Exam 1

Question 1

Average Normal Adult Temp : Oral

Answer 1

36.0 C- 37.6 C (96.8-99.68)

Question 2

Average Normal Adult Temp : Axillary

Answer 2

35.5-37.0 C ( 95.9-98.6)

Question 3

Average Normal Adult Temp: Rectal

Answer 3

34.4 - 37.8 C ( 93.92-100.04F)

Question 4

Average Normal Adult Temp : Tympanic

Answer 4

35.6- 37.4 C (96.08-99.32 F )

Question 5

Average Normal Adult Temp: Temporal

Answer 5

36.1-37.3 ( 96.98- 99.13 F )

Question 6

What are the situations that require vital sign assessments?

Answer 6

1. On admission
2. As part of a physical exam
3. Inpatient stay, as routine monitoring
4. Change in health status, i.e. Chest pain, shortness of breath, feeling hot, faint or dizzy
5. BEFORE and AFTER SURGERY or invasive procedures
6. BEFORE and AFTER administration of meds
7. BEFORE and AFTER ambulation
8. Ongoing care, to detect improvement in patient condition
9. BEFORE DISCHARGE or transfer from unit

Question 7

Vital signs are typically done every _____ for stable patients and _______ for postprocedures or post surgical patients and ______ for critical or unstable patients.

Answer 7

4-8 hours - Stable patient

15-60 minutes- postprocedures or post surgical patients

5 minutes for critical

Question 8

What’s the normal respiration rate for adults?

Answer 8

12-20 bpm

Question 9

Ways of measuring temperature ?

Answer 9

Oral 
Rectal 
Temporal 
Axillary 
Tympanic 
In dwelling

Question 10

What makes temperature abnormal?

Answer 10

Environment, ingestion, technique, metabolic process, disease, injury, and circadian rhythm

Question 11

What’s the proper way of taking someone’s pulse?

Answer 11

Using index and middle finger at arterial pulse point

** NEVER THUMB

Question 12

When would you use a Doppler?

Answer 12

Pulse is difficult to detect, specially pedal pulses

Question 13

What is tachycardia ?

Answer 13

An excessively fast heart rate > 100 bpm in adults

Question 14

What is bradycardia?

Answer 14

Slow heart rate of <60 bpm

Question 15

What’s a pulse deficit?

Answer 15

Results when the apical pulse rate exceeds the radial pulse rate

Question 16

Pulse rate needs to be assessed by?

Answer 16

RATE. RHYTHM. VOLUME

I.e. 76 bpm, regular, normal

Question 17

What makes a respiration abnormal?

Answer 17

Technique, metabolic process, disease, injury, activity, and emotions

Question 18

Assessment of respiration always includes measurements of ?

Answer 18

Rate. Depth. Quality

Question 19

What’s a good measurement of assessing the respiratory component of acid-base balance and adequacy of oxygenation?

Answer 19

ABG’s

Question 20

Orthostatic hypotension occurs when ?

Answer 20

Person moves from supine to sitting or standing position

Question 21

Orthostatic hypotension is measured by?

Answer 21

A decline of 20 mm Hg in the systolic pressure & 10 mm Hg in the diastolic pressure

Question 22

Korotkoff sounds

Answer 22

Sounds which the nurse listens when assessing blood pressure

Question 23

Auscultatory gap

Answer 23

Absence of Korotkoff sounds after the initial systolic pressure

Question 24

Pain is what type of experience for the patient?

Answer 24

Subjective & the intensity and quality of pain are whatever the patient says they are.