Fundamentals of Nursing Q 302
The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment?
A. Sitting upright.
B. Lying flat on the back with knees flexed.
C. Lying flat on the back with arms and legs fully extended.
D. Side-lying with the knees flexed.
Correct Answer: A. Sitting upright.
If the patient is able, the nurse should have the patient sit upright to obtain vital signs in order to allow the nurse to easily access the anterior and posterior chest for auscultation of heart and breath sounds. It allows for full lung expansion and is the preferred position for measuring blood pressure. Additionally, patients might be more comfortable and feel less vulnerable when sitting upright (rather than lying down on the back) and can have direct eye contact with the examiner. However, other positions can be suitable when the patient’s physical condition restricts the comfort or ability of the patient to sit upright.
Option B: Lying flat on the back with knees flexed or supine horizontal recumbent is most commonly used during breast exam.
Option C: Lying flat on the back with arms and legs fully extended can make the patient feel uncomfortable.
Option D: Sim’s position is usually used to obtain rectal temperature.