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EPCC Nursing Foundations > Normal Ranges for Vitals Signs / ATI / EOCHQ > Flashcards

Normal Ranges for Vitals Signs / ATI / EOCHQ Flashcards

1
Q

Normal body temp for adults

A

36 - 37.5 Celsius // 96.8 - 99.5 Farenheit

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2
Q

Normal beats per minute (pulse for adults)

A

60 - 100 BBM

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3
Q

What are the phases of Korotkoff sounds?

A

1 = faint, clear, tapping (systolic)
2 = muffled, wooshing, swishing
3 = blood flows freely
4 = muffled, soft, blowing
5 = pressure level when last sound is heard (diastolic)

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4
Q

Normal blood pressure

A

120 / 80

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5
Q

What is the apical pulse valve called?

A

Mitral valve and is refereed to as the Point of Max Impulse (PMI)
Apical pulse = apex

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6
Q

Where can you find the apical pulse?

A

LEFT of the sternum palpate to 5th intercostal space. Move finger to MCL (midclavicular line)

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7
Q

Normal breathing (respiration) rate

A

12 -20 breaths per min

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8
Q

Where are the pulse sites on the body?

A
  1. Radial - peripheral
  2. Brachial
  3. Carotid
  4. Femoral
  5. Popliteal
  6. Posterior tibial
  7. Dorsalis pedis
    - Peripheral = ankle or wrist
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9
Q

Normal oxygen levels

A

95% - 100%

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10
Q

Normal range of Mean Arterial Pressure (MAP)

A

70 - 110 mmHg

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11
Q

Normal pulse pressure

A

40 mmHg

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12
Q

Normal rectal / tympanic temperature

A

0.5 - 1 higher than oral temp

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13
Q

Normal axillary temp

A

0.5 - 1 LOWER than oral temp

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14
Q

A nurse is preparing to measure a clients vital signs. The nurse should identify that which of the following factors will affect the methods that are used?

A

The client reporting a stuffy nose
The client taking digoxin for an irregular Heart Beat
The client had a mastectomy 2 years ago

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15
Q

A nurse assessing a clients respiration. Which of the following actions should the nurse take?

A

Elevate the head of the clients bed to 45 - 60 degrees

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16
Q

A nurse is preparing to auscultate a clients apical pulse at the point of max impulse. Which of the following locations should the nurse position the stethoscope?

A

Over the fifth intercostal space at the left midclavicular line

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17
Q

A nurse is obtaining a clients vital signs. The client has a new onset of a temp. 39 degrees Celsius or 102 degrees F. Which of the other vital signs should the nurse expect?

A

An elevated pulse rate - a fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate.

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18
Q

A nurse is preparing to record the difference between a clients systolic and diastolic blood pressure. Which of the following terms defines this info when documenting?

A

Pulse pressure

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19
Q

A nurse is taking an adult clients temp rectally. Which of the following actions should the nurse take?

A

Insert the probe about 2.5 cm (1 - 1.5 in) into the clients anus.

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20
Q

A nurse is obtaining a clients BP and notices a pressure reading on the manometer when listening to the 4th Korotkoff sound. Which of the following factors does this pressure reading correlate to?

A

It might not follow with a 5th K sound

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21
Q

A nurse is collecting data about a clients respiratory condition. Which of the flowing actions should the nurse take to determine the depth of the clients respiration?

A

Observe the degree of chest wall movement during inspiration and expiration

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22
Q

A nurse is auscultating a clients apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs?

A

When the semilunar valves close

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23
Q

A nurse is establishing a baseline for a clients respirations. Which of the following actions should the nurse take?

A

Observe the clients chest movements while appearing to assess their pulse

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24
Q

A nurse is obtaining VS from a client. Which of the following findings is the priority for the nurse to report to the provider?

A

Respirations of 30/min - this is above the expected reference range of 12 - 20/ min. and indicates for immediate attention. The pt is experiencing SOB, or dyspnea. This could become a life threatening situation without intervention.

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25
Q

A nurse is preparing to use a tympanic thermometer to acquire a clients temp. Which of the following should the nurse take to ensure an accurate reading?

A

Pull the pinna up and back

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26
Q

A nurse is measuring a clients temp orally. Which of the following actions should the nurse take?

A

Place the probe in the posterior lingual pocket lateral to the midline

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27
Q

What are the phases of a fever?

A
  1. Onset (Cold or Chill phase)
  2. Course (Plateau phase) {Malaise, achy muscles, weakness}
  3. Defervescence (Fever abatement and flush phase) {Breaking a fever = dehydration and sweating}
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28
Q

What is the body temperature during a heat stroke?

A

41.1 Celsius or 106 F or higher

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29
Q

What is the body temperature during HYPOthermia?

A

less than 36 C or 96.8 F

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30
Q

What is bradycardia?

A

Less than 60 BPM

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31
Q

What is tachycardia?

A

Greater than 100 BPM

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32
Q

How quickly do you release the BP valve so that the pressure decreases?

A

2 - 3 mmHg per second

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33
Q

After the brachial pulse disappears, how much higher do you pump the BP cuff to?

A

30 mmHg above the point where the brachial pulse disappears

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34
Q

What is the systolic and diastolic BP for stage 1 hypertension?

A

130 -139 (systolic)
80 - 89 (diastolic)

35
Q

What is the systolic and diastolic BP for stage 2 hypertension?

A

Greater than 140 (systolic)
Greater than 90 (diastolic)

36
Q

What is the BP for hypertensive crisis?

A

Higher than 180 (systolic)
Higher than 120 (diastolic)

37
Q

Normal ranges for VS

A

Temp - 96.8 - 99.5
HR - 60 - 100 BPM
RR - 12 -20
BP - 120/80
O2 - 95 - 100

38
Q

Describe the ranges on the numeric pain scale

A

1-3 = mild
4-6 = moderate
7-10= severe

39
Q

When do you take VS?

A

Before and after surgery
When the pt has SOB (change in health status)

40
Q

Pain typically increases which two VS?

41
Q

This is the most frequently used method to estimate core body temperature

42
Q

Surface temperature is effected by the _______________.

A

Environment

43
Q

Core temperature is a measure of

A

The temperature of the deep tissues of the body

44
Q

Factors that affect the body’s heat production are

A

*Basal metabolic rate (rate of energy usage)
*Muscle activity (shivering)
Thyroxine output
Epinephrine (stress)
Fever

45
Q

Which is more accurate core temperature or surface temperature?

46
Q

Rectal and tympanic (ear) temperature are ____-____ higher than oral temperature.

47
Q

A pt who falls in an icy lake will experience ____________ heat loss

A

Conduction (most serious type of heat loss)
[The body loses heat 25x faster in cold water]

48
Q

Describe the 4 types of heat loss

A

Radiation - infrared rays
Conduction - when skin is subject to cold water
Convection - normal heat loss
eVAPORation - sweat/ insensible water loss

49
Q

Factors that affect body temperature

A

Age
Circadian rhythms
Exercise
Hormones
Stress
Environment

50
Q

The part of the brain that regulates temperature is the_____________.

A

Hypothalamus

51
Q

Malaise, weakness, and aching muscles occur in this phase of a fever

A

Course or plateau phase

52
Q

Dehydration and sweating (breaking a fever) occur in this phase of a fever

A

Defervesces

53
Q

A hyperpyrectic fever is __________F and can cause ___________ to the brain

A

105.8 F
Damage

54
Q

Heat exhaustion and heat stroke are not a fever

55
Q

Hypothermia or frostbite most commonly occurs in these places of the body

A

Hands
Feet
Nose
Ears

56
Q

Who are affected the most by hypothermia?

A

Elderly
Children

57
Q

This place loses heat the most

58
Q

If the pt is dehydrated the pulse will be _____________.

59
Q

The apical pulse is assessed for how long?

60
Q

Describe inhalation

A

Diaphragm contracts
Ribs - up and out
Sternum - down
Thorax enlarges

61
Q

Describe exhalation

A

Diaphragm relaxes
Ribs - down and in
Sternum - in
Thorax - decrease

62
Q

The part of the brain that is considered the respiratory center is the

A

Medulla oblongotta
and Pons

63
Q

List the respiratory retractions

A

Suprasternal
Intercostal
Substernal
Altered chest movements

64
Q

The pulse oximeter can be placed on a pts:

A

Forehead
Finger
Toe
Nose
Ear

65
Q

If the pulse ox is 70% this means ______

A

Life threatening

66
Q

The difference between the systolic and diastolic BP numbers is called

A

Pulse pressure

67
Q

Elevated Mean Arterial Pressure (MAP) occurs in pts with _________ and _________

A

Arteriosclerosis and cardiovascular disease

68
Q

Low pulse or MAP pressure occurs in pts in

A

Severe heart failure

69
Q

MAP measures what?

A

Pressure delivered to the body’s organs

70
Q

During inhalation the sternum moves

A

Sternum - down

71
Q

During exhalation the sternum moves

A

Sternum - in

72
Q

A pt with a BP reading 130-139 / 80-89 has which type of hypertension?

73
Q

A pt with a BP reading above 140 / 90 has which type of hypertension?

74
Q

A pt with a BP reading over 180 / over 120 has which type of hypertension?

A

Hypertensive crisis

75
Q

Factors associated with HTN are:

A

Smoking
Obesity
Sedentary lifestyle
Thick arterial walls

76
Q

If a Pt does not have arms, you must take their BP at this place on their body

A

Upper thigh or below their calf

77
Q

To assess for orthostatic hypotension, what are you checking for?

A

Drop in BP 20 mmHg (systolic)/ 10 mmHg (diastolic) and an increase of pulse by 20 beats/ min

78
Q

How will a small BP cuff affect BP readings

A

It will read falsely high

79
Q

How will a big BP cuff affect BP readings

A

It will read falsely low

80
Q

After phase 5 of the Korotkoff sounds (pressure level when the last sound is heard), how long do you wait to make sure there is no further noise?

81
Q

Before administering digoxin, you must check which VS

82
Q

Why would digoxin be administered?

A

To treat an irregular heart beat or heart failure

83
Q

If heart rhythm is irregular, you must asses the pt for _______ seconds

84
Q

Factors that alter pulse rate are

A

Medications affecting HR (digoxin)
Emotional status
Activity level
Beta blocker
Calcium channel blocker

EPCC Nursing Foundations (43 decks)

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