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Vital Signs

Fundamentals of Nursing Test #3

Which route requires minimal patient repositioning and can be used without disturbing the patient? Tympanic
Which route is not required for a patient with epilepsy? Oral
(True/False) Rectal temperatures do not require positioning and may increase patient agitation False; they do require positioning and may increase patient agitation
Which temperatures need long measurement times & continuous positioning by the nurse? Axillary
(True/False) Oral temps are not used for patients who have has oral surgery, trauma, or shaking chills True
What is temporal artery temperature affected by ______. Skin moisture (diaphoresis or sweating)
What is the best site to assess an infant or young child's pulse? Brachial/apical pulse; other pulses are deep and difficult to palpate
The pulse that is easily accessible during physiological shock or cardiac arrest is ______. Carotid
How does a nurse obtain a radial pulse? Place the tips of the first two or middle 3 fingers of the hand over the groove along the radial of the thumb of the patient's inner wrist
What occludes the pulse and impairs blood flow? Too much pressure
What is the easiest of all vital signs to assess? Respiratory; often the most haphazardly measured
The difference between the systolic pressure and diastolic pressure is known as ______________. Pulse pressure
Which sites do you not attach the pulse oximeter to if the area is edematous or skin integrity is compromised? Finger, ear, bridge of nose
(True/False) The concentration of hemoglobin reflects the patient's capacity to carry oxygen. True
What are the normal hemoglobin ranges for males and females? Males: 10-18 g/ 100 mL Females:12-16 g/ 100 mL
What is the acceptable blood pressure for a healthy, middle aged adult? 120/80
The normal HR for an adult is ________. 60-100 bpm
What increases BP in adults? Smoking (lasts 15 minutes), caffeine (3 hours), and stress
How long should a patient rest before BP is measured? 5 minutes
The normal HR for an infant is ________. 120-160 bpm
The normal HR for a toddler is ___________. 90-140 bpm
(True/False) The acceptable body temperature for older adults is 96.8 F. True
Who has poor vasomotor control, reduced amounts of subQ tissue, and reduced metabolism? Older Adults
Which thermometer is especially beneficial when used in premature infants, newborns, and children because there is no risk of injury to the child and nurse? Temporal
What is the acceptable RR range for a newborn? 30-60 breaths
Who is expected to have a RR between 30-50 breaths/min? Infant (6 months) & Older
Which age group has a RR range of 25-32 breaths/min? Toddler
A child should breathe _______________. 20-30 breaths/min
Which age group should breathe 16-19 breaths/min? Adolescents
An adult should breathe _______. 12-20 breaths/min
How long should you wait to allow children to recover from recent activities to check BP? 15 min
(True/False) Korotkoff sounds are difficult to hear in children because of low freq and amplitude. True
(True/False) Electronic BP measurement is not recommended w/ irregular HR or when the BP is <90 mmHg systolic. True
Because of their sensitivity, improper cuff placement/movement of the arm causes what tongue incorrect readings? Electronic devices
What should a nurse do if the pulse is irregular? Do an apical/radial pulse assessment to detect a pulse deficit
If pulse count differs by more than 2, what should a nurse realize? A pulse deficit exists, which sometimes indicates alterations in CO
What three circumstances require delays in taking oral temps? 1) Ingestion of hot/cold foods 2)smoking 3) Receiving O2 by mask/cannula
What should the nurse inform the patient of? BP value & the need for perodic reassessment of the BP; Nurse should document BP readings as well as any interventions
(True/False) Rectal temps are 0.9 degrees Fahrenheit higher than oral temps. True
What temps are lower than oral? Axillary
Who should report abnormalities to the nurse? NAP; not allowed to retake BP or other VS after nurse has assessed the patient.
How inaccurate pulse oximetry readings occur? -Outside light sources -CO -Patient motion -Jaundice -Nail Polish/Artificial Nails
What are the risk factors linked to hypertension? -Obesity -Cigarette smoking -Heavy alcohol -High Blood Cholesterol -Continued Exposure to Stress
(True/False) If the posterior hypothalamus senses the body's temp is lower than the set point, the body imitates heat conservation mechanisms. True
What reduces blood flow to the skin and extremities? Vasoconstriction
What controls heat loss by inducing sweating, vasodilation of blood vessels, and inhibition of heat production? Anterior hypothalamus
What is the transfer of heat away from the body by air movement ? Convection
The transfer of heat from one object to another with direct contact is called ______________. Conduction
The transfer of heat from the surface of one object to the surface of another w/o direct contact between the two is called __________________. Radiation
What is the transfer of heat energy when a liquid is changed to a gas? Evaporation
How much body heat does an infant lose through the head? 30%
When is body temperature the lowest during the day? 1:00-4:00 AM
How much does body temp change during the 24hr period? 0.9-1.8 degrees
(True/False) A fever is not usually harmful if it stays below 102.2 degrees Fahrenheit. True
What determines a fever? Several temp readings @ diff times of the day compared w/ the usual value for that person @ the time
What occurs because heat loss mechanisms are unable to keep pace w/ excess heat production that results in an abnormal rise in body temp? Pyrexia (Fever)
(True/False) The set point is the temperature point determined by the hypothalamus. True
What happens during the plateau phase of fever? Chills subside and the person feels warm and dry as heat production and loss are equal at the new level
What happens when a patient comes afebrile? Fever breaks
An elevated body temp related to the body's inability to promote heat loss or reduce heat promotion is called _____________. Hyperthermia; does not shift in a set point
What happens during a fever? Cellular metabolism increases and O2 consumption rises.
Who is responsible for assessing changes in body temp? The Nurse