Module 2 Dr. Hill Flashcards
If a patient is drinking something prior to taking temperature, what temperature should you take and how long should you wait?
Axillary (arm pit) and 30 mins
This is an ABNORMAL finding when assessing the heart and it narrows the blood vessel, creates turbulence, and causes blowing/swishing sound!
Carotid bruit
Should you report a Carotid Bruit to the HCP?
Yes because it is an abnormal finding
When should you use the rectal temperature?
ONLY when other options are not acceptable for the condition of the patient.
Should patients know when you are assessing respirations?
NO
If a patient doesn’t speak your native language (English) what should you do?
Have an interpreter
What should you do if a patient’s radial pulse is abnormal?
Check the apical pulse for one full minute
______ and ______ can cause blood pressure to increase temporarily.
Smoking and cafffeine
What should you give a patient who has fever and is restless?
Oxygen
What should you never assess at the same time?
The carotid arteries
Where do you assess the dorsal pedal pulse?
the top of the foot
Where do you assess the popliteal pulse?
The bend of the knee (back part)
If you are assessing a 2 year old’s tympanic membrane, how do you position the ear?
down and back
What is the normal assessment of pupils when performing an exam?
Pupils clear, equal, round, and reactive to light
What are signs and symptoms of diabetic patients?
Fruity breath
What is the acceptable range for an adult when assessing PULSE RATE?
60-100
What is the normal range for temperature when assessing an adult?
96.8 to 100.4 average 98.6
If a patient is experiencing blood loss, what happens to their heart rate and blood pressure?
Heart rate increases and blood pressure decreases
Does fever increase heart rate?
yes
A _______ heart will have a lower heart rate at rest. And it is NORMAL for them. (football player, people who are active)
Conditioned
What is hypoxemia?
low blood level of oxygen
What is the normal range for an O2 saturation in an adult?
95 to 100 but low is considered less than 90
shallow breathing can cause what?
pneumonia
Pulse pressure needs to be between ___ to ___
40 to 60
How do you calculate pulse pressure?
By subtracting the systolic and diastolic pressure
this is less than 12 breaths/min
bradypnea
this is less than 60 beats/min
bradycardia
this is more than 22 breaths/min, theyre breathing fast
tachypnea
hypoventilation is when respiratory rate is abnormally ___ and depth is depressed
low
hyperventilation is when the rate and depth of respirations _____
increase
This is when respirations stop for several seconds
apnea
A normal blood pressure for an adult is ….
less than 120/80
atherosclerosis is when fatty deposit is built up in artery and what can it do to pulse pressure?
increase
An O2 saturation of less than 86 should be assessed when?
first
what do opiod analgesics cause peoples respirations to do after they have taken them?
Decrease in respiration
What is a reading for a patient who is PRE HYPERtensive?
systolic 120 to 139 and diastolic 80 to 89
What is a reading for a patient who is Stage 1 HYPERtensive?
systolic 140 to 159 and diastolic 90 to 99
What is a reading for a patient who is Stage 2 HYPERtensive?
systolic greater than or equal to 160 and diastolic greater than or equal to 100
Can UAP’s ambulate patients if they are being discharged home?
Yes
If a patient was having respirations of 8 breaths/minute what would be needed?
Immediate follow-up
Can a UAP perform vital signs on a stable patient?
Yes
What are some UAP duties?
Raise head of bed, empty urinal, place patient on a bed pan, feed patients, report any unusual observations, assist the RN or LPN, ambulate patients being discharged
If a patient is experiencing dyspnea, what position do you place them in?
Semi-Fowlers
What should the nurse do if the UAP gets abnormal blood pressure reading?
Follow up and do their own assessment
What is the position you should place your patient in for a vaginal exam?
Lithotomy
pyrexia means…
fever
afebrile means…
they do NOT have fever
Hypertension is more or less common than hypotension?
more common
_____ elevate body temperature
pyrogens
Pain increases/decreases blood pressure, heart rate, and respiratory rate
INCREASES
If a patient does not have insurance, how much oxygen can you give them for free?
2 liters
Tachypenic means they are breathing too slow/fast?
fast
What does an antipyretic do? Like acetaminophen
Temperature reducer
Does body weight have an effect on temperature? If so, how or why?
Yes because as people get older, they lose sub-q tissue.
How long should you wait to retake blood pressure?
2 to 3 minutes
The best site to obtain a body core temperature is…
rectal
This process occurs when heat loss mechanisms are unable to keep up with EXCESS HEAT production…
fever
An abnormally elevated body temperature greater than 101.5
Hyperthermia
You cannot give ____ to children because it causes a condition called ryes syndrome
aspirin
This is when your body temperature is less than 95
Hypothermia
For the elderly population this range of temperature is normal….
95-97
Capillary refill needs to be
less than 3 seconds
Why do we use a lateral downward position when assessing the thorax?
It provides a full expansion of the lungs
What are lung sounds called that are high pitched and musical? This is an ABNORMAL lung sound
Wheezing
this lung sound is NORMAL soft, breezy, and low pitched (created by air moving through small airways)
vesicular
This is a NORMAL lung sound that is blowing sounds that are medium pitched (air moving through large airways)
bronchovesicular
This is a NORMAL lung sound that is high-pitched w/ hollow quality (air moving through trachea, close to chest wall)
Bronchial
This is an ABNORMAL lung sound that is lung bases and does not clear with cough.
Crackles or rales
This is an ABNORMAL lung sound that is cleared by cough and is a sonorous wheeze
Rhonchi
This is an ABNORMAL lung sound that is a dry or grating and rubbing sound
Pleural friction rub
This is when fluid gets outside the vessel
peripheral edema
Vital signs are before or after the general survey?
after
what is bleeding under the skin called?
petechiae
Bleb or Wheal is ______ under the skin to see if you have a reaction to it. (TB test)
medicine
Skin that is indented 6 mm / +3 is what type of edema?
Moderate pitting edema
This is when Blood Pressure DROPS because a client changes positions from lying to sitting, or standing or from peripheral vasodilation, medication adverse effect, fluid depletion, or anemia.
orthostatic hypotension
Dizziness, weakness, and fainting are signs and symptoms of what?
orthostatic hypotension
If a patient is clubbing that indicates
respiratory problems
An orthostatic hypotension patient should or should not be delegated?
SHOULD NOT
How do you perform an assessment on a patient with orthostatic hypotension?
place patient in sitting position if dizzy, obtain in supine, sitting, and standing, check 1 to 3 minutes apart
Use oxygen cautiously in COPD patients because they can develop oxygen toxicity and high carbon dioxide levels called
hypercapnia
What are some indications of an increased heart rate?
PAIN LEVEL OF 10!!! , running, fever, climbing up stairs
What is done to assess the postoperative circulation of the lower extremities
dorsal pedal pulse
what are the signs and symptoms of fever?
oxygen consumption rises, heart and respiratory rates increase, sweating, chills and shivering, headaches, muscle aches.
what are some signs and symptoms of poor skin turgor?
skins stays pinched or indented or moves back slowly
