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Vital signs
| Question | Answer |
|---|---|
| What patient would require follow up | An adult with respiratory rate of 10 breaths per minute |
| Normal respiratory rate for newborns | 30-60 per minute |
| Normal respiratory rate for children | 20 per minute |
| Normal respiratory for teenager | 16-20 |
| Adult respiratory | 12-20 |
| Average body temp for older adult | 36 C (96.8F) |
| Normal heart rate for older adults | 60-100 |
| Normal respiratory for older adult | 16-25 |
| Average BP for older adult | Less than 120 over 80 |
| Pulse oximetry | 95% - 100% |
| The nurse has delegated the task of temperature assessment to the NAP which info should be provided to the NAP | The type of temperature required, The frequency for taking or monitering temp, What changes to report immediately to the nurse |
| Which situations may affect parents vitals | Time of day, Moving from lying to standing, Pain rated as 7 on a scale of 1-10 |
| Why is it necessary to take vitals preoperatively | To provide a set of vitals to use for comparison during and after surgery and to verify the patient is not experiencing any complications that may contraindication surgery or require intervention |
| What patient would be appropriate for the nurse to delegate Vitals | Elderly nursing home resident |
| The patient should not eat, drink,born smoke for _____ minutes before assessing _____ temp | 20, oral |
| For which patient would a tympanic thermometer be preferred to use | A tachypneic patient who is receiving oxygen by nasal cannula |
| What patients would require frequent assessment of their temp | A patient receiving a blood transfusion for chronic anemia, An adult female in the recovery room after hysterectomy, A young adult with a white blood count of 15,000/mm3 |
| If patient has a fever what to do | Remove blankets administer antipyretic as ordered |
| Hyperthermia blanket | Used to raise body temp |
| Red tipnfor thermometer is used for | Rectal |
| Blue tip is used for | Axillary temp and oral |
| Normal temp falls between | 96.8-100.4 (36-38c) |
| Temporal artery thermometer reflects rapid change in core temp and can he used on | Newborns |
| The task of pulse assessment could be delegated to the NAP for which of the following patients | A raisin pulse on a patient with a 1200 mL fluid restriction, The temporal pulse of a child |
| Which patients would be at risk for having an alteration in peripheral pulse | The patient who was just informed of a diagnosis of cancer, a patient with peripheral vascular disease, a patient who is receiving bolus IV fluids |
| Whenever there is an alteration in the radial pulse rate rhythm or amplitude the nurse should initially do which of the following | Auscultate the apical pulse for quality and rate |
| Normal pulse range for adult | 60-100 beats per minute |
| Normal pulse for 2 year old | 90-140 beats |
| The nurse should routinely auscultate the apical pulse with the bell side of the stethoscope band use the diaphragm side to identify heart murmurs | False |
| What patients would the nurse expect to find a decrease in pulse rate | A patients returning from the OR, A patient who received morphine for pain |
| The new NAP is unable to palpate a patients radial pulse what could be a possible explanation for this difficulty | The NAP is assessing for a pulse ok the ulnar side of the wrist, the NAP is pressing down too hard on the patients radial site |
| Which may increase both rate and depth of respiration | Walking a mile briskly, Feeling anxious when taking a test, having an addiction problem with cocaine |
| The nurse assesses the BP in both arms of a newly admitted patient why would the nurse do this | To determine if there is a difference in the reading between the two arms |
| Hypertension for BP | Systolic greater than 140 and diastolic greater than 90 more than two separate times |
| Those higher risk for hypertension | African americans, obesity |
| For which patient should you avoid using a lef pressure cuff | A patient with a deep vein thrombosis |
| Which patient is at high risk for the pulse oximetry alarm to sound | A patient with a continuous pulse oximetry reading of 84% |
Created by:
Hydecar