Chapter 28—Vital Signs

Question 1

when to assess VS

Answer 1

On every admission, every office visit
Before & after procedures/interventions
Anytime there is a change in status
Before d/c

Question 2

normal temp oral

Answer 2

98.6 to 99.5 F

36 to 37.5 C

Question 3

VS

Answer 3

temp
HR
RR
BP
O2
pain

Question 4

2 types of body temp

Answer 4

surface

core

Question 5

________ regulates temp

Answer 5

hypothalamus

Question 6

URGENT temp assessment

Answer 6

<95 F or 35 C

>103.1 F or 39.5 C

Question 7

5 temp routes

Answer 7

oral
axillary
tympanic
temporal (TAT)
rectal

Question 8

safest but least accurate temp reading

Answer 8

axillary

Question 9

preferred temp route for newborns

Answer 9

axillary

Question 10

rectal temp is taken if pt…

Answer 10

is comatose, confused, having seizures, or unable to close the mouth

Question 11

insert rectal thermometer ____ into anus

Answer 11

1.5”

Question 12

leave axillary thermometer in for ___ mins

Answer 12

10

Question 13

rectal temp is ____ higher than oral temp

Answer 13

0. 7 to 1 F

0. 5 C

Question 14

axillary temp is _____ lower than oral temp

Answer 14

1 F

0.5 C

Question 15

tympanic temp is _____ higher than oral temp

Answer 15

1. 4 F

0. 8 C

Question 16

TAT temp is a little bit ______ than oral

Answer 16

higher

Question 17

location of apical pulse

Answer 17

5th intercostal space (adult)

midclavicular

Question 18

normal HR for adults

Answer 18

60-100 bpm

Question 19

pulse locations

Answer 19

Apical, temporal, carotid, radial, ulnar, brachial, femoral, popliteal, posterior tibial, dorsalis pedis

Question 20

count for _____ time for apical pulse

Answer 20

1 full minute

Question 21

dehydration effect on pulse

Answer 21

HR increases, then decreases as we lose fluid volume

Question 22

5 things when assessing pulse

Answer 22

Rate
Rhythm
Strength
Elasticity
Symmetry

Question 23

Pulse deficit

Answer 23

difference between apical & peripheral pulse, or 2 peripheral pulses

Question 24

pulse alternans

Answer 24

irregular - strong & weak together

Question 25

pulse bisferiens

Answer 25

double heartbeats - aortic valve regurgitation

Question 26

normal RR

Answer 26

12-20 breaths/min

Question 27

breathing controlled by…

Answer 27

medulla oblongata, pons, carotid and aortic bodies

Question 28

4 things when assessing respiration

Answer 28

Rate (Inspiration and expiration)
Rhythm (Interval between breaths)
Depth (Body position and medications)
Quality (The effort to breathe of sound)

Question 29

SPO2

Answer 29

O2 saturation level

Question 30

normal O2 sat

Answer 30

97%-100%

Question 31

possible emergency O2 sat

Answer 31

<85%

Question 32

how to document doppled or palpated BP

Answer 32

120/doppled or palpated

Question 33

normal BP

Answer 33

110/70 mmHg

Question 34

hypotension

Answer 34

<100 SBP

Question 35

hypertension

Answer 35

> 120 SBP

Question 36

point of maximal impulse

Answer 36

best place to palpate apical pulse

Question 37

mean arterial pressure

Answer 37

the average arterial pressure throughout one cardiac cycle, systole, and diastole

Question 38

finding mean arterial pressure

Answer 38

[2(DBP) + SBP] / 3