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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
Should children with a fever be given aspirin if they recently had a viral illness? Why?
NO risk of reye's syndrome
26
What are the nursing actions for a fever/hyperthermia?
- obtain specimens - assess WBC/electrolytes - fluid - rest - control environmental temp
27
What is hypothermia?
abnormally low body temp
28
What is considered hypothermic?
less than 95 F
29
What are the nursing actions for hypothermia?
- warm environment - fluids - keep head covered - cardiac monitoring - have emergency resuscitation equipment on standby
30
What is ventilation?
exchange of oxygen and carbon dioxide in lungs through inspiration and expiration
31
How is ventilation measured?
with respiratory rate, rhythm, and depth
32
What is diffusion?
exchange of oxygen and carbon dioxide between alveoli and RBCs
33
How is diffusion measured?
with pulse oximetry
34
What is perfusion?
the flow of RBC to and from the pulmonary capillaries
35
How is perfusion measured?
with pulse oximetry
36
What is an expected respiratory rate range?
12-20 breaths/minute
37
What are factors that influence respiratory rate?
exercise anxiety body position neurological injury smoking pain medications hemoglobin function
38
What should be assessed for respirations?
rate depth rhythm
39
What is an expected respiratory rate range for newborns?
30-60 breaths/min
40
What is an expected respiratory rate range for children 3 -5 years old?
20-25 breaths/min
41
How does pain affect respirations?
decrease the depth and increase the rate
42
How does anxiety affect respirations?
increases rate and depth
43
How does smoking affect respirations?
resting rate of respirations increase
44
How does body position affect respirations?
upright positions allow chest wall to expand fully
45
How do medications affect respirations?
opioids, sedatives, bronchodilators, general anesthetics decrease respiratory rate and depth
46
How does neurologic injury affect respirations?
decreases respiratory rate and rhythm
47
What is SaO2 and SpO2?
oxygen saturation
48
What is the expected oxygen saturation range?
95-100%
49
What sites can a pulse oximeter be placed?
finger earlobe bridge of nose foot
50
What is bradypnea?
regular breathing, but rate less than 12/min
51
What is hypoventilation?
shallow breathing pattern with low rate
52
What is apnea?
periods of no breathing
53
What is tachypnea?
regular breathing pattern, but rate more than 20/min
54
What is hyperventilation?
deep breathing pattern with high rate
55
What can hyperventilation lead to?
decreased levels of CO2 and hyperoxygenation
56
What is hyperpnea?
respiratory rate, depth, and work of breathing increased
57
What are cheyne-stokes respirations?
irregular rate and depth of respirations that follow a cyclical pattern
58
What are kussmaul respirations?
increased respiratory rate and regular pattern, but abnormally deep
59
Define blood pressure
Cardiac output (CO) x Systemic vascular resistance (SVR) systolic/diastolic
60
How is cardiac output determined?
heart rate x stroke volume
61
What happens to CO and BP if HR increases or decreases?
CO and BP increase if HR increases CO and BP decrease if HR decreases
62
What are common errors in measuring BP?
cuff size inflation deflation arm level repeating too quickly
63
What is a normal BP?
<120 / <80
64
What is an elevated BP?
120-129 / <80
65
What is prehypertension (stage 1) BP?
130-139 / 80-89
66
What is hypertension (Stage 2) BP?
> or equal to 140 / > or equal to 90
67
What is hypertensive crisis BP?
>180 and/or >120
68
How will you classify a client's BP?
By the highest reading
69
If a client has a BP of 124/92, what category are they placed in?
stage 2 hypertension
70
What is hypotension?
BP with sys below 90
71
What is hypotension a result of?
fluid depletion heart failure vasodilation
72
What is pulse pressure?
difference between sys and dias
73
What is orthostatic hypotension?
decrease in BP when changing postions
74
How does stress affect BP?
increases it
75
How do mediations affect BP?
opiates, antihypertensives, and cardiac meds lower BP cocaine, nicotine, cold medications, oral contraceptives, alc, and antidepressants raise BP
76
What should clients do before have BP measured?
- 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
What is an expected pulse rate for adults?
60-100 beats/min
78
What should be assessed when finding the pulse?
rate rhythm strength equality
79
What is a pulse grade of 0?
absent, not palpable
80
What is a pulse grade of +1?
barely palpable, diminished
81
What is a grade pulse of +2?
easily palpable, normal
82
What is a grade pulse of +3?
full, increased strength
83
What is a grade pulse of +4?
bounding, full volume
84
What are sites for checking pulses?
carotid brachial radial femoral popliteal posterior tibial pedal
85
What is noted in pulses for children as they age?
pulse will be high, but then decrease as they age
86
What is the purpose of a physical assessment?
- gather baseline data - make clinical decisions - evaluate outcomes of care
87
Describe acute pain
- sudden - decreases overtime - direct cause - can lead to chronic
88
Describe chronic pain
- ongoing or recurs frequently - lasting longer than 6 months
89
Define somatic pain
pain in bones, joints, muscles, skin, or connective tissue
90
Define visceral pain
pain in internal organs
91
Define cutaneous pain
pain in skin or subcutaneous tissue
92
What is assessed in a pain assessment?
precipitating factors quality region and radiation severity timing
93
What are nonpharmacologic interventions for pain?
relaxation distractions, music positioning cold/heat TENS massage herbal/dietary supplements
94
What are pharmacologic interventions for pain?
non opioids opioids adjuvants - corticosteroids - antidepressants - anti seizure - GABA receptor agonists - cannabinoids
95
What are common side effects of opioids?
constipation respiratory depression sedation nausea, vomiting urinary retention pruritus

Fundamentals (7 decks)

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