140 data collection

Question 1

What type of temperature method is used when the normal is: 96.4 - 99.1

Answer 1

-Oral
-Tympanic

Question 2

What type of temperature method is used when the normal is: 97.4- 100.1

Answer 2

-Rectal

Question 3

What type of temperature method is used when the normal is: 95.4-98.1

Answer 3

-Axillary

Question 4

What is the normal temperature for Oral and Tympanic

Answer 4

96.4-99.1

Question 5

What is the normal temperature for Rectal

Answer 5

97.4-100.1

Question 6

What is the normal temperature for Axillary

Answer 6

95.4-98.1

Question 7

What is the normal pulse rate for an Adult

Answer 7

60-100 bpm

Question 8

What is the normal pulse rate for an Infant (birth - 1 year)

Answer 8

100-160 bpm

Question 9

What is the normal pulse rate for a Toddler (1-3 years)

Answer 9

90-150 bpm

Question 10

What is the normal pulse rate for an Preschooler ( 3-6 years)

Answer 10

80-140 bpm

Question 11

What is the normal pulse rate for an School- age child (6-12 years)

Answer 11

70-120 bpm

Question 12

What is the normal pulse rate for an Adolescent (12-18 years)

Answer 12

60-100 bpm

Question 13

What is the normal respiration rate for an Adult

Answer 13

12- 20 rpm

Question 14

What is the normal respiration rate for an Infant (birth- 1 year)

Answer 14

30-60 rpm

Question 15

What is the normal respiration rate for a Toddler (1-3 years)

Answer 15

24-40 rpm

Question 16

What is the normal respiration rate for a Preschooler (3-6 years)

Answer 16

22-34 rpm

Question 17

What is the normal respiration rate for a School-age (6-12 years)

Answer 17

18-30 rpm

Question 18

What is the normal respiration rate for an Adolescent (12-18 years)

Answer 18

12-16 rpm

Question 19

What are some clinical situations that would cause the use of the thigh as an alternate BP site

Answer 19

-Injury/disease bilaterally on the shoulder, arm or hand
-Dressings or cast on the arm
-IV therapy being administered in the arm
-History of axilla or lymph node surgery in the arm (mastectomy)
-Dialysis access in the arm (Fistula)

Question 20

What is phase 1 Korotkoff sound

Answer 20

Systolic reading
(First, faint clear tapping or thumping

Question 21

What is phase 2 Korotkoff sound

Answer 21

Sounds have muffled, whooshing, swishing quality

Question 22

What is phase 3 Korotkoff sound

Answer 22

Sounds are crisper and more intense

Question 23

What is phase 4 Korotkoff sound

Answer 23

Sounds become more muffled and have a soft, blowing quality

Question 24

What is phase 5 Korotkoff sound

Answer 24

Diastolic reading
-Last sound is heard, followed by silence

Question 25

What is: -Associated with reduced peripheral blood flow caused by changes in the pulse wave

Answer 25

Oscillatory gap

Question 26

What risk does a nurse take by not finding the Oscillatory gap before taking BP

Answer 26

-Inaccurate systolic assessment -Unneeded compression of the arm which may cause injury

Question 27

What is normal BP for an Adult

Answer 27

-Systolic: Less than 120 mmHg -Diastolic: Less than 80mmHg

Question 28

What is normal BP for a Pediatric

Answer 28

-80 + 2x child's age -Diastolic will be heard at phase 4 Korotkoff sound

Question 29

What is the range for an Elevated BP

Answer 29

Systolic: 120-129 Diastolic: Less than 80mmHg

Question 30

What is the range for Hypertension stage 1

Answer 30

Systolic: 130-139 Diastolic: 80-89 mmHg

Question 31

What is the range for Hypertension stage 2

Answer 31

Systolic: 140 or higher Diastolic: 90 or higher

Question 32

What is the range for Hypertensive crisis

Answer 32

Systolic: Higher than or 180 Diastolic: Higher than 120

Question 33

What is the first step of the nursing process

Answer 33

Assessment

Question 34

What is the second step of the nursing process

Answer 34

Nursing diagnosis

Question 35

What is the third step of the nursing process

Answer 35

Planning

Question 36

What is the fourth step of the nursing process

Answer 36

Implementation

Question 37

What is the fifth step of the nursing process

Answer 37

Evaluation

Question 38

What concept is: -Respiratory and cardiovascular systems work together -Provides oxygen and nutrients to every cell in the body

Answer 38

The concept of perfusion

Question 39

Where do you place the BP cuff on the radial artery

Answer 39

On the wrist

Question 40

Where do you place the BP cuff on the brachial artery

Answer 40

On the upper arm

Question 41

Where do you place the BP cuff on the Dorsalis pedis artery and posterior tibial artery

Answer 41

Midcalf

Question 42

Where do you place the BP cuff on the popliteal artery

Answer 42

Above the knee

Question 43

What is associated with: Reduced peripheral blood flow caused by changes in the pulse wave

Answer 43

Oscillatory gap