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skills exam 2 Flashcards

1
Q

What is the normal range for temperature?

A

96.8F-100.4F (36C-38C)

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2
Q

What is the normal range for heart rate?

A

60-100 BPM

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3
Q

What is the normal range for respirations?

A

12-20 breaths per min

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4
Q

What is the normal range for blood pressure?

A

> 90/60-<120/80

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5
Q

What are the normal findings for SpO2?

A

≥94%

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6
Q

What are the six vital signs?

A 
Heart rate
Temperature
Respirations
Blood pressure
Oxygen saturation
Pain
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7
Q

What controls temperature in the body?

A

The hypothalamus

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8
Q

What is the medical term for fever?

A

Pyrexia

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9
Q

What are the most common temperature measurement sites?

A 
Oral
Temporal
Tympanic (ear)
Rectal
Axillary (armpit)
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10
Q

When are vital signs taken?

A
  • On admission to a healthcare facility
  • During home care visits
  • Before a provider examines the patient and after any invasive procedures
  • In a hospital on a routine schedule according to standards of practice or provider’s order
  • Before, during, and after blood transfusion
  • Before, during, and after surgery or invasive diagnostic/treatment procedure
  • Before, during, and after administrating medication/therapies that can affect vitals
  • When a patient’s condition changes
  • Before, during, and after nursing interventions
  • When a patient reports nonspecific symptoms of physical distress
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11
Q

What is tachycardia?

A

Elevated HR (>100 bpm)

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12
Q

What is bradycardia?

A

Slow HR (<60 bpm)

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13
Q

What do you do if the pulse is irregular?

A

Auscultate the apical pulse for 1 minute

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14
Q

How do you find the apical pulse?

A
  1. Have the patient sit or lay down
  2. Find the sternal notch, located in between the clavicles
  3. Find the angle of louis, right below the sternal notch
  4. Move your hand slightly to their left side, and begin to count intercostal spaces (begin at space #2)
  5. Once you find the fifth intercostal space, move your hand so that it is midclavicle
  6. Place the diaphragm of your stethoscope in this location, place firmly and securely on chest
  7. Each “lub-dub” is one beat, count for 60 seconds to determine accurate heart rate
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15
Q

What can cause an oral temperature to be inaccurate?

A
  • If the patient consumes food/fluid

- If the patient is receiving oxygen

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16
Q

What is diaphoresis?

A

Visible perspiration

17
Q

What is blood pressure measured in?`

A

mm Hg (millimeters of mercury)

18
Q

What is systolic pressure?

A

The top number, force of contraction, the first sound you hear

19
Q

What is diastolic pressure?

A

The bottom number, the relaxation/filling phase of heart cycle, the last sound you hear

20
Q

How much will the systolic reading change for a lower extremity?

A

10 mmHg or more (because of gravity)

21
Q

When should you avoid using an extremity to take blood pressure?

A

If dressing, cast, peripheral IV, or fistula is present

22
Q

When is pain considered chronic?

A

Pain that lasts longer than 3 to 6 months

23
Q

What are six descriptors for pain?

A

Dull, aching, throbbing, sharp, stabbing, burning

24
Q

What is the maximum 24 hour dose for Tylenol?

A

4 grams per 24 h in a healthy individual, 3 grams in an older adult or a patient with liver disease

25
Q

What is the generic name for Tylenol?

A

Acetaminophen

26
Q

What are three NSAIDS?

A

Aspirin, ibuprofen, and naproxen

27
Q

What does NSAIDS mean?

A

Non-steroidal anti-inflammatory drugs

28
Q

What are two risks with NSAIDS?

A

Increases gastrointestinal irritation
Can reduce blood flow to the kidneys and cause kidney related issues, avoid giving NSAIDS to older adults (they already have decreased kidney function)

29
Q

What is a risk with Tylenol?

A

Can cause hepatotoxicity (liver toxicity)

30
Q

What does a nurse need to assess before and after administering opioids?

A

Vital signs before and after: HR, BP, RR, O2
Pain level
Mental status

skills exams (7 decks)

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