exam 1 Flashcards
What are the 6 vital signs measurements?
- Temperature
- Pulse
- Blood Pressure
- Respiratory Rate
- Oxygen Saturation
- Pain
What is the normal range for adult body temperature?
96.8°F - 100.4°F
When should vital signs be assessed?
- On admission
- Per physician order (routine, Q4h)
- Any change in patient’s condition
- Before and after any major procedure
- During blood transfusion
- After medications or interventions that affect vital signs
What is the normal pulse rate for adults?
60-100 beats per minute
What is the normal respiratory rate for adults?
12-20 breaths per minute
What is considered normal blood pressure for adults?
Less than 120/80 mmHg
Fill in the blank: The method of measuring body temperature that is least influenced by external factors is _______.
[Temporal Temperature]
What are the factors affecting body temperature?
- Circadian Rhythm
- Age
- Hormonal Level
- Environment
True or False: Fever is usually not harmful if below 102.2°F.
True
What are the signs and symptoms of hyperthermia?
- Dry, hot skin
- Confusion
- Excess thirst
- Muscle cramps
- Increased heart rate
- Decreased blood pressure
- No sweating
What is the method to convert Fahrenheit to Celsius?
C = (F - 32) x 5/9
What is the radial pulse used for?
Routine vital signs and assessing circulation status to the hand
What should be done if a patient has an irregular radial pulse?
Assess the apical pulse rate for 1 full minute
What is the acceptable range for oxygen saturation?
95% - 100%
What are the consequences of impaired gas exchange?
- Ineffective ventilation
- Reduced capacity for gas transportation
- Inadequate perfusion
What is the normal mean arterial pressure (MAP) range?
70 to 100 mmHg
How do you calculate mean arterial pressure (MAP)?
MAP = (2 x DBP + SBP) / 3
What are the symptoms of hypotension?
- Skin mottling
- Clamminess
- Confusion
- Increased heart rate
- Decreased urine output
What is the primary purpose of recording blood pressure?
To assess the force exerted against blood vessels by the blood
Fill in the blank: The process of transporting oxygen into cells and carbon dioxide out of cells is called _______.
[Gas Exchange]
What should be documented for a normal respiratory assessment?
Respirations 18, regular and unlabored, pulse ox reading 98%
What should be done for a low blood pressure reading?
- Check oxygen saturation
- Provide fluids
- Educate patient to call when getting up
- Place patient in Trendelenburg position
What is the typical pulse pressure measurement?
The difference between systolic and diastolic pressure
List the temperature assessment sites.
- Oral
- Rectal
- Axillary
- Tympanic membrane
- Temporal artery
True or False: Blood pressure can be influenced by medications.
True
How is Mean Arterial Pressure (MAP) calculated?
MAP = (2 × diastolic + systolic) / 3
MAP provides an average blood pressure in a person’s arteries during one cardiac cycle.
What is the normal range for Mean Arterial Pressure (MAP)?
70 to 100 mmHg
MAP is considered crucial for assessing perfusion to organs.
If a patient has a blood pressure of 140/90, what is the Mean Arterial Pressure (MAP)?
107
The calculation is (2 × 90 + 140) / 3 = 107.
What does the ‘P’ in the PQRST mnemonic for pain assessment stand for?
Provokes/Palliates
This helps identify what makes the pain worse or better.
What does the ‘Q’ in the PQRST mnemonic for pain assessment stand for?
Quality
This refers to the type or nature of the pain experienced.
What does the ‘R’ in the PQRST mnemonic for pain assessment stand for?
Region/Radiation
This indicates where the pain is located and if it spreads to other areas.
What does the ‘S’ in the PQRST mnemonic for pain assessment stand for?
Severity and Setting
This assesses how bad the pain is and under what circumstances it occurs.
What does the ‘T’ in the PQRST mnemonic for pain assessment stand for?
Timing
This involves understanding when the pain occurs and its duration.
On a scale of 0-10, what does a score of 0 represent?
No pain
This scale is commonly used to assess pain intensity.
On a scale of 0-10, what does a score of 10 represent?
Worst pain
This is used for patients to express their maximum pain level.
What should a nurse do before procedures regarding pain?
Assess pain and medicate if available
Pain assessment is critical to ensure patient comfort.
How often should pain be reassessed after medication is given?
At least 30 minutes
This allows for monitoring the effectiveness of pain relief.
What is the nurse’s responsibility regarding vital signs?
Measurement and documentation
Accurate recording is essential for patient care.
What is important to remember about assessing vital signs?
Know the baseline and assure equipment is functional
This ensures accurate readings and effective patient monitoring.
True or False: Vital signs should be taken at the same time every day.
True
Consistency in timing helps track patient changes effectively.
What should a nurse do if vital signs are not within normal limits (WNL)?
Tell someone ASAP
Timely communication is crucial for patient safety.
What are some nursing interventions for managing pain?
Provide pain medications, reduce activity, provide distraction activities
These interventions help manage pain effectively.
What should be documented in the EMR regarding pain?
Values, accompanying symptoms, interventions, follow-up assessment
Comprehensive documentation supports continuity of care.
