Vital Signs

Question 1

What is the purpose of taking vital signs?

Answer 1

To monitor a change in a person condition

Question 2

What do you do when the vital sign is abnormal?

Answer 2

Try to take it twice and switch arms & if still abnormal report to nurse

Question 3

When do you asses vital signs?

Answer 3

-On admission
-Discharge
-Pre and Post-opt
-Change in condition
-Loss of consciousness
-When medications are given that affect cardiac rate and rhythm
-Per MD order or hospital policy

Question 4

What are the physiological responses for temperature?

Answer 4

-disease or trauma of the hypothalamus or spinal cord will alter temperature
-hypothalamus also receives messages from cold and warm thermal receptors located throughout body

Question 5

What is the most common way to take temp in a hospital?

Answer 5

Orally

Question 6

What temp sites are considered core temp?

Answer 6

Tympanic, rectal, and temporal artery

Question 7

What are surface temp measurement sites?

Answer 7

Skin, mouth, and axiallae

Question 8

How do you take tympanic temp?

Answer 8

Pull up and back (ear)

Question 9

What temp is more accurate?

Answer 9

Core temperature

Question 10

What are the four mechanisms of heat transfer?

Answer 10

Radiation, Convection, Evaporation, and Conduction

Question 11

What is radiation (mechanism of heat transfer)?

Answer 11

Diffusion or dissemination of heat by electromagnetic waves (ex. Gives of heat from uncovered areas)

Question 12

What is convection (mechanism of heat transfer)?

Answer 12

Dissemination of heat by motion between areas of density (ex. Fan blows cool air across warm)

Question 13

What is Evaporation (mechanism of heat transfer)?

Answer 13

Conversion of liquid to vapor (ex. Sweating)

Question 14

What is conduction (mechanism of heat transfer)?

Answer 14

Transfer of heat to another object during contact (ex. Ice pack)

Question 15

What is the primary source for body heat?

Answer 15

Metabolism

Question 16

What other two mechanisms play a role in generation of body heat?

Answer 16

Hormones and exercise

Question 17

What factors affect variations in temperature?

Answer 17

Circadian Rhythms, gender/age, illness, environment

Question 18

What does pyrexia mean?

Answer 18

Has fever (febrile)

Question 19

What does a febrile mean?

Answer 19

No fever

Question 20

What is hyperpyrexia?

Answer 20

Condition where the body temp goes above 106.7 (life-threatening issue)

Question 21

What is hypothermia?

Answer 21

Condition where the body temp drops really low, commonly caused by prolonged exposure to cold

Question 22

What are the expected ranges in oral temp?

Answer 22

96.8 to 100.4 (average is 98.6)

Question 23

What are expected ranges of rectal temp?

Answer 23

Usually 0.9 degrees higher than oral and tympanic

Question 24

What is expected ranges of axillary temp?

Answer 24

Usually 0.9 degrees lower than oral and tympanic temp

Question 25

What are expected temporal temp ranges?

Answer 25

Are close to rectal, but they are nearly 1 degree higher than oral and 2 degree higher than axillary

Question 26

What are the fever signs/symptoms?

Answer 26

Hot, dry skin, flush, general malaise, and increased heart rate

Question 27

What is intermittent fever?

Answer 27

Body temp comes back to normal in 24 hours

Question 28

What is remittent fever?

Answer 28

Does not come back to normal but does fluctuate

Question 29

What is relapsing fever?

Answer 29

Returns back to normal then fluctuates

Question 30

What are some nursing interventions for fever?

Answer 30

VS, I&O, fluids (IV or oral), Meds, Tepid bath, cooling blanket, oral hygiene, dry clothing and linen

Question 31

Before taking an oral temp what should you ask the patient?

Answer 31

If they have had anything cold or hot within the last 20 minutes

Question 32

What are the pulse physiological responses?

Answer 32

1. Autonomic system 2. Parasympathetic nervous system 3. Sympathetic nervous system

Question 33

What is the autonomic nervous system

Answer 33

Controls heart rate

Question 34

What is the parasympathetic nervous system?

Answer 34

Lowers heart rate “rest & relax”

Question 35

What is the sympathetic nervous system?

Answer 35

Raises the heart rate “Fight or Flight”

Question 36

Where is the apical point?

Answer 36

In the 5th intercostal space

Question 37

What does the acronym APETM stand for?

Answer 37

Aortic area Pulmonic area Erb’s point Tricuspid area Mitral area

Question 38

What factors affect the pulse rate?

Answer 38

Age: lowers it Exercise: raises it Pain: raises it Hemorrhage: raises it Fever: raises it Stress: raises it Illness: raises it

Question 39

Where is the carotid artery?

Answer 39

On both sides of the neck; never squeeze both at same time

Question 40

Where is the brachial artery?

Answer 40

In the inner elbow lines up with the pinky

Question 41

Where is the radial pulse?

Answer 41

On the wrist below the thumb

Question 42

Where is the femoral pulse?

Answer 42

On the inner thigh by pubis region

Question 43

Where is the popliteal pulse?

Answer 43

Behind the knee

Question 44

Where is the dorsalis pedis?

Answer 44

On the foot right above the big toe and 2nd toe

Question 45

How do you assess the pulse?

Answer 45

Rate, Rhythm, Quality/Strength, Equal Bilaterally

Question 46

What is a pulse deficit?

Answer 46

Difference between apical rate and radial rate

Question 47

What is pulmonary ventilation?

Answer 47

Movement of air in and out of lungs

Question 48

What is diffusion?

Answer 48

Exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood

Question 49

What is perfusion?

Answer 49

The exchange of oxygen and carbon dioxide between circulating blood and tissue cells

Question 50

What factors influence respiratory rate?

Answer 50

-Age -Acid-base balance -C-V disease -Pain -Emotions -Opiod-narcotics -Anesthesia -CNS injury

Question 51

What do you assess during respirations?

Answer 51

-Rate -Depth -Rhythm(pattern) -Quality -Procedure

Question 52

What is Eupnea?

Answer 52

Normal breathing

Question 53

What is apnea?

Answer 53

Absence breathing

Question 54

What is orthopnea?

Answer 54

Difficulty breathing when laying down

Question 55

What is blood pressure?

Answer 55

Force of moving blood against the atrial walls

Question 56

What is orthostatic hypotension?

Answer 56

BP drops when patient stands (within 3 minutes takes the BP again)

Question 57

What is pulse pressure?

Answer 57

Difference between systolic & diastolic

Question 58

What is the range for a normal pulse pressure?

Answer 58

40-60mmHg

Question 59

What factors affect BP?

Answer 59

-Age -Circadian Rhythm -Gender -Eating food -Weight -Emotions -Body Position -Race -Medications

Question 60

When taking someone blood pressure what should you ask beforehand?

Answer 60

-Have you had an recent surgeries on either arms they would not let me use the arm for BP? -Any extremity with IV or AV shunt

Question 61

What is the 1st phase of Korotkoff Sounds?

Answer 61

Systolic

Question 62

What is the 5th phase of Korotkoff Sounds?

Answer 62

Diastolic

Question 63

How should you measure what size BP cuff you should use?

Answer 63

Width 40% of arm circumference

Question 64

Why is BP often higher in older adults?

Answer 64

Decreased elasticity in arterial walls

Question 65

What is considered the 5th vital sign?

Answer 65

Pain (Scale 0-10)

Question 66

What is the 6th vital sign?

Answer 66

Pulse oximetry

Question 67

What is the normal range for pulse ox?

Answer 67

95%-100%

Question 68

How can you maintain adequate oxygenation?

Answer 68

-Positioning -Promoting proper breathing -Turn, Cough and Deep Breathe -Providing supplemental oxygen

Question 69

Why is documentation important for vital signs?

Answer 69

You note significant changes and report, and compare/trend