Term
| What are the normal temperature ranges for an adult/elderly person? |
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Definition
| 36.0 C - 37.5 C with a younger adult starting about a degree higher(37). 97 F - 99.5 F |
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Term
| When is taking temperature by mouth contraindicated? |
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Definition
| If the patient can't close their mouth, has impaired mental faculties, or has diseases of the nose/mouth |
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Term
| When is taking temperature by the axillary route contraindicated? |
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Definition
| If the patient can't close their arm over the axilla or they have had surgery on that side of the body that would jeopardize the healing process |
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Term
| When is taking temperature by the rectal route contraindicated? |
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Definition
| In newborns, children with diarrhea, or instances where the patient has had rectal or cardiac surgery or has a low white blood cell count |
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Term
| Why are mercury thermometers no longer used. |
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Definition
| A glass thermometer is prone to breaking and mercury is a very hazardous material |
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Term
| How do axillary and rectal temperatures vary from an oral reading? |
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Definition
| The axillary temp will be about 1 degree F lower and the rectal temp will be about one degree F higher |
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Term
| What color coding differentiates and oral or axillary thermometer from a rectal thermometer? |
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Definition
| An oral/axillary thermometer has a blue cap and the rectal thermometer has a red cap |
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Term
| What are the different routes for taking body temperature? |
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Definition
| Oral, Axillary, Temporal, tympanic, and Rectal |
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Term
| Which routes of taking temperature are surface vs core methods of taking temperature? |
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Definition
| Oral, Axillary, and Temporal are surface. Tympanic and rectal are core. |
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Term
| What is the normal value range for an adult/elderly person for pulse? |
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Definition
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Term
| What scale is used to illustrate the quality or fullness of a patients pulse? This is also referred to as amplitude. |
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Definition
| 0 (absent) - No pulse is felt despite extreme pressure. 1+ (Thready pulse) - Pulsation is not easily felt, and slight pressure causes it to disappear. 2+ (Weak Pulse - Stronger than a thready pulse; light pressure causes it to disappear. 3+ (Normal pulse) - Pulsation is easily felt, takes moderate pressure to cause it to disappear. 4+ (Bounding pulse) - The pulsation is strong and does not disappear with moderate pressure |
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Term
| If unable to palpate pulse, describe alternate method of assessing a pulse (whom would you notify?). |
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Definition
| You can either assess the pulse by measuring the apical value using a stethoscope or assess it using doppler ultrasound |
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Term
| When must you take a pulse rate for a full minute? |
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Definition
| In cases of poor circulation where the pulse is weak or irregular. |
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Term
| Differentiate between tachycardia and bradycardia |
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Definition
| tachycardia is a rapid pulse of 100 - 180 beats/min with decreased cardiac output. Bradycardia is a lower than normal pulse rate with beats/min of less than 60 |
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Term
| What routes can you use to assess patient pulse? |
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Definition
| radial, brachial, carotid, popliteal, femoral, apical, dorsalis pedis, and posterior tibial. |
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Term
| What is the apical-radial test? |
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Definition
| In cases of poor circulation the apical and radial pulses are assessed simultaneously using a nursing team for the pulse evaluation. The pulse deficit is then measured with the apical value being higher than the radial. The difference between the two gives you the pulse deficit. |
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Term
| When assessing pulse by doppler ultrasound what must you do so that other healthcare professionals responsible for the patient can find the pulse. |
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Definition
| Document the route used to assess the pulse and use a indelible sharpee to mark the spot on the patient where it was found |
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Term
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Definition
| Point of maximal impulse. Apex of heart lies closest to chest wall(5th - 6th intercostal space, midclavicular line) |
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Term
| What is the normal value range for respirations for an adult/elderly person? |
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Definition
| An adult normal range is 12 - 20 respirations/min with an elderly person at 15 - 20 respirations/min. |
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Term
| Why should the patient be unaware that you are taking a respiratory rate? |
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Definition
| The patients awareness will change their normal breathing value. |
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Term
| What factors could affect the respiratory rate of your patient? |
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Definition
| exercise, respiratory and cardiovascular disease, alterations in fluid and electrolyte and acid base balances, medications, trauma, infection, pain, and emotions |
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Term
| What what is the normal BP value for an adult/elderly person? |
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Definition
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Term
| What is the value range for stage 1 and 2 hypertension |
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Definition
Stage 1 is 140-159/90-99
Stage 2 160/100 or greater |
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Term
| What is systolic pressure? |
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Definition
| Maximum pressure exerted on walls of arteries when the left ventricle of the heart contracts |
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Term
| What is diastolic pressure? |
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Definition
| The lowest pressure exerted against the artery walls |
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Term
| Using this equipment do your obtained values get recorded to the nearest odd or even number? |
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Definition
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Term
| What are Korotkoff Sounds? |
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Definition
| A series of sounds heard via stethoscope when BP is being assessed. The 1st clear sound represents systolic pressure and the last clear sound represents diastolic pressure |
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Term
| Describe blood pressure assessment errors that can produce false lows? |
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Definition
1) Applying too wide a cuff
2) Releasing the valve to rapidly
3) Failing to pump the cuff 20 to 30 mmHg above the disappearance of the pulse
4) Viewing the meniscus from above eye level |
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Term
| Describe blood pressure assessment errors that can produce false highs? |
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Definition
1) Using a manometer not calibrated at the zero mark
2) Assessing the BP immediately after exercise
3) Releasing the valve to slowly
4) Viewing the meniscus from below eye level |
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Term
| Describe the procedure to assess the patient for "orthostatic hypotension" |
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Definition
| 1) Have the patient lay supine for 3-10mins then take the 1st reading 2) Have them sit on the bedside with legs dangling for 1-3mins then take second reading. 3) Wait 2-3mins and have the patient stand then take 3rd reading. A 40 beat/min rise in pulse or a decrease of 30mmHg BP is an abnormal finding |
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Term
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Definition
| The difference between systolic and diastolic values |
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Term
| What factors can effect body temperature? |
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Definition
Circadian rhythms
Age and gender
Environmental temperatures |
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Term
| What is the difference between fever and hyperthermia with respect to hypothalamic set point |
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Definition
| The hypothalamic set point is changed with fever but not in the case of hyperthermia |
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Term
| Name some nursing interventions for situations of abnormal body temperature? |
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Definition
1) Monitor temperature as frequently as appropriate
2) Monitor BP, P, & R as appropriate
3) Administer IV fluids as appropriate
4) Monitor intake & output |
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Term
| What factors can effect patients pulse? |
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Definition
Tachycardia
- A decrease in BP due to blood lose
- elevated temp(7-10 beats/min/1 F temp rise
- Poor oxygenation
- Some medications
Bradycardia
- age
- medication
- vagal stimulation
- myocardial infarction |
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Term
| When should you assess vital signs? |
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Definition
1)Upon admission to any healthcare agency
2)Based on agency institutional policy and procedures
3)Any time there is a change in the patient’s condition
4)Before and after surgical or invasive diagnostic procedures
5)Before and after activity that may increase risk
6)Before administering medications that affect cardiovascular or respiratory functioning |
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Term
| How is body temperature regulated in the body? |
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Definition
1)Thermoregulatory center in the hypothalamus regulates temperature
2)Center receives messages from cold and warm thermal receptors in the body
3)Center initiates responses to produce or conserve body heat or increase heat loss |
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Term
| Name sources of heat production in the body? |
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Definition
1)Primary source is metabolism
2)Hormones, muscle movements, and exercise increase metabolism
3)Epinephrine and norepinephrine are released and alter metabolism
4)Energy production decreases and heat production increases |
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Term
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Definition
1)Skin (primary source)
2)Evaporation of sweat
3)Warming and humidifying inspired air
4)Eliminating urine and feces |
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Term
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Definition
| Radiation is the diffusion or dissemination of heat by electromagnetic waves, such as occurs with an uncovered head. |
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Term
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Definition
| Convection is the dissemination of heat by motion between areas of unequal density. |
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Term
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Definition
| Evaporation is the conversion of a liquid to a vapor. |
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Term
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Definition
| Conduction is the transfer of heat to another object during direct contact. |
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Term
| How is pulse regulated in the body? |
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Definition
| Regulated by the autonomic nervous system through cardiac sinoatrial node |
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Term
| How does Parasympathetic stimulation effect heart rate? |
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Definition
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Term
| How does Sympathetic stimulation effect heart rate? |
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Definition
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Term
| How is pulse rate defined? |
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Definition
| number of contractions over a peripheral artery in 1 minute |
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Term
Tell whether the following statement is true or false. The normal pulse rate for adolescents and adults ranges from 60 to 100 beats per minute.
A. True
B. False |
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Definition
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Term
Changes in the rate and depth of inhalation and exhalation are brought about by the inhibition or stimulation of the respiratory muscles by respiratory centers in the medulla and pons.
A. True
B. False |
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Definition
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Term
| How are changes in the rate and depth of breathing activated? |
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Definition
| by impulses from chemoreceptors |
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Term
| What is the most powerful respiratory stimulant with respect to changes in depth and rate of breathing? |
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Definition
| An increase in carbon dioxide |
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Term
What is the cardiac output of an adult with a stroke volume of 70 mL and a heart rate of 80 beats/minute?
A. 5.6 L/min
B. 1.14 L/min
C. 8.75 L/min
D. 1.50 L/min |
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Definition
Answer: A. 5.6 L/min
The cardiac output equals stroke volume x heart rate. It is the amount of blood pumped per minute and averages from 3.5 L/min to 8.0 L/min in a healthy adult |
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Term
| What factors can effect BP? |
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Definition
1)Age, gender, race
2)Circadian rhythm
3)Food intake
4)Exercise
5)Weight
6)Emotional state
7)Body position
8)Drugs/medications |
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Term
| What equipment can you use to assess temperature? |
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Definition
1)Electronic and digital thermometer
2)Tympanic membrane thermometer
3)Glass thermometer
4)Disposable single-use thermometer
5)Temporal artery thermometer
6)Automated monitoring devices |
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Term
| Name some equipment options for assessing BP? |
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Definition
1)Stethoscope and sphygmomanometer
2)Doppler ultrasound
3)Electronic or automated devices |
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Term
| At what sites can the pulse be assessed? |
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Definition
1)Palpating peripheral arteries
2)Auscultating apical pulse with stethoscope
3)Assessing apical-radial pulse |
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Term
Which one of the following pulse sites is located on the inside of the elbow?
A. Temporal
B. Radial
C. Femoral
D. Brachial |
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Definition
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Term
| Methods of assessing respirations are? |
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Definition
1)Inspection
2)Listening with stethoscope
3)Monitoring arterial blood gas results
4)Using a pulse oximeter |
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Term
| What are the most common sites for assessing BP? |
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Definition
| The brachial artery and popliteal artery are commonly used |
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