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Knowledge and Skills for Adult Nursing > Observations > Flashcards

Observations Flashcards

- Recording Temperature: Disposable thermometers - Recording Temperature: Tympanic thermometers - Recording Temperature: Electronic thermometers - Assessing the Pulse - Assessment of Respiration - Measuring Blood Pressure Parts 1, 2 and 3 - Pulse Oximetry - Urine Testing: Observation - Urine Testing: Urinalysis - Assessing and measuring fluid balance

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1
Q

What is is the standard core temperature?

A

37 degrees c

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2
Q

Should you use the same or different method when calculating multiple temp readings from one patient?

A

the same

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3
Q

What is the standard oral temperature?

A

36.8 degrees

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4
Q

What is another word for fever?

A

Pyrexia

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5
Q

What is pyrexia?

A

a fever (abnormally high temp)

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6
Q

Why does the body become pyrexic?

A

raises the bodies’ thermoregulatory point in order to fight infection

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7
Q

How many minutes should you wait before taking the temp of patient who has eaten/drunk hot/cold food?

A

20/30 mins

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8
Q

why should you wait 20-30 min taking the temp of patient who has eaten/drunk hot/cold food?

A

It could distort the reading

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9
Q

What should you gain before taking a patient’s temp?

A

their consent

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10
Q

Before opening a disposable thermometer what should you do?

A

decontaminate hands

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11
Q

What should you check before opening disposable thermometer?

A

it’s expiry date

any perforations in the packaging.

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12
Q

When taking temperature orally, where should you place the disposable thermometer?

A

in the sublingual heat pockets.

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13
Q

How long should you keep a disposable thermometer in the patient’s mouth?

A

1 minute

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14
Q

What is the axillary route?

A

under the arm

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15
Q

when taking temp via the axillary route, where should you place the disposable thermometer?

A

vertically, aligning the spine

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16
Q

how long should you leave the disposable thermometer via the axillarry route?

A

3 minutes

17
Q

How does a tympanic thermometer measure temperature?

A

measures reflected infrared emissions from the tympanic membrane

18
Q

When should you not use the tympanic method for taking temperature?

A

if the patient complains of earache or ear discharge

19
Q

If the patient has hearing aids, how long should you wait before taking a tympanc temperature?

A

10 minutes

20
Q

why should you pull back the ear prior to inserting the tympanic temp probe?

A

to straighten the ear canal

21
Q

which ear should you use for a tympanic reading?

A

use both and take the highest value

22
Q

what routes can be used for electronic thermometers?

A

oral
axillary
rectal, when using an appropriate probe cover

23
Q

when using a disposable thermometer, which routes provides the lower temperature?

A

axillary route

24
Q

what’s the temp difference between taking a disposable temp via the axillary and oral route?

A

approximate 0.6 degrees

25
Q

What is the normal range of heart rate for adolecents to adults?

A

60-115

26
Q

when assessing capillary refill, how long should you expect the finger to flush red in a healthy individual?

A

about 2secs or less

27
Q

Which artery is most commonly used for pulse palpitation?

A

radial pulse

28
Q

What is urinalysis?

A

involves microbiological, chemical, microscopical and physical examination of freshy voided urine

29
Q

What are the functions of urinalysis?

A

Screening for systemic diseas

Diagonosis

Monitoring

30
Q

What is the normal rnge of pH for urine?

A

4.5-9

31
Q

What are some of the reason s for a high pH?

A

Stale urine samples

UTI

ammonia forming organisms

32
Q

What pH might someone with a UTI have?

A

high/alkaline

33
Q

What pH may someone with diabees ketoacidosis have?

A

low/acidic

34
Q

what is the normal specific gravity range for urine sample?

A

1.002-1.035

35
Q

What may cause a high specific gravity in urine?

A

dehydration

36
Q

How might dehydration affect specific gravty of urine?

A

high values produced

37
Q

What may cause a low specific gravity in urine?

A

high fluid intake, diabetes insipidus, renal failiure.

38
Q

How might renal failiure affect specific gravity of urine sample?

A

Low values produced.

Knowledge and Skills for Adult Nursing (13 decks)

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