Vitals

Question 1

6 Vital Signs

Answer 1

Temperature
Pulse
Respiratory rate
Blood pressure
Pain 
Oxygen saturation

Question 2

Average oral temp? Range?

Answer 2

98. 6

96. 4 - 100

Question 3

Advantages to oral temp? Disadvantages?

Answer 3

Convenient, accessible

Safety, physical abilities, accuracy

Question 4

Average axillary temp? Range?

Answer 4

.9-1 degree lower than oral

97. 6
98. 8-99

Takes 5-10 min manual

Question 5

Rect temperature average? Range?

Answer 5

1 degree higher than oral
.7 - .9

97.3 - 101

Question 6

Tympanic temperature average? Range?

Answer 6

Set to either oral or rectal

Question 7

How to do a tympanic temperature? Child? Adult?

Answer 7

Point towards tympanic membrane

Child: pull down and back
Adult: pull up and back

Question 8

Variables affecting temperature

Answer 8

Circadian rhythms - lowest 1st thing in the morning

Hormones
Age
Exercise
Stress

Question 9

Afebrile vas. Febrile

Answer 9

No fever

Fever

Question 10

Hyperthermia

Answer 10

Above normal temperature reading

Question 11

Hypothermia

Answer 11

below normal temperature reading

Question 12

What does pulse measure?

Answer 12

Speed and strength of heart contractions, peripheral artery pressures, rhythm

Question 13

Normal pulse range

Answer 13

60 -100 bpm

Question 14

Pulse rating scale (volume)

Answer 14

4 point scale for measuring

Question 15

0 for pulse means

Answer 15

weak or absent

Question 16

+1

Answer 16

weak

Question 17

+2

Answer 17

normal

Question 18

+3

Answer 18

strong/increased

Question 19

+4

Answer 19

bounding

Question 20

6 places to check pulse

Answer 20

carotid, brachial, radial, femoral, popliteal, pedal

Question 21

8 factors affecting heart rate

Answer 21

age
gender
activity
emotional status
pain
environmental factors
stimulants
medications

Question 22

how to check the apical pulse

Answer 22

most direct
5th intercostal space
midclavicular line (mid clavicle)
regular: 30sec x2
irregular: 60 seconds

Question 23

Tachycardia

Answer 23

greater than 100 bpm

Question 24

Bradycardia

Answer 24

less than 60 bpm

Question 25

asystole

Answer 25

without heart beat

Question 26

What would you do first if your patient has a radial pulse of 120 bpm

Answer 26

take an apical pulse

Question 27

Normal respiration range

Answer 27

12-20 per minute

Question 28

Eupnea

Answer 28

normal

Question 29

tachypnea

Answer 29

fast over 20

Question 30

bradypnea

Answer 30

less than 12

Question 31

apnea

Answer 31

not breathing

Question 32

dyspnea

Answer 32

difficulty/irregular breathing

Question 33

orthopnea

Answer 33

upright have easier time breathing

Question 34

what is blood presure

Answer 34

force exerted by the flow of blood pumped into the large arteries

Question 35

factors that determine blood pressure (5)

Answer 35

cardiac output peripheral vascular resistance volume of circulating blood elasticity of blood vessel walls (increase)

Question 36

Measuring BP - sytole

Answer 36

contraction

Question 37

Measuring BP - diastole

Answer 37

relaxation

Question 38

pulse pressure

Answer 38

difference between systole and diastole

Question 39

BP sites

Answer 39

brachial | thigh

Question 40

avoid what for bp

Answer 40

av shunts or fistulas | affected arm of post-mastectomy patient

Question 41

BP at Brachial Site

Answer 41

palpate brachial pulse | auscultation of BP

Question 42

Normal BP - systolic/diastolic

Answer 42

systolic < 120 | diastolic < 80

Question 43

hypotension (orthostatic)

Answer 43

drop in systolic bp of at least 20 or at least 10 for diastolic BP within three minutes of standing drop in bp from sitting to standing

Question 44

Hypertension

Answer 44

high blood pressure

Question 45

Elevated BP (pre-hypertension)

Answer 45

120 - 129/<80

Question 46

Hypertension Stage 1

Answer 46

130-139 or 80-89

Question 47

Hypertension stage 2

Answer 47

greater than or equal to 140 | greater than or equal to 90

Question 48

Common errors in BP measurements

Answer 48

``` incorrect cuff size unrecognized ausculatory gap incorrect cuff placement above the heart legs dangling ```

Question 49

Factors influencing BP

Answer 49

``` age, sex, race diurnal rhythm weight exercise emotion/stress/pain white coat syndrome medications hypervolemia, hypovolemia ```

Question 50

5th vital sigh

Answer 50

pain asses treat evaluate pain (0-10)

Question 51

pulse oximetry

Answer 51

measurement of the oxygen saturation of the hemoglobin molecule normal is greater than 95%

Question 52

you measure pulse ox on your patient having a routine physical exam, and it is 90%. What do you do first

Answer 52

recheck the reading at another site | have them take a deep breath

Question 53

thready pulse

Answer 53

feeble, weak difficult to feel or once felt is obliterated easily with slight pressure

Question 54

When assessing a clients pulse the nurse is able to palpate for some time before losing it when exerting more pressure. The pulse is beating at 80 bpm, Which of these should the nurse document as the character of the clients pulse?

Answer 54

thready pulse

Question 55

an athlete wants to increase her intake of complex carbs and asks the nurse about potential sources. Which food is considered a complex carb?

Answer 55

bread

Question 56

polypharmacy

Answer 56

use of many medications at the same time, can pose many hazards for older adults.

Question 57

a nurse in a clinic is caring for a female client who is of chidlbearing age. Which vitamins or minerals should the nurse recommend to prevent neural tube defects during pregnancy?

Answer 57

folic acid