Temperature, Pulse & Respiration

Question 1

Define afebrile

Answer 1

without fever

Question 2

Define febrile

Answer 2

with fever

Question 3

Define hyperthermia

Answer 3

unusually high fever - greater than 38.5 degrees

Question 4

Define hypothermia

Answer 4

core body temperature below 35 degrees

Question 5

When is someone considered having a fever?

Answer 5

when temperature reads over 38 degrees

Question 6

Define hyperpyrexial

Answer 6

hyperthermia greater than 41.5 degrees

Question 7

Define pulse

Answer 7

throbbing caused by the regular contraction and alternate expansion of an artery as the wave of blood passes through the vessel as a result of each heart beat

Question 8

Define bradycardia

Answer 8

slow heartbeat - pulse rate below 60bpm in an adult

Question 9

Define apnea

Answer 9

temporary cessation of breathing and therefore decrease body’s intake of oxygen and release of carbon dioxide

Question 10

Define bradypnea

Answer 10

abnormally slow breathing

Question 11

Define cheyne stokes

Answer 11

breathing pattern marked by a period of apnea lasting 10-60 sec, followed by increased depth and frequency of respirations

Question 12

Define eupnea

Answer 12

unimpaired respiration

Question 13

Define hyperventilation

Answer 13

increased minute volume ventilation, which results in lowered C02 levels

Question 14

Define hypoventilation

Answer 14

reduced rate and depth of breathing that causes increased C02

Question 15

Define tachycardia

Answer 15

abnormally rapid heart beat - greater than 100 bpm

Question 16

What is the average oral or tympanic temperature for a healthy adult?

Answer 16

37.0 degrees

Question 17

What are 3 factors that can significantly alter a patients pulse rate?

Answer 17

1. pain
2. blood loss
3. infection

Question 18

What is a nurse referring to when she states a patient’s pulse as bounding?

Answer 18

the strength of a pulse

Question 19

What are two factors to observe when assessing a clients respiration?

Answer 19

• rate, depth, rhythm and character

- note the patients skin colour and level of consciousness

Question 20

Where is an apical pulse best heard?

Answer 20

over the 5th intercostal space, 7-9cm left of mid-sternum, just below left nipple

Question 21

When is an apical pulse used?

Answer 21

when pulse rate is noted as being irregular for one minute or if there is any double of pulse assessment

Question 22

Why are respirations assessed unobtrusively?

Answer 22

because people tend to find it hard to breath normal when they know they’re being assessed

Question 23

Name 7 factors that could influence temperature.

Answer 23

1. diurnal cycle
2. menstruation cycle
3. activity level
4. age
5. stress
6. environment
7. fever

Question 24

What are the 5 possible routes for taking temperature?

Answer 24

• oral
• rectal
• tympanic
• axilla
• temporal artery

Question 25

What must you remember when taking a tympanic temperature for an adult vs. a child?

Answer 25

- adults pull ear up | - children pull ear down

Question 26

When should you not take oral temperatures? (8 answers)

Answer 26

1. disorientated 2. confused 3. unconscious 4. seizuring 5, mouth infections or mouth surgery 6. very young children 7. after hot/cold drinks 8. smoking

Question 27

What is the purpose of a pulse assessment?

Answer 27

indicates hearts function and tissue circulation

Question 28

What is the normal pulse range?

Answer 28

6--100 beats per minute in adults

Question 29

What does PMI stand for?

Answer 29

point of maximum impulse

Question 30

What are some things to consider before taking a pulse?

Answer 30

- asepsis - handwashing and is stethascope cleaned in between patients - person centered care - introduce and ask patient if it is a good time for them - organization - pulse site to be assessed

Question 31

What are 4 characteristics to take into account when taking a pulse?

Answer 31

- rate (60-100 beats per minute) - rhythm (regular or irregular) - strength (strong, bounding, weak, thready) - bilateral equity (both radial pulses for example)

Question 32

Name 9 factors that can affect a pulse

Answer 32

- age - exercise - temperature - pain - emotions - hemorraging - medications - posture change - manner of approach

Question 33

What is the purpose of evaluating respirations?

Answer 33

to evaluate the exchange of oxygen and carbon dioxide

Question 34

What is the normal respiratory rate?

Answer 34

12-20 rpm

Question 35

What are 4 characteristics to watch for when assessing respirations?

Answer 35

- rate (number of breath cycles per minute) - depth (estimate by observing, deep, normal or shallow) - rhythm (regular or irregular) - effort (easy or laboured)

Question 36

What are 9 factors affecting respiration?

Answer 36

- exercise - acute pain - illness - anxiety/stress - smoking - body position - meds - neurological injury - hemoglobin