Which adult vital sign should be reported to the nurse right away?
- Respirations of 16 breaths per minute
- Oral temperature of 98.4 degrees F
- Blood pressure of 118/76 mm Hg
- Pulse of 124 beats per minute at rest
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D. Pulse of 124 beats per minute at rest
A resting pulse of 124 is well above the normal adult range of 60 to 100. The respirations, temperature and blood pressure listed are all within normal adult ranges.
Reference: Basic nursing skills: vital signs; reporting abnormal readings
A nursing assistant feels that a resident's radial pulse is irregular. How long should the pulse be counted?
- One full minute
- 15 seconds, then multiply by 4
- 30 seconds, then multiply by 2
- 10 seconds, then multiply by 6
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A. One full minute
An irregular pulse is counted for a full minute, because a short sample multiplied up can miss or double-count the uneven beats. The irregular rhythm is also reported to the nurse.
Reference: Basic nursing skills: vital signs (pulse)
A resident's pulse is regular. The nursing assistant counts 38 beats in 30 seconds. What pulse rate is recorded?
- 38 beats per minute
- 76 beats per minute
- 114 beats per minute
- 152 beats per minute
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B. 76 beats per minute
A 30-second count is doubled to give beats per minute: 38 x 2 = 76. Recording 38 forgets to multiply, and 152 multiplies by 4 as if the count had been for 15 seconds.
Reference: Basic nursing skills: vital signs (pulse)