C 29 Flashcards
What is the least invasive and most accurate method of obtaining core temperature?
Measuring the temporal artery
Measurement of vital signs includes:
Physiological measurement of temperature, pulse, BP, respirations, and oxygen saturation
Respiration assessment includes determination the effectiveness of:
Ventilation, perfusion, and diffusion
What variables can affect oxygen saturation?
Ventilation, perfusion, and diffusion
Hypertension is diagnosed when:
The average of two or more subsequent readings reveal an elevated BP
A PT with diabetes admitted for community acquired pneumonia had a temperature of 100.8 via temporal artery. Which additional assessment needed in planning intentions for the pts infection?
Heart rate, presence of diaphoresis, respiratory rate, pts normal temp
A PT was admitted to a surgical unit after repair of a fractured left arm and leg. She a,do has a laceration on her forehead. An IV line is infusing in the right antecubital fossa, and pneumatic compression stockings ate on the right lower leg. Se is receiving oxygen via a face mask. What sites do you instruct the NAP to use for obtaining pts BP and temp?
Right popliteal and right axillae
A PT is receiving oxygen via 4 L nasal cannula. His respiratory rate is 26 breath/min, and his oxygen saturation is 92%. Which information is most helpful I’m determining your priority nursing interventions?
Baseline vital signs
A PT nots that she feels her heart “racing” in the later morning, early afternoon, or just before she goes to bed. Her radial pulse is 68 beats/min and regular; her BP is 134/82. What addition information is helpful in evaluating the pts racing heart rate?
Dietary habits and medication list
The pts BP range over the past 24 hours is 134/64 to 126/72. The student used a BP cuff that was too narrow for the PT. Which of the following BP readings made by the student is most likely caused by the incorrect choice in cuff?
156/82
Why would you remove nail polish from a 19 year old with severe asthma while obtaining the oxygen saturation?
Nail polish interferes with sensory function
Which of the following pts is most at risk for techypnea?
PT just admitted with 4 rib fractures
Woman who is 9 months pregnant
A PT returns to your post operative care following surgery for right shoulder rotator cuff repair. The LNP reports that she had difficulty obtaining the pts hr from his right radial pulse. What is your best response?
Perform a complete assessment of all pulses
