Vital signs

Question 1

Acceptable temp range:

Answer 1

96.8-100.4 F

Question 2

Most accurate temp reading:

Answer 2

Rectal because measures core

Question 3

Body temp regulations: (4)

Answer 3

Neuro and vascular control (hypothalamus)
Heat production (post. pituitary)
Heat loss (ant. pituitary)
Skin temperature

Question 4

Convection:

Answer 4

Transfer of heat away from the body by air movement

Ex- Fan or cool breeze

Question 5

Conduction:

Answer 5

Transfer of heat from one object to another with direct contact

Ex- Application of ice pack to cool temp

Question 6

Radiation:

Answer 6

Transfer of heat from the surface of one object to the surface of another without direct contact between the two

Ex- environment is warmer than the skin, the skin absorbs the heat

Question 7

Evaporation:

Answer 7

Transfer of heat energy when a liquid is changed to a gas

Ex- sweating

Question 8

The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take?

Answer 8

Place the patient on oxygen.

Question 9

Fastest measurement time for temp:

Answer 9

Tympanic

Question 10

Best sites for assessing an infant or young child’s pulse:

Answer 10

Brachial or apical

Question 11

Why must you use oxygen cautiously in patients with chronic lung disease?

Answer 11

Hypoxemia controls ventilation by providing stimulus that allows a patient to breathe

Question 12

Normal capnography value:

What does it measure?

Answer 12

35-45 mm Hg

Exhaled CO2

Question 13

The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient’s low heart rate?

Answer 13

The patient has calcium channel blockers or digitalis medication prescriptions.

Question 14

Normal hemoglobin level:

Answer 14

14-18 g/100 mL in males

12-16 g/100 mL in females

Question 15

What to assess prior to obtaining an oxygen saturation reading:

Answer 15

Latex allergy

Question 16

If pulse is irregular, what should the nurse do?

Answer 16

Do an apical/radial pulse assessment to detect a pulse deficit

Question 17

A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature?

Answer 17

Tympanic, esophagus, and pulmonary artery

Question 18

How to take a radial pulse:

Answer 18

Place tips of the first two fingers over the groove along the thumb side of the patient’s wrist

Question 19

Normal pulse/ HR:

Answer 19

60-100 BPM

Question 20

Normal SpO2:

Answer 20

95-100%

Question 21

Normal respiration rate:

Answer 21

12-20 breaths/min

Question 22

Pulse pressure value:

How to find?

Answer 22

30-50 mmHg (systolic-diastolic)

Question 23

How to rate strength of pulse:

Answer 23

4- Bounding
3- Full or strong
2- Normal and expected
1- Barely palpable or diminished
0- Absent

Question 24

For a regular pulse-

Answer 24

Count rate for 30 secs and multiply by 2

Question 25

For irregular pulse-

Answer 25

Count for full 60 secs

Question 26

How to locate PMI/apical impulse:

Answer 26

Over the apex of the heart in the 5th intercostal space at the left midclavicular line

Question 27

Which action would take priority if a patient’s apical pulse has an irregular rhythm?

Answer 27

Reassess for 1 full min

Question 28

How to find a pulse deficit:

Answer 28

2 nurses- one measures apical, one measures radial pulse. Subtract the radial rate from the apical rate. If the difference is more than 2 BPM, a pulse deficit exists.

Question 29

F/u care for a pt with a pulse deficit:

Answer 29

Signs or sxs of decreased cardiac output, such as edema, cyanosis or pallor of the skin, and dizziness or syncope.

Question 30

Normal BP in patients with elevated BP:

Answer 30

Systolic: 120-129 mm Hg Diastolic: less than 80 mm Hg

Question 31

Normal BP in patients with stage 1 HTN:

Answer 31

Systolic: 130-139 mm Hg Diastolic: 80-89 mm Hg

Question 32

Normal BP in patients with stage 2 HTN:

Answer 32

Systolic: 140 mm Hg Diastolic: 90 mm Hg

Question 33

Using a blood pressure cuff that is too wide would cause:

Answer 33

Low BP

Question 34

Using a blood pressure cuff that is too loose would cause:

Answer 34

High BP

Question 35

Vasoconstriction effect on temp:

Answer 35

Decreased temp -> blood vessels constrict-> less blood reaches the skin to promote heat production

Question 36

Vasodilation effect on temp:

Answer 36

Increased temp -> blood vessels dilate-> more blood reaches the skin to promote heat loss

Question 37

Why does fever cause increased HR and respiratory rate

Answer 37

Increased metabolism to replenish energy stores from fighting fever requires additional oxygen/heat For every 1° C rise in temp, the body’s chemical reactions increase 10% (WBC production, decrease in iron concentration, stimulation of interferons)

Question 38

Hyperthermia:

Answer 38

When the body cannot reduce heat production or promote heat loss

Question 39

Heatstroke:

Answer 39

Prolonged exposure to sun overwhelms heat-loss mechanisms

Question 40

Heat exhaustion:

Answer 40

Excess sweating that causes dehydration

Question 41

Hypothermia:

Answer 41

Heat loss through prolonged exposure to cold, decreased heat production

Question 42

Cardiac output=

Answer 42

SV x HR

Question 43

Diaphragm of stethoscope:

Answer 43

Detects high pitched sounds

Question 44

Bell of stethoscope:

Answer 44

Detects low pitched sounds

Question 45

S1 sound:

Answer 45

Low pitched "lub"

Question 46

S2 sound:

Answer 46

High pitched "dub"

Question 47

How to measure rhythm of strength:

Answer 47

Can be regularly irregular or irregularly irregular

Question 48

Ventilation:

Answer 48

Movement of gases in/out of the lungs

Question 49

Diffusion:

Answer 49

Movement of oxygen and carbon dioxide between alveoli and RBC

Question 50

Perfusion:

Answer 50

Distribution of RBC to and from pulmonary capillaries

Question 51

Ventilatory depth (breathing depth):

Answer 51

Shallow, deep, normal, or labored

Question 52

Factors affecting SpO2:

Answer 52

- Outside light sources - Carbon monoxide elevates SpO2 - Patient movement - Jaundice - Nails - Intravascular dyes - Dark skin

Question 53

Hyperpnea:

Answer 53

Respirations are labored, increased rate, increased depth

Question 54

Hyperventilation:

Answer 54

Increased rate, increased depth

Question 55

Hypoventilation:

Answer 55

Deceased rate, decreased depth

Question 56

Hypovolemia:

Answer 56

Shock and severe dehydration causes extracellular fluid loss and reduced circulating blood volume