Vitals expected ranges

Question 1

Adult BP expected reference range

Answer 1

Systolic 90 to 119; Diastolic 60 to to 70 mm Hg

Question 2

Adult pulse expected reference range

Answer 2

60 to 100 bpm

Question 3

Adult body temp expected reference range

Answer 3

35.9° to 38° (96.7° to 100.5° F)

Question 4

Adult respiration expected reference range

Answer 4

12 to 20 breaths/minute

Question 5

Adult oxygen saturation expected reference range

Answer 5

95% to 100%

Question 6

Sites for measuring BP

Answer 6

upper arm and thigh

Question 7

Manifestations of bradypnea

Answer 7

dizziness, fatigue, confusion, impaired coordination

Question 8

Elevated BP

Answer 8

Systolic 120 to 129 and Diastolic less than 80

Question 9

Stage I hypertension

Answer 9

Systolic 130 to 139 OR Diastolic 80 to 89

Question 10

Stage II hypertension

Answer 10

Systolic 140 or higher OR Diastolic 90 or higher

Question 11

Hypertensive crisis

Answer 11

Systolic higher than 180 AND/OR Diastolic higher than 120

Question 12

When is orthostatic hypertension indicated?

Answer 12

-decrease in systolic BP of greater than or equal to 20 mm Hg
-increase in diastolic BP of greater than or equal to 10 mm Hg
-within 3 minutes of change of position

Question 13

What to do to check for orthostatic hypotension?

Answer 13

-take BP with pt laying supine
-take BP with pt sitting on side of bed
-take BP with pt standing

Question 14

When is hypotension indicated?

Answer 14

Lower than 90/60 mm Hg

Question 15

What are symptoms of hypotension?

Answer 15

dizziness, tachycardia, pallor, increased sweating, blurred vision, nausea and confusion

Question 16

When is BP not supposed to be used on a limb?

Answer 16

-IV line
-arteriovenous shunt or fistula
-side of mastectomy or axillary lymph node removal

Question 17

What is eupnea?

Answer 17

normal, unlabored respiration; one respiration to four heartbeats

Question 18

What is tachypnea?

Answer 18

increased respiratory rate; may occur in response to an increased metabolic rate
breaths greater than 24 a minute

Question 19

What is bradypnea?

Answer 19

decreased respiratory rate; occurs in some pathologic conditions
breaths less than 10 a minute

Question 20

What is apnea?

Answer 20

periods when no breathing occurs

Question 21

What is dyspnea?

Answer 21

difficult or labored breathing

Question 22

What is orthopnea?

Answer 22

changes in breathing when sitting or standing

Question 23

What is hyperpyrexia?

Answer 23

Fever equal to or greater than 41° C (106)

Question 24

When should you not use oral temp on a pt?

Answer 24

oral cavity disease
nose or mouth surgery
risk of seizures
receiving O2 via mask

Question 25

When should you not use tympanic temp on a pt?

Answer 25

drainage from the ear ear pain ear infection scars on tympanic membrane

Question 26

Where should a temporal temperature not be taken?

Answer 26

on side of head that pt has been lying on or over scar tissue, open lesions or abrasions

Question 27

When should rectal temp not be used?

Answer 27

on children with diarrhea pts who have undergone rectal surgery pts who have diseases of the rectum cardiac or cardiac surgery pts

Question 28

How do you document temp?

Answer 28

record temp in EHR identify site used if other than oral report abnormal findings to the primary care provider

Question 29

How do you document pulse?

Answer 29

Record pulse rate Amplitude and quality (bounding, full, expected, diminished, absent) rhythm (regular or irregular) Identify site of assessment (apical, radial, femoral, carotid) Report abnormal findings to primary care provider

Question 30

How do you document respirations?

Answer 30

Respiratory rate depth rhythm report any abnormal findings to the primary care provider

Question 31

How do you document BP?

Answer 31

record findings on EHR or flow sheet place readings under time of acquiring BP not time of entering the values report any abnormal findings to the primary care provider Identify arm used and site of assessment for BP (if other than brachial used)

Question 32

How do you document pulse ox?

Answer 32

Date and time of reading SPO2 value amount of oxygen and delivery method (if pt is on O2) Lung assessment (if relevant) any relevant interventions required as a result of the reading

Question 33

What does afebrile mean?

Answer 33

normal body temperature

Question 34

What chemicals are released in the body when additional heat is required?

Answer 34

epinephrine and norepinpehrine

Question 35

What is an example of radiation?

Answer 35

The body gives off waves of heat from uncovered surfaces

Question 36

What is an example of convection?

Answer 36

An oscillating fan blows currents of cool air across the surface of a warm body

Question 37

What is an example of evaporation?

Answer 37

Body fluid in the form of perspiration and insensible loss is vaporized from the skin

Question 38

What is an example of conduction?

Answer 38

The body transfers heat to an ice pack, causing the ice to melt

Question 39

What are pyrogens?

Answer 39

substances that cause fever

Question 40

What is tachycardia?

Answer 40

HR of 100-180 bpm

Question 41

What are some tachycardia causes?

Answer 41

elevated temp condition causing poor oxygenation of the blood exercise pain strong emotions some medications

Question 42

What is bradycardia?

Answer 42

HR below 60 bpm

Question 43

What are some bradycardia causes?

Answer 43

sleep hypothermia aging medications vagal stimulation (body movement)

Question 44

How do you document bradycardia?

Answer 44

report any difficulty breathing, changes in LOC, decreased BP, EKG changes, chest pain

Question 45

What parts of the brain control respiratory rate and depth?

Answer 45

medulla and pons

Question 46

What activates respiratory rate and depth?

Answer 46

impulses from chemoreceptors

Question 47

What is the most powerful respiratory stimulant?

Answer 47

CO2

Question 48

What is primary hypertension?

Answer 48

characterized by increase above normal in both systolic and diastolic pressures no known cause

Question 49

What is secondary hypertension?

Answer 49

caused by another disease condition common causes include kidney disease, adrenal cortex disorders, and aorta disorders

Question 50

What is a neurogenic fever?

Answer 50

fever of unknown origin (38.9° C or 101° F) lasting longer than 3 weeks does not respond to antipyretics result of damage to hypothalamus increased intracranial pressure

Question 51

When is an axillary temperature used?

Answer 51

when both oral and rectal sites are contraindicated or inaccessible

Question 52

What can cause tachypnea?

Answer 52

exercise age increased metabolic rate any condition causing increased CO2 and decrease in O2 increased altitude anemia anxiety

Question 53

What can cause bradypnea?

Answer 53

increased intracranial pressure Medications (opioids like morphine and hydromorphone)

Question 54

Expected range for school age BP

Answer 54

94 to 106/ 55 to 62 mm Hg

Question 55

Toddler heart rate expected range

Answer 55

80 to 130 bpm

Question 56

Expected reference range for toddler respiratory rate

Answer 56

25 to 30 breaths/min

Question 57

School age expected reference range for heart rate

Answer 57

74 to 110 bpm

Question 58

Adolescent expected reference range for heart rate

Answer 58

70 to 100 bpm

Question 59

School age child expected reference range for respiratory rate

Answer 59

18 to 30 breaths/min

Question 60

Preschooler respiratory reference range

Answer 60

22 to 34 breaths/min

Question 61

Preschooler expected reference range for heart rate

Answer 61

75 to 129 bpm

Question 62

Infant expected reference range for heart rate

Answer 62

80 to 140 bpm