MEDizzy - The nurse has taken the vital signs of a 95-year old client:

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The nurse has taken the vital signs of a 95-year old client: oral temperature = 98.6°F; pulse = 84 with a regular irregularity; respirations = 18; blood pressure = 140/86. Which nursing assessment(s) should be done first to obtain more data?

ExplanationIf the pulse rhythm is irregular, assessment must occur for 60 seconds rather than 30 seconds. An apical pulse provides more information than a radial pulse. Carotid pulse generally assesses cranial circulation. There is no indication from the client’s vital signs that cranial circulation is impaired. Temperature is normal. There is no indication in the client’s vital signs of respiratory distress. The client’s blood pressure is within an acceptable range.