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Fundamentals > Midterm > Flashcards

Midterm Flashcards

1
Q

What is the average temperature for young adults?

A

98.6 F

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2
Q

What is the average temperature for elderly?

A

95-97 F

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3
Q

What are the different temperature sites?

A

oral
tympanic
temporal artery
axillary
rectal

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4
Q

What is the expected temp range for oral?

A

96.8-100.4 F

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5
Q

What is the expected temp range for rectal?

A

0.9 F higher than oral and tympanic temps

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6
Q

What is the expected temp range for axillary?

A

0.9 F lower than oral and tympanic temps

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7
Q

What is the expected temp range for temporal?

A

1 F higher than oral and 2 F higher than axillary

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8
Q

What should a newborn’s temp be?

A

97.7-99.5 F

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9
Q

How are older adult client’s temp affected?

A

loss of subcutaneous fat results in lower body temps

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10
Q

How will illness or injury affect temperature?

A

increases temp

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11
Q

What will interfere when taking an oral measurement?

A

recent food/fluid intake
smoking

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12
Q

What temperature site would a nurse use for clients who are 4 years or older?

A

oral

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13
Q

Who would a nurse not use the oral site for temperature?

A

for clients who breathe through their mouth

have trauma to face or mouth

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14
Q

Which is more accurate for temp, rectal or axillary?

A

rectal

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15
Q

How far should the rectal probe enter for an adult?

A

1-1.5 inches

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16
Q

Who should not have temperatures taken at the rectal site?

A

patients with
- diarrhea
- low platelet count
- rectal disorders
- younger than 3 months

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17
Q

How would the nurse take the tympanic temp for an adult?

A

pull the ear up and back

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18
Q

Who should not have temperatures taken at the tympanic site?

A

infants younger than 3 months old

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19
Q

What can affect the temperature reading at the tympanic site?

A

excess earwax

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20
Q

What is another term for fever?

A

pyrexia

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21
Q

What is considered a fever?

A

more than 102.2 F

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22
Q

What is hyperthermia?

A

abnormally elevated body temp

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23
Q

What is considered hyperthermic?

A

more than 104 F

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24
Q

What can be administered for elevated body temp?

A

antibiotics

antipyretics
- aspirin
- acetaminophen
- ibuprofen

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25
Q

Should children with a fever be given aspirin if they recently had a viral illness? Why?

A

NO

risk of reye’s syndrome

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26
Q

What are the nursing actions for a fever/hyperthermia?

A
  • obtain specimens
  • assess WBC/electrolytes
  • fluid
  • rest
  • control environmental temp
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27
Q

What is hypothermia?

A

abnormally low body temp

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28
Q

What is considered hypothermic?

A

less than 95 F

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29
Q

What are the nursing actions for hypothermia?

A
  • warm environment
  • fluids
  • keep head covered
  • cardiac monitoring
  • have emergency resuscitation equipment on standby
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30
Q

What is ventilation?

A

exchange of oxygen and carbon dioxide in lungs through inspiration and expiration

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31
Q

How is ventilation measured?

A

with respiratory rate, rhythm, and depth

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32
Q

What is diffusion?

A

exchange of oxygen and carbon dioxide between alveoli and RBCs

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33
Q

How is diffusion measured?

A

with pulse oximetry

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34
Q

What is perfusion?

A

the flow of RBC to and from the pulmonary capillaries

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35
Q

How is perfusion measured?

A

with pulse oximetry

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36
Q

What is an expected respiratory rate range?

A

12-20 breaths/minute

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37
Q

What are factors that influence respiratory rate?

A

exercise
anxiety
body position
neurological injury
smoking
pain
medications
hemoglobin function

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38
Q

What should be assessed for respirations?

A

rate
depth
rhythm

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39
Q

What is an expected respiratory rate range for newborns?

A

30-60 breaths/min

40
Q

What is an expected respiratory rate range for children 3 -5 years old?

A

20-25 breaths/min

41
Q

How does pain affect respirations?

A

decrease the depth and increase the rate

42
Q

How does anxiety affect respirations?

A

increases rate and depth

43
Q

How does smoking affect respirations?

A

resting rate of respirations increase

44
Q

How does body position affect respirations?

A

upright positions allow chest wall to expand fully

45
Q

How do medications affect respirations?

A

opioids, sedatives, bronchodilators, general anesthetics decrease respiratory rate and depth

46
Q

How does neurologic injury affect respirations?

A

decreases respiratory rate and rhythm

47
Q

What is SaO2 and SpO2?

A

oxygen saturation

48
Q

What is the expected oxygen saturation range?

A

95-100%

49
Q

What sites can a pulse oximeter be placed?

A

finger
earlobe
bridge of nose
foot

50
Q

What is bradypnea?

A

regular breathing, but rate less than 12/min

51
Q

What is hypoventilation?

A

shallow breathing pattern with low rate

52
Q

What is apnea?

A

periods of no breathing

53
Q

What is tachypnea?

A

regular breathing pattern, but rate more than 20/min

54
Q

What is hyperventilation?

A

deep breathing pattern with high rate

55
Q

What can hyperventilation lead to?

A

decreased levels of CO2 and hyperoxygenation

56
Q

What is hyperpnea?

A

respiratory rate, depth, and work of breathing increased

57
Q

What are cheyne-stokes respirations?

A

irregular rate and depth of respirations that follow a cyclical pattern

58
Q

What are kussmaul respirations?

A

increased respiratory rate and regular pattern, but abnormally deep

59
Q

Define blood pressure

A

Cardiac output (CO) x Systemic vascular resistance (SVR)

systolic/diastolic

60
Q

How is cardiac output determined?

A

heart rate x stroke volume

61
Q

What happens to CO and BP if HR increases or decreases?

A

CO and BP increase if HR increases
CO and BP decrease if HR decreases

62
Q

What are common errors in measuring BP?

A

cuff size
inflation
deflation
arm level
repeating too quickly

63
Q

What is a normal BP?

A

<120
/
<80

64
Q

What is an elevated BP?

A

120-129
/
<80

65
Q

What is prehypertension (stage 1) BP?

A

130-139
/
80-89

66
Q

What is hypertension (Stage 2) BP?

A

> or equal to 140

/

> or equal to 90

67
Q

What is hypertensive crisis BP?

A

> 180

and/or

> 120

68
Q

How will you classify a client’s BP?

A

By the highest reading

69
Q

If a client has a BP of 124/92, what category are they placed in?

A

stage 2 hypertension

70
Q

What is hypotension?

A

BP with sys below 90

71
Q

What is hypotension a result of?

A

fluid depletion
heart failure
vasodilation

72
Q

What is pulse pressure?

A

difference between sys and dias

73
Q

What is orthostatic hypotension?

A

decrease in BP when changing postions

74
Q

How does stress affect BP?

A

increases it

75
Q

How do mediations affect BP?

A

opiates, antihypertensives, and cardiac meds lower BP

cocaine, nicotine, cold medications, oral contraceptives, alc, and antidepressants raise BP

76
Q

What should clients do before have BP measured?

A
  • avoid nicotine or caffeine 30 prior
  • rest for 5 min before
  • sit in chair, flat feet, back and arm supported, and arm at heart level
77
Q

What is an expected pulse rate for adults?

A

60-100 beats/min

78
Q

What should be assessed when finding the pulse?

A

rate
rhythm
strength
equality

79
Q

What is a pulse grade of 0?

A

absent, not palpable

80
Q

What is a pulse grade of +1?

A

barely palpable, diminished

81
Q

What is a grade pulse of +2?

A

easily palpable, normal

82
Q

What is a grade pulse of +3?

A

full, increased strength

83
Q

What is a grade pulse of +4?

A

bounding, full volume

84
Q

What are sites for checking pulses?

A

carotid
brachial
radial
femoral
popliteal
posterior tibial
pedal

85
Q

What is noted in pulses for children as they age?

A

pulse will be high, but then decrease as they age

86
Q

What is the purpose of a physical assessment?

A
  • gather baseline data
  • make clinical decisions
  • evaluate outcomes of care
87
Q

Describe acute pain

A
  • sudden
  • decreases overtime
  • direct cause
  • can lead to chronic
88
Q

Describe chronic pain

A
  • ongoing or recurs frequently
  • lasting longer than 6 months
89
Q

Define somatic pain

A

pain in bones, joints, muscles, skin, or connective tissue

90
Q

Define visceral pain

A

pain in internal organs

91
Q

Define cutaneous pain

A

pain in skin or subcutaneous tissue

92
Q

What is assessed in a pain assessment?

A

precipitating factors
quality
region and radiation
severity
timing

93
Q

What are nonpharmacologic interventions for pain?

A

relaxation
distractions, music
positioning
cold/heat
TENS
massage
herbal/dietary supplements

94
Q

What are pharmacologic interventions for pain?

A

non opioids
opioids

adjuvants
- corticosteroids
- antidepressants
- anti seizure
- GABA receptor agonists
- cannabinoids

95
Q

What are common side effects of opioids?

A

constipation
respiratory depression
sedation
nausea, vomiting
urinary retention
pruritus

Fundamentals (7 decks)

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