Explanation: Heart rate reflects the number of times the heart beats per minute and is an essential vital sign in assessing cardiovascular function.

a. Respiratory rate measures the number of breaths per minute, not heartbeats.

b. Blood pressure is the force of blood against the walls of arteries and is measured in mmHg, not heartbeats per minute.

d. Oxygen saturation measures the percentage of hemoglobin that is saturated with oxygen, not heartbeats per minute.

Answer: d. Notify the healthcare provider of the elevated blood pressure.

Explanation: A blood pressure reading of 160/100 mmHg indicates hypertension and requires further evaluation by the healthcare provider to determine appropriate management.

a. Rechecking the blood pressure with a different cuff size may be appropriate if the initial reading was inaccurate, but it does not address the elevated blood pressure result.

b. Documenting the finding is important, but further action is required for elevated blood pressure.

c. Administering antihypertensive medication without consulting the provider is not appropriate; medication decisions should be made by the healthcare provider.

Explanation: A respiratory rate of 8 breaths per minute is significantly below the normal range (12-20 breaths per minute), indicating potential respiratory distress. The nurse should perform a thorough respiratory assessment to gather more information and determine appropriate interventions.

a. Administering oxygen may be necessary, but the nurse should first assess the client's respiratory status before initiating any interventions.

b. Placing the client in a supine position is not indicated and may worsen respiratory distress in some situations.

c. Reassessing after 1 hour is not appropriate when a client is experiencing abnormal vital signs; immediate action is needed.

Answer: c. Faces Pain Scale - Revised (FPS-R) Explanation: The Faces Pain Scale - Revised (FPS-R) is commonly used for children who are too young to verbalize their pain intensity. It consists of a series of faces depicting different levels of pain intensity.

a. The Numeric Rating Scale (NRS) and Visual Analog Scale (VAS) require verbal or numerical expression of pain intensity, which may not be possible for young children.

d. The Wong-Baker FACES Pain Rating Scale is also commonly used for children and includes a series of faces to assess pain intensity, but the FPS-R is more widely used.

Answer: d. 86%

Explanation: An oxygen saturation level of 86% indicates severe hypoxemia and requires immediate intervention to ensure adequate oxygenation.

a. Oxygen saturation levels of 95% are within the normal range and do not require immediate intervention.

b. Oxygen saturation levels of 92% are relatively low but may not require immediate intervention depending on the client's clinical condition.

c. Oxygen saturation levels of 89% indicate significant hypoxemia and require intervention, but immediate intervention is required at a level of 86%.

Answer: c. Notify the healthcare provider of the significant difference.

Explanation: A significant difference in blood pressure readings between the right and left arms may indicate arterial occlusion or other circulatory abnormalities. The nurse should notify the healthcare provider for further evaluation and intervention.

a. Rechecking the blood pressure with a different cuff size may be appropriate if the initial readings were inaccurate, but it does not address the significant difference between the arms.

b. Documenting the finding is important, but further action is required to investigate the cause of the discrepancy.

d. Performing a Doppler ultrasound may be done as part of the diagnostic process to assess blood flow, but the healthcare provider should be notified first for appropriate evaluation.

Answer: c. Swipe the thermometer gently across the client's forehead.

Explanation: Temporal artery thermometers are used by swiping the thermometer gently across the client's forehead. The device measures the temperature of the temporal artery, which correlates with core body temperature.

a. Inserting the thermometer into the rectum is not the appropriate method for using a temporal artery thermometer.

b. Placing the thermometer in the axilla is appropriate for axillary temperature measurement but not for temporal artery thermometers.

d. Holding the thermometer under the tongue is appropriate for oral temperature measurement but not for temporal artery thermometers.

indicate poor sensor placement or a faulty pulse oximeter. The nurse should reapply the pulse oximeter on a different finger to obtain an accurate reading.

a. An irregular waveform is not a normal variation and should be investigated further.

c. Assessing the client for signs of respiratory distress is important but may not directly address the irregular waveform.

d. Notifying the healthcare provider may be necessary if the issue persists after reapplying the pulse oximeter.

Answer: c. Place the bell of the stethoscope over the brachial artery.

Explanation: To obtain an accurate blood pressure reading, the nurse should place the bell of the stethoscope over the brachial artery, which is located in the antecubital fossa.

a. Inflating the cuff to 20 mmHg above the estimated systolic pressure may be appropriate for initial inflation, but the cuff should be inflated further until the radial pulse disappears, and then slowly deflated to obtain accurate readings.

b. Deflating the cuff at a rate of 2-3 mmHg per second is recommended to obtain accurate blood pressure readings.

d. Palpating the radial artery while auscultating for Korotkoff sounds is not necessary for accurate blood pressure measurement and may interfere with accurate assessment.