Chapter 30: Vital Signs

Question 1

What are Average Temperature Ranges? (In Celsius)

Answer 1

36ºC - 38ºC

Question 2

What are Average Temperature Ranges? (In Fahrenheit)

Answer 2

96.8ºF - 100.4ºF

Question 3

oral/tympanic temp? (In Celsius)

Answer 3

37ºC

Question 4

oral/tympanic temp? (In Fahrenheit)

Answer 4

98.6ºF

Question 5

rectal temp? (In Celsius)

Answer 5

37.5 ºC

Question 6

rectal temp? (In Fahrenheit)

Answer 6

99.5ºF

Question 7

Axillary temp? (In Celsius)

Answer 7

36.5ºC

Question 8

Axillary temp? (In Fahrenheit)

Answer 8

97.7ºF

Question 9

What is the range for a normal pulse rate?

Answer 9

60-100 bpm

Question 10

Normal pulse oximetry

Answer 10

Sp02 greater than or equal to 95%

Question 11

What is the range for normal respiration’s?

Answer 11

12-20 breaths per minute

Question 12

What is an acceptable systolic pressure?

Answer 12

less than 120 mm Hg

Question 13

What is an acceptable diastolic pressure?

Answer 13

less than 80 mm Hg

Question 14

What is an acceptable range for pulse pressure?

Answer 14

30-50 mm Hg

Question 15

How do you calculate the pulse pressure?

Answer 15

Subtract the systolic number from the diastolic number

Question 16

What is the pulse pressure for a Blood pressure that is 120/80?

Answer 16

40

Question 17

What are the 4 patterns of a fever?

Answer 17

Sustained

Intermittent

Remittent

Relapsing

Question 18

Patterns of Fever: What does sustained mean?

Answer 18

a body temp consistently above 38ºC (100.4ºF)

Question 19

Patterns of Fever: What does intermittent mean?

Answer 19

Fever spikes but falls back to normal at least once within 24 hours

Question 20

Patterns of Fever: What does remittent mean?

Answer 20

Fever spikes and falls but does not return to acceptable temperatures.

Question 21

Patterns of Fever: What does relapsing mean?

Answer 21

Periods of fever episodes and normal temperatures that lasts longer than 24 hours.

Question 22

What are the three classifications of hypothermia?

Answer 22

Mild

Moderate

Severe

Question 23

What are the temperatures for the classification of hypothermia stage: Mild in Celsius?

Answer 23

34ºC-36ºC

Question 24

What are the temperatures for the classification of hypothermia stage: Mild (Fahrenheit)

Answer 24

93.2ºF-96.8ºF

Question 25

What are the temperatures for the classification of hypothermia stage: Moderate (Celsius)

Answer 25

30ºC-34ºC

Question 26

What are the temperatures for the classification of hypothermia stage: Moderate (Fahrenheit)

Answer 26

86.0ºF-93.2ºF

Question 27

What are the temperatures for the classification of hypothermia stage: severe (Celsius)

Answer 27

less than 30ºC

Question 28

What are the temperatures for the classification of hypothermia stage: severe (Fahrenheit)

Answer 28

less than 86ºF

Question 29

What are the advantages of oral temperature sites?

Answer 29

easily accessible accurate surface temperature reflects rapid change in core temperature

Question 30

What are the disadvantages of oral temperature sites?

Answer 30

delay in measurement if patient recently ingested hot/cold fluid, food, smoked, or receiving respiratory intervention.

Question 31

What are the advantages of tympanic temperature sites?

Answer 31

Easily accessible sensitive to core temperatures rapid measurement (2-5 seconds) Unaffected by oral intake Not influenced by environmental temperatures

Question 32

What are the disadvantages of tympanic temperature sites?

Answer 32

inconsistent temperature readings Cerumen impacts reading Not for patients with history of ear/tympanic surgery Does not accurately measure core temperatures changes during or after exercise

Question 33

What are the advantages of rectal temperature sites?

Answer 33

More reliable when oral temperature cannot be obtained

Question 34

What are the disadvantages of rectal temperature sites?

Answer 34

requires a lubricant not for routine vitals on newborns Readings can be influenced by impacted stool

Question 35

What are the advantages of skin temperature sites?

Answer 35

Inexpensive Continuous readings safe and noninvasive used for neonates

Question 36

What are the disadvantages of skin temperature sites?

Answer 36

Reading affected by the environment contraindicated for patients with adhesive allergies

Question 37

What are the advantages of Temporal Artery temperature sites?

Answer 37

easy to use rapid measurement used for infants, newborns, and children reflects rapid core temperature change Sensor not required

Question 38

What are the disadvantages of Temporal Artery temperature sites?

Answer 38

Affected by skin moisture

Question 39

What are the advantages of Axillary temperature sites?

Answer 39

safe inexpensive reliable under stable conditions

Question 40

What are the disadvantages of Axillary temperature sites?

Answer 40

long measurement time measurement lags behind core temperatures during raid temp changes not recommended for detecting fevers Affected by environmental factors underestimates core temperatures

Question 41

What interventions should you perform when a patient has a fever?

Answer 41

obtain blood cultures minimize heat production activities Maximize heat loss by removing covers without inducing shivering Encourage oral hygiene because oral mucus membranes dry easily from dehydration Identify onset and duration of febrile episodes Control environmental temperatures to 21ºC -27ºC (70ºF-80ºF)

Question 42

What are the 10 pulse sites?

Answer 42

``` Temporal Carotid Apical Brachial Radial Ulnar Femoral Popliteal Posterior Tibial Dorsalis Pedis ```

Question 43

What is the location of the Temporal pulse site?

Answer 43

Over the temporal bone of the head, above and lateral to the eye

Question 44

What is the location of the Carotid pulse site?

Answer 44

Along medial edge of the sternocleidomastoid muscle in neck

Question 45

What is the location of the Apical pulse site?

Answer 45

fourth to fifth intercostal space at left midclavicular