Chapter 11

Question 1

Checking for vital sigs is an example of which phase of nursing process?

Answer 1

ASSESSMENT

Question 2

what is the procedure to check apical radial pulse?

Answer 2

• Auscultate the apical pulse at the left 4 or 5th intercostal space for one full minute while ANOTHER nurse feels for the radial pulse at the same time.

Question 3

what is tachycardia?

Answer 3

Pulse above 100.

Caused by shook, acute pain.

Question 4

calculate the pulse pressure of 150/90

Answer 4

60

Question 5

what are the signs of dyspnea

Answer 5

difficulty breathing manifested by labored breathing, flared nostrils and short of breath. (pursed lip breathing)

Question 6

define eupnea

Answer 6

regular breathing

Question 7

what is bradypnea

Answer 7

respiration below 10.

Slow, resp rate

Question 8

what is apnea

Answer 8

not breathing

Question 9

what is the normal range for the following

Tempreture
pulse
respiration
BP-

Answer 9

Temperature : 97-99.6
pulse : 60-100
respiration: 12-20
BP - 
Adult 18 and above: 100-120/ 70-80
older adult: 130-140 / 90-95
Pre hypertension: 120-139 /80/89
Hypertention. > 140/ > 90

Question 10

when is it appropriate to use the tympanic method to check the temperature

Answer 10

if you cannot check it orally or rectally - rectal surgery, seizure, precautions, unconscious etc.

Question 11

what is the most common site for checking the pulse or heart rate

Answer 11

RADIAL

Question 12

where is dorsals pedis pulse located?

Answer 12

top of the foot

Question 13

what is the purpose of checking the dorsals pedal pulse?

Answer 13

to assess blood flow to the foot

Question 14

how long would you count a pulse?

Answer 14

30 seconds and then multiply by 2.

Question 15

while counting pulse- the nurse notices that the pulse is irregular, what is the nurses best action?

Answer 15

count for one full minute

Question 16

a cuff that is too tight or small will give what kind of reading?

Answer 16

high reading.

Question 17

a cuff that is too big will give what kind of reading?

Answer 17

low reading

Question 18

what is the order in taking VS

Answer 18

tempreture
pulse
respiration 
BP
pain

Question 19

define hyperventilation

Answer 19

increase in the volume and depth of respiration

Question 20

chyene stokes respiration -

Answer 20

alternating period of apnea and deep rapid breathing

Question 21

kussmaul-

Answer 21

rapid, deep and labored

Question 22

dysthymia-

Answer 22

irregular pulse

Question 23

what are the conditions that would prevent you from taking BP in one or both arms?

Answer 23

IV infusing in antecubital fossa (ELBOW JOINT), wounds, lower arm casts, traumatized diseased arm, arteriovenous shunt, breast or axilla surgery.

Question 24

what are the guidelines for assessing respiration

Answer 24

head of the bed elevated
obtain respiration at the same time as the pulse
if patient was active, wait 5-10 mins.

Question 25

an increase in temperature can cause an increase in what other vital signs

Answer 25

increase in pulse, increase in respiration, increase in BP

Question 26

contraindications for rectal temperature

Answer 26

rectal surgery
hemorrhoids
traction
condition of periunem
low platelet count
neutropenic precautions.

Question 27

;; mine ;; what means increase in tempreture?

Answer 27

pyrexia/ febrile/ hyperthermia

Question 28

;; mine ;; signs of systemic infection

Answer 28

thirst, anorexia, headache and chills