measure the most important vital sign for the client. 1. Pulse oximeter
2. Tympanic thermometer
3. Watch with second hand
4. Oscillometric blood pressure device
5. Stethoscope and watch with second hand

Answer 1

3, 1, 4, 5, 2
3. The respiratory rate (RR) is the most important value because ventilation provides oxygen to the arterial blood, and all tissue depends on oxygenated blood to create energy. Measuring the RR implies an adequate airway or the RR would be zero and it complies with the client hierarchy of needs established by air-way-breathing-circulation.
1. The second most important vital sign to monitor is the client's oxygen saturation because if the client is breathing but not oxygenating, the values for the remaining vital signs are irrelevant until tissue oxygen demands are met with oxygenated arterial blood.
4. Third, the nurse measures the blood pressure to ensure adequate blood flow be-cause vital organs need a minimum blood pressure of 80 mm Hg to function. The blood can be completely saturated with oxygen; however, oxygenated blood is no help to the client if the blood does not perfuse tissue. For convenience, the nurse uses an oscillometric blood pressure device until the client is stable.
5. The nurse measures the apical pulse to monitor the rate and regularity of the cardiac rhythm. A fast, irregular heart rate is frequently unable to sustain the client's baseline blood pressure because a heart beating quickly does not have enough filling time, so the stroke volume (volume of blood ejected from myocardial contraction) decreases and leads to decreased cardiac output and a lower blood pressure.
2. Finally, the nurse records the client's temperature; one reading is usually sufficient.