Page 301 - Saunders Comprehensive Review For NCLEX-RN

include exercise, pain, anxiety, smoking, and body
position.
C. Assessing respiratory rate
1. Count the client’s respirations after measuring the
radial pulse. (Continue holding the client’s wrist
while counting the respirations or position the hand
on the client's chest.)
2. One respiration includes both inspiration and
expiration.
3. The rate, depth, pattern, and sounds are assessed.

The respiratory rate may be counted for 30 seconds and

multiplied by 2, except in a client who is known to be very ill or is
exhibiting irregular respirations, in which case respirations are counted
for 1 full minute.
V. Blood Pressure
A. Description
1. Blood pressure (BP) is the force on the walls of an
artery exerted by the pulsating blood under pressure
from the heart.
2. The heart’s contraction forces blood under high
pressure into the aorta; the peak of maximum
pressure when ejection occurs is the systolic pressure;
the blood remaining in the arteries when the
ventricles relax exerts a force known as the diastolic
pressure.
3. The difference between the systolic and diastolic
pressures is called the pulse pressure.
4. For an adult (age 18 years and older), a normal BP is a
systolic pressure below 120 mm Hg and a diastolic
pressure below 80 mm Hg.
5. Categories of hypertension (Box 10-3).
6. In postural (orthostatic) hypotension, a normotensive
client exhibits symptoms and low BP on rising to an
upright position.

7. To obtain orthostatic vital sign measurements,

check the BP and pulse with the client supine, sitting,
and standing; readings are obtained 1 to 3 minutes
after the client changes position.
B. Nursing considerations

1. Factors affecting BP

a. BP tends to increase as the aging
process progresses.
b. Stress results in sympathetic

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