140 data collection Flashcards

1
Q

What type of temperature method is used when the normal is: 96.4 - 99.1

A

-Oral
-Tympanic

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2
Q

What type of temperature method is used when the normal is: 97.4- 100.1

A

-Rectal

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3
Q

What type of temperature method is used when the normal is: 95.4-98.1

A

-Axillary

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4
Q

What is the normal temperature for Oral and Tympanic

A

96.4-99.1

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5
Q

What is the normal temperature for Rectal

A

97.4-100.1

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6
Q

What is the normal temperature for Axillary

A

95.4-98.1

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7
Q

What is the normal pulse rate for an Adult

A

60-100 bpm

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8
Q

What is the normal pulse rate for an Infant (birth - 1 year)

A

100-160 bpm

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9
Q

What is the normal pulse rate for a Toddler (1-3 years)

A

90-150 bpm

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10
Q

What is the normal pulse rate for an Preschooler ( 3-6 years)

A

80-140 bpm

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11
Q

What is the normal pulse rate for an School- age child (6-12 years)

A

70-120 bpm

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12
Q

What is the normal pulse rate for an Adolescent (12-18 years)

A

60-100 bpm

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13
Q

What is the normal respiration rate for an Adult

A

12- 20 rpm

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14
Q

What is the normal respiration rate for an Infant (birth- 1 year)

A

30-60 rpm

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15
Q

What is the normal respiration rate for a Toddler (1-3 years)

A

24-40 rpm

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16
Q

What is the normal respiration rate for a Preschooler (3-6 years)

A

22-34 rpm

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17
Q

What is the normal respiration rate for a School-age (6-12 years)

A

18-30 rpm

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18
Q

What is the normal respiration rate for an Adolescent (12-18 years)

A

12-16 rpm

19
Q

What are some clinical situations that would cause the use of the thigh as an alternate BP site

A

-Injury/disease bilaterally on the shoulder, arm or hand
-Dressings or cast on the arm
-IV therapy being administered in the arm
-History of axilla or lymph node surgery in the arm (mastectomy)
-Dialysis access in the arm (Fistula)

20
Q

What is phase 1 Korotkoff sound

A

Systolic reading
(First, faint clear tapping or thumping

21
Q

What is phase 2 Korotkoff sound

A

Sounds have muffled, whooshing, swishing quality

22
Q

What is phase 3 Korotkoff sound

A

Sounds are crisper and more intense

23
Q

What is phase 4 Korotkoff sound

A

Sounds become more muffled and have a soft, blowing quality

24
Q

What is phase 5 Korotkoff sound

A

Diastolic reading
-Last sound is heard, followed by silence

25
Q

What is:
-Associated with reduced peripheral blood flow caused by changes in the pulse wave

A

Oscillatory gap

26
Q

What risk does a nurse take by not finding the Oscillatory gap before taking BP

A

-Inaccurate systolic assessment
-Unneeded compression of the arm which may cause injury

27
Q

What is normal BP for an Adult

A

-Systolic: Less than 120 mmHg
-Diastolic: Less than 80mmHg

28
Q

What is normal BP for a Pediatric

A

-80 + 2x child’s age
-Diastolic will be heard at phase 4 Korotkoff sound

29
Q

What is the range for an Elevated BP

A

Systolic: 120-129
Diastolic: Less than 80mmHg

30
Q

What is the range for Hypertension stage 1

A

Systolic: 130-139
Diastolic: 80-89 mmHg

31
Q

What is the range for Hypertension stage 2

A

Systolic: 140 or higher
Diastolic: 90 or higher

32
Q

What is the range for Hypertensive crisis

A

Systolic: Higher than or 180
Diastolic: Higher than 120

33
Q

What is the first step of the nursing process

A

Assessment

34
Q

What is the second step of the nursing process

A

Nursing diagnosis

35
Q

What is the third step of the nursing process

A

Planning

36
Q

What is the fourth step of the nursing process

A

Implementation

37
Q

What is the fifth step of the nursing process

A

Evaluation

38
Q

What concept is:
-Respiratory and cardiovascular systems work together
-Provides oxygen and nutrients to every cell in the body

A

The concept of perfusion

39
Q

Where do you place the BP cuff on the radial artery

A

On the wrist

40
Q

Where do you place the BP cuff on the brachial artery

A

On the upper arm

41
Q

Where do you place the BP cuff on the Dorsalis pedis artery and posterior tibial artery

A

Midcalf

42
Q

Where do you place the BP cuff on the popliteal artery

A

Above the knee

43
Q

What is associated with:
Reduced peripheral blood flow caused by changes in the pulse wave

A

Oscillatory gap