Clinical

Question 1

Normal BP for adults

Answer 1

120/80

Question 2

Normal bp for newborn

Answer 2

70/45

Question 3

normal respirations adults

Answer 3

12-20

Question 4

normal newborn respirations

Answer 4

30-50

Question 5

normal pulse adults

Answer 5

60-100

Question 6

normal pulse newborn

Answer 6

100-170

Question 7

normal temp for adults

Answer 7

98.6

Question 8

normal temp for newborn

Answer 8

96.0-99.5

Question 9

normla temp for elderly

Answer 9

96.8

Question 10

How can acute pain affect vital signs?

Answer 10

Increase pulse, respiratory depth and rate, and BP

Question 11

What can pain do to Cardiac output?

Answer 11

Increases it and vasoconstriction occurs

Question 12

What are the 4 ways to take temp?

Answer 12

Orally
Rectally
Tympanic
Axillary

Question 13

What do you need to remember to ask when taking oral temp?

Answer 13

Have you had anything cold or hot to drink in the last 15-30 min?

Question 14

In cardiovascular patients, which way would you NOT take their temp?

Answer 14

Rectally

Question 15

Which type of temp is the least accurate?

Answer 15

Axillary

Question 16

What are the 5 areas to assess heart sounds?

Answer 16

APE To Man: Aortic, Pulmonic, Erb’s Point, Tricuspid, Mitral

Question 17

What is the S1?

Answer 17

Lub
Beginning of systally
AV valves close (mitral and tricuspid)
measurement of max pressure against arterial walls
Reflection of cardiac output

Question 18

Where is S1 heard the loudest?

Answer 18

Mitral (apex of heart)

Question 19

What is the S2?

Answer 19

Dub
End of systally/beginning of distally
Relax and filling (measurement of pressure remaining in the arteries during relaxation phase)
Pulmonic and Aortic valves close
Reflection of PVR

Question 20

What is Bradycardia?

Answer 20

Less than 60 bpm

Question 21

What is Tachycardia?

Answer 21

More than 100 bpm

Question 22

When assessing heard sounds or pulses, what are you listening for?

Answer 22

Quality
Rate
Rhythm - regular or irregular (dysrhythmia)
Volume - weak, thready, strong, bounding

Question 23

When assessing new patient, where should you listen to heart sounds and take pulse?

Answer 23

Heart sounds: all 5 areas

Pulse: all peripheral pulses

Question 24

What are the 9 sites for assessing pulse?

Answer 24

Temporal
Carotid
Apical
Brachial
Radial
Ulnar
Femoral
Posterior tibial
Dorsalis pedis

Question 25

What is BP a measure of?

Answer 25

Pressure in the arteries

Question 26

What factors affect BP?

Answer 26

Cardiac Output -inc = inc Blood volume - inc. = Inc Viscosity - inc = inc PVR (peripheral vascular resistance) -

Question 27

What is systally?

Answer 27

max pressure against arterial walls | Reflection of cardiac output

Question 28

What is diastally?

Answer 28

pressure remaining in arteries during relaxation | Reflection of PVR

Question 29

What happens if the cuff is too big?

Answer 29

BP will be too low

Question 30

What happens if the cuff is too wide?

Answer 30

BP will be too low

Question 31

What happens if the cuff is too small?

Answer 31

BP will be too high

Question 32

When assessing weight, what do you need to remember?

Answer 32

Weigh the same time, in the same place, same clothes and document.

Question 33

What patients do you need to weigh daily?

Answer 33

Renal and Cardiac patients

Question 34

What is cardiac output?

Answer 34

volume of blood pumped by the heart in 1 min.

Question 35

What is stroke volume?

Answer 35

volume of blood that enters the aorta with each ventricular contraction

Question 36

What does hemorrhage do to stroke volume?

Answer 36

Decreases it

Question 37

What does IV fluids to do stroke volume?

Answer 37

Increases it

Question 38

What is viscosity?

Answer 38

thickness of blood | Greater the thickness the harder the heart has to work

Question 39

What is PVR? Peripheral Vascular Resistance

Answer 39

size and distensibility of the arteries | Plaque

Question 40

What is orthostatic hypotension?

Answer 40

postural hypotension Refers to a sudden drop of 25 mm Hg in systolic pressure and 10 mm Hg in diastolic when a client moves from a lying to a sitting or sitting to a standing position

Question 41

How do we assess for orthostatic hypotension?

Answer 41

After 5 min of laying flat After 1 min of sitting After 1 min of standing After 2 min of standing

Question 42

What are the volume assessments for pulse?

Answer 42

0=absent 1+ is weak or thready 2+ is normal 3+ is bounding

Question 43

What is euprea?

Answer 43

normal respirations 12-20

Question 44

What is bradypnea?

Answer 44

below 10 respirations

Question 45

What is tachypnea?

Answer 45

Above 24 respirations

Question 46

What is hypoventilation?

Answer 46

shallow respirations

Question 47

What is hyperventilation?

Answer 47

deep respirations

Question 48

What is dyspnea?

Answer 48

difficulty breathing, shortness of breath

Question 49

Where do you assess lung sounds?

Answer 49

10 front/12 back | Inspect/palpate/percuss/auscultation

Question 50

What are the 3 types of lung sounds?

Answer 50

Vesicular Bronchovesicular Bronchial

Question 51

What are vesicular lung sounds?

Answer 51

soft, breezy, low pitch inspiration > expiration heard on lung periphery

Question 52

what are bronchovesicular lung sounds?

Answer 52

Medium pitch Inspiration = expiration Heard posterior b/ scapula

Question 53

What are Bronchial lung sounds?

Answer 53

Loud, high pitch Expiration > inspiration Heard at trachea

Question 54

What are some abnormalities of lung sounds?

Answer 54

Crackles - heard on inspiration Rhonchi - heard on expiration, trachea, musical Wheezes - heard on expiration, snoring Pleural friction rub - creaking Stridor- heard on inspiration, crowing sound

Question 55

What order do you assess abdominal?

Answer 55

Inspection, Auscultation, percussion, palpation

Question 56

What order do you assess quadrants?

Answer 56

start lower right, upper R, upper L, lower L

Question 57

How long do you assess for bowel sounds?

Answer 57

Listen at least 5 minutes if not hearing sounds | should hear high pitched gurgling every 5-15 sec

Question 58

What is the Sims' position and when do we use it?

Answer 58

on side with upper leg flexed | Used for rectal exam

Question 59

What is Prone position?

Answer 59

Laying on stomach musculoskeletal observation intolerable for patient with respiratory difficulty

Question 60

What is Dorsal Recumbent?

Answer 60

Knees flexed | Promotes abdominal relaxation

Question 61

What is supine?

Answer 61

Laying on back, most relaxed | easy access to abdomen

Question 62

When should sitting be used?

Answer 62

For full expansion of lungs