Normal Ranges for Vitals Signs / ATI / EOCHQ

Question 1

Normal body temp for adults

Answer 1

36 - 37.5 Celsius // 96.8 - 99.5 Farenheit

Question 2

Normal beats per minute (pulse for adults)

Answer 2

60 - 100 BBM

Question 3

What are the phases of Korotkoff sounds?

Answer 3

1 = faint, clear, tapping (systolic)
2 = muffled, wooshing, swishing
3 = blood flows freely
4 = muffled, soft, blowing
5 = pressure level when last sound is heard (diastolic)

Question 4

Normal blood pressure

Answer 4

120 / 80

Question 5

What is the apical pulse valve called?

Answer 5

Mitral valve and is refereed to as the Point of Max Impulse (PMI)
Apical pulse = apex

Question 6

Where can you find the apical pulse?

Answer 6

LEFT of the sternum palpate to 5th intercostal space. Move finger to MCL (midclavicular line)

Question 7

Normal breathing (respiration) rate

Answer 7

12 -20 breaths per min

Question 8

Where are the pulse sites on the body?

Answer 8

1. Radial - peripheral
2. Brachial
3. Carotid
4. Femoral
5. Popliteal
6. Posterior tibial
7. Dorsalis pedis
   - Peripheral = ankle or wrist

Question 9

Normal oxygen levels

Answer 9

95% - 100%

Question 10

Normal range of Mean Arterial Pressure (MAP)

Answer 10

70 - 110 mmHg

Question 11

Normal pulse pressure

Answer 11

40 mmHg

Question 12

Normal rectal / tympanic temperature

Answer 12

0.5 - 1 higher than oral temp

Question 13

Normal axillary temp

Answer 13

0.5 - 1 LOWER than oral temp

Question 14

A nurse is preparing to measure a clients vital signs. The nurse should identify that which of the following factors will affect the methods that are used?

Answer 14

The client reporting a stuffy nose
The client taking digoxin for an irregular Heart Beat
The client had a mastectomy 2 years ago

Question 15

A nurse assessing a clients respiration. Which of the following actions should the nurse take?

Answer 15

Elevate the head of the clients bed to 45 - 60 degrees

Question 16

A nurse is preparing to auscultate a clients apical pulse at the point of max impulse. Which of the following locations should the nurse position the stethoscope?

Answer 16

Over the fifth intercostal space at the left midclavicular line

Question 17

A nurse is obtaining a clients vital signs. The client has a new onset of a temp. 39 degrees Celsius or 102 degrees F. Which of the other vital signs should the nurse expect?

Answer 17

An elevated pulse rate - a fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate.

Question 18

A nurse is preparing to record the difference between a clients systolic and diastolic blood pressure. Which of the following terms defines this info when documenting?

Answer 18

Pulse pressure

Question 19

A nurse is taking an adult clients temp rectally. Which of the following actions should the nurse take?

Answer 19

Insert the probe about 2.5 cm (1 - 1.5 in) into the clients anus.

Question 20

A nurse is obtaining a clients BP and notices a pressure reading on the manometer when listening to the 4th Korotkoff sound. Which of the following factors does this pressure reading correlate to?

Answer 20

It might not follow with a 5th K sound

Question 21

A nurse is collecting data about a clients respiratory condition. Which of the flowing actions should the nurse take to determine the depth of the clients respiration?

Answer 21

Observe the degree of chest wall movement during inspiration and expiration

Question 22

A nurse is auscultating a clients apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs?

Answer 22

When the semilunar valves close

Question 23

A nurse is establishing a baseline for a clients respirations. Which of the following actions should the nurse take?

Answer 23

Observe the clients chest movements while appearing to assess their pulse

Question 24

A nurse is obtaining VS from a client. Which of the following findings is the priority for the nurse to report to the provider?

Answer 24

Respirations of 30/min - this is above the expected reference range of 12 - 20/ min. and indicates for immediate attention. The pt is experiencing SOB, or dyspnea. This could become a life threatening situation without intervention.

Question 25

A nurse is preparing to use a tympanic thermometer to acquire a clients temp. Which of the following should the nurse take to ensure an accurate reading?

Answer 25

Pull the pinna up and back

Question 26

A nurse is measuring a clients temp orally. Which of the following actions should the nurse take?

Answer 26

Place the probe in the posterior lingual pocket lateral to the midline

Question 27

What are the phases of a fever?

Answer 27

1. Onset (Cold or Chill phase) 2. Course (Plateau phase) {Malaise, achy muscles, weakness} 3. Defervescence (Fever abatement and flush phase) {Breaking a fever = dehydration and sweating}

Question 28

What is the body temperature during a heat stroke?

Answer 28

41.1 Celsius or 106 F or higher

Question 29

What is the body temperature during HYPOthermia?

Answer 29

less than 36 C or 96.8 F

Question 30

What is bradycardia?

Answer 30

Less than 60 BPM

Question 31

What is tachycardia?

Answer 31

Greater than 100 BPM

Question 32

How quickly do you release the BP valve so that the pressure decreases?

Answer 32

2 - 3 mmHg per second

Question 33

After the brachial pulse disappears, how much higher do you pump the BP cuff to?

Answer 33

30 mmHg above the point where the brachial pulse disappears

Question 34

What is the systolic and diastolic BP for stage 1 hypertension?

Answer 34

130 -139 (systolic) 80 - 89 (diastolic)

Question 35

What is the systolic and diastolic BP for stage 2 hypertension?

Answer 35

Greater than 140 (systolic) Greater than 90 (diastolic)

Question 36

What is the BP for hypertensive crisis?

Answer 36

Higher than 180 (systolic) Higher than 120 (diastolic)

Question 37

Normal ranges for VS

Answer 37

Temp - 96.8 - 99.5 HR - 60 - 100 BPM RR - 12 -20 BP - 120/80 O2 - 95 - 100

Question 38

Describe the ranges on the numeric pain scale

Answer 38

1-3 = mild 4-6 = moderate 7-10= severe

Question 39

When do you take VS?

Answer 39

Before and after surgery When the pt has SOB (change in health status)

Question 40

Pain typically increases which two VS?

Answer 40

BP and HR

Question 41

This is the most frequently used method to estimate core body temperature

Answer 41

Tympanic

Question 42

Surface temperature is effected by the _______________.

Answer 42

Environment

Question 43

Core temperature is a measure of

Answer 43

The temperature of the deep tissues of the body

Question 44

Factors that affect the body's heat production are

Answer 44

*Basal metabolic rate (rate of energy usage) *Muscle activity (shivering) Thyroxine output Epinephrine (stress) Fever

Question 45

Which is more accurate core temperature or surface temperature?

Answer 45

Core temp

Question 46

Rectal and tympanic (ear) temperature are ____-____ higher than oral temperature.

Answer 46

0.5 - 1 F

Question 47

A pt who falls in an icy lake will experience ____________ heat loss

Answer 47

Conduction (most serious type of heat loss) [The body loses heat 25x faster in cold water]

Question 48

Describe the 4 types of heat loss

Answer 48

Radiation - infrared rays Conduction - when skin is subject to cold water Convection - normal heat loss eVAPORation - sweat/ insensible water loss

Question 49

Factors that affect body temperature

Answer 49

Age Circadian rhythms Exercise Hormones Stress Environment

Question 50

The part of the brain that regulates temperature is the_____________.

Answer 50

Hypothalamus

Question 51

Malaise, weakness, and aching muscles occur in this phase of a fever

Answer 51

Course or plateau phase

Question 52

Dehydration and sweating (breaking a fever) occur in this phase of a fever

Answer 52

Defervesces

Question 53

A hyperpyrectic fever is __________F and can cause ___________ to the brain

Answer 53

105.8 F Damage

Question 54

Heat exhaustion and heat stroke are not a fever

Answer 54

True

Question 55

Hypothermia or frostbite most commonly occurs in these places of the body

Answer 55

Hands Feet Nose Ears

Question 56

Who are affected the most by hypothermia?

Answer 56

Elderly Children

Question 57

This place loses heat the most

Answer 57

The head

Question 58

If the pt is dehydrated the pulse will be _____________.

Answer 58

Elevated

Question 59

The apical pulse is assessed for how long?

Answer 59

1 minute

Question 60

Describe inhalation

Answer 60

Diaphragm contracts Ribs - up and out Sternum - down Thorax enlarges

Question 61

Describe exhalation

Answer 61

Diaphragm relaxes Ribs - down and in Sternum - in Thorax - decrease

Question 62

The part of the brain that is considered the respiratory center is the

Answer 62

Medulla oblongotta and Pons

Question 63

List the respiratory retractions

Answer 63

Suprasternal Intercostal Substernal Altered chest movements

Question 64

The pulse oximeter can be placed on a pts:

Answer 64

Forehead Finger Toe Nose Ear

Question 65

If the pulse ox is 70% this means ______

Answer 65

Life threatening

Question 66

The difference between the systolic and diastolic BP numbers is called

Answer 66

Pulse pressure

Question 67

Elevated Mean Arterial Pressure (MAP) occurs in pts with _________ and _________

Answer 67

Arteriosclerosis and cardiovascular disease

Question 68

Low pulse or MAP pressure occurs in pts in

Answer 68

Severe heart failure

Question 69

MAP measures what?

Answer 69

Pressure delivered to the body's organs

Question 70

During inhalation the sternum moves

Answer 70

Sternum - down

Question 71

During exhalation the sternum moves

Answer 71

Sternum - in

Question 72

A pt with a BP reading 130-139 / 80-89 has which type of hypertension?

Answer 72

Stage 1

Question 73

A pt with a BP reading above 140 / 90 has which type of hypertension?

Answer 73

Stage 2

Question 74

A pt with a BP reading over 180 / over 120 has which type of hypertension?

Answer 74

Hypertensive crisis

Question 75

Factors associated with HTN are:

Answer 75

Smoking Obesity Sedentary lifestyle Thick arterial walls

Question 76

If a Pt does not have arms, you must take their BP at this place on their body

Answer 76

Upper thigh or below their calf

Question 77

To assess for orthostatic hypotension, what are you checking for?

Answer 77

Drop in BP 20 mmHg (systolic)/ 10 mmHg (diastolic) and an increase of pulse by 20 beats/ min

Question 78

How will a small BP cuff affect BP readings

Answer 78

It will read falsely high

Question 79

How will a big BP cuff affect BP readings

Answer 79

It will read falsely low

Question 80

After phase 5 of the Korotkoff sounds (pressure level when the last sound is heard), how long do you wait to make sure there is no further noise?

Answer 80

10 mmHg

Question 81

Before administering digoxin, you must check which VS

Answer 81

BP

Question 82

Why would digoxin be administered?

Answer 82

To treat an irregular heart beat or heart failure

Question 83

If heart rhythm is irregular, you must asses the pt for _______ seconds

Answer 83

60

Question 84

Factors that alter pulse rate are

Answer 84

Medications affecting HR (digoxin) Emotional status Activity level Beta blocker Calcium channel blocker