Skills: Vital Signs

Question 1

Introduction

Answer 1

• Introduce yourself
• Check ID (2 identifiers; DOB & name)
• Explain procedure
• Provide privacy
• Check physician orders

Question 2

Reduces microorganisms

Answer 2

Wash hands and don gloves

Question 3

Promotes efficiency and time management

Answer 3

Gather appropriate equipment

Question 4

Demonstrate knowledge of appropriate time intervals for data accuracy

Answer 4

Verbalize knowledge of frequency of vitals

Once the PT is admitted, per the health care providers notes, and per the nurses judgement if the PT’s condition worsens

Question 5

Reduces transmission of microorganisms

Answer 5

Sanitize, Sanitize, Sanitize

Question 6

Oral Temperature

Ensure accuracy

Answer 6

Question: has the client eaten, drank fluids or smoked within 20-30 min.?

Question 7

Ensure accurate reading

Oral

Answer 7

Effectively applies probe and places thermometer into posterior sublingual pocket and removes after audible signal

Question 8

Reduces spread of microorganisms

Oral

Answer 8

Remove probe from PT’s mouth and toss in trash

Question 9

Rectal

Ensures accurate thermometer placement

Answer 9

Assist PT into Sim’s position (lies on their left side, with right hip and knees bent).
Move bed linens and expose only rectal area

Question 10

Ensure safety, of yourself and the PT

Rectal

Answer 10

Don gloves, remove therm. from charging unit, use red probe

Question 11

Prevents possible rectal perforation

Rectal

Answer 11

Lube probe prior, insert 1.5in into rectum.
Hold therm. until signal
- DO NOT FORCE THERM. -

Question 12

Provide comfort and hygiene

Rectal

Answer 12

Carefully remove probe and toss cover into trash

- Clean area of lube and possible feces

Question 13

Reduces spread of microorganisms

Rectal

Answer 13

Remove and dispose of gloves, wash hands

Question 14

Axillary

Ensure correct therm. placement for accuracy

Answer 14

Assist PT into supine position

Question 15

Maintains proper positioning of temperature probe

Axillary

Answer 15

Place probe in center of axilla, lowers arm over therm., places arm across PT’s chest

Question 16

Reduces spread of microorganisms

Axillary

Answer 16

Remove from axilla, places probe in trash

Question 17

Tympanic

Ensures comfort and exposes auditory canal for accurate reading

Answer 17

Assist PT to a comfortable position with head turned away from nurse

Question 18

Preps unit to measure temp. and reduces spread of microorganisms
(Tympanic)

Answer 18

Slides disposable plastic cover over otoscope until click

Question 19

Ensures correct placement

Tympanic

Answer 19

Gently tugs ear pinna upward and back for adults; down and back for child

Question 20

Ensures correct placement and accurate reading

Tympanic

Answer 20

Fits probe into ear canal snugly. Clicks button and waits for signal when complete

Question 21

Reduces spread of microorganisms

Tympanic

Answer 21

Carefully remove from ear, press eject button to remove speculum into trash

Question 22

Brachial Pulse

Ensure accuracy and prevent nurse from feeling own pulse

Answer 22

Locates groove between biceps and triceps muscle above elbow at antecubital fossa. Place index and middle fingers in groove to locate pulsation

Question 23

Ensures accurate pulse rate

Brachial Pulse

Answer 23

Counts pulse for 15sec x 4, 30sec x 2, or 60sec, using timer. Adjusts technique according to regularity/irregularity of pulse.

Question 24

Ensure accuracy of info/data

Brachial Pulse

Answer 24

Records pulse rate, rhythm and volume/strength.

Question 25

Apical Pulse

Ensure correct placement for accurate auscultation

Answer 25

Locates pulse by placing stethoscope on chest at PMI

Question 26

Provides accurate rate and identifies abnormalities

Apical Pulse

Answer 26

Counts pulse for 1 full min. and evaluates rhythm

Question 27

Radial Pulse

Ensures nurse is feeling PT’s pulse and not their on

Answer 27

Locates radial pulse by placing tips of index and middle fingers over radial artery, and applies light but firm pressure until palpated

Question 28

Ensures accurate pulse rate data

Radial Pulse

Answer 28

Counts pulse for 15sec x 4, 30sec x 2, or 60sec, using timer. Adjusts technique according to regularity/irregularity of pulse.

Question 29

Ensure accuracy of info/data

Radial Pulse

Answer 29

Records pulse rate, rhythm and volume/strength.

Question 30

Blood Pressure

Facilitates locating the brachial artery and ensures accuracy

Answer 30

Removes clothing of upper arm, positions arm at heart level extended with palm supine

Question 31

Places cuff at best position for occluding blood flow through the brachial artery
(Blood Pressure)

Answer 31

Places cuff around upper arm so that inflatable bag is centered over the brachial artery. The lower edge of the cuff should be 1-2in above antecubital

Question 32

Provides approx. systolic assessment

Blood Pressure

Answer 32

Palpates radial artery and inflates cuff. Notes the point on gauge at which the radial pulse is obliterated

Question 33

Avoids auscultatory gap that may provide an incorrect reading
(Blood Pressure)

Answer 33

Palpates the brachial artery and places the stethoscope bell over it. Re-inflates cuff to 30 mm Hg above where the radial pulse was obliterated

Question 34

Determines diastolic pressure

Blood Pressure

Answer 34

Slowly releases air, so that mercury falls at a rate of 2-3 mm Hg per sec. Notes when a distinct soft muffling sound is heard or no sound is heard

Question 35

Ensures accurate data

Blood Pressure

Answer 35

Records systolic and diastolic BP.

Question 36

Respirations

Client will be unaware of being watched and will discourage control of breathing during assessment

Answer 36

While fingertips are in place after counting pulse rate, observes clients respirations

Question 37

Determines respiratory rate per min

Respirations

Answer 37

Notes each rise and fall of clients chest as breathing occurs

Question 38

Ensures accuracy of data

Respirations

Answer 38

Counts pulse for 15sec x 4, 30sec x 2, or 60sec, using timer. Adjusts time according to normal or abnormal breathing patterns