Vital Sign Self-Study

Question 1

What are vital signs (V/S)?

Answer 1

Indicators of physiologic functioning that reflect a persons health status (T,P,R,BP)

Question 2

What is the normal range of BP?

Answer 2

120/80

Question 3

What is the normal range of P?

Answer 3

60-100

Question 4

What is the normal range of R?

Answer 4

12-20

Question 5

What is the normal range of T?

Answer 5

96.4 - 99.5

Question 6

What is the normal range of O2?

Answer 6

> 95%

Question 7

How factors affect V/S?

Answer 7

AGE
Biological Sex
Food
Exercise
Weight
Emotional state
Body Position
Race
Drugs/ Medications

Question 8

What is orthostatic blood pressure (BP)?

Answer 8

Results from an inadequate physiologic response to postural changes

-Orthostatic hypotension/postural hypotension is a temporary fall in BP associated with assuming an upright position.

Question 9

What are nursing interventions for patients who have orthostatic BP?

Answer 9

• Rising and moving slowly especially after long periods of bed rest
• First raise the head of the patients bed, than assist to sitting position, on the side of the bed or dangling.
• If pt becomes dizzy or faint, return to sitting position in bed.

Question 10

What is hypertension (HTN)?

Answer 10

Hypertension is one of the most common health problems and is when a persons BP is above normal for a sustained period.
- Systolic is greater than 130 and the diastolic is above 80.

Question 11

What ethnicity is high risk for HTN?

Answer 11

Hypertension is more prevalent in African American and Hispanic adults.

Question 12

What is the physiology of BP in elderly?

Answer 12

Hypertension is more prevalent in African American and Hispanic adults.

Question 13

When there is a consistent inter-arm difference, which arm should be used to measure BP?

Answer 13

the arm with the higher pressure should be used.

Question 14

When is it contraindicated to take BP?

Answer 14

BP assessment should not be taken on arms with intravenous line or with an arteriovenous line or shunt. BP should also be avoided on the side of an axillary node dissection or mastectomy since it can increase the risk of lymphedema developing in the affected area.

Question 15

What are Korotkoff sounds?

Answer 15

Series of sounds for which the nurse listens when assessing the blood pressure

Question 16

Korotkoff sounds

PHASE 1

Answer 16

• first appearance of faint but clear tapping

- the first tapping sound is the Systolic pressure

Question 17

Korotkoff sounds

PHASE 2

Answer 17

• muffled or swishing sounds

- after after the auscultatory gap

Question 18

Korotkoff sounds

PHASE 3

Answer 18

• distinct, LOUD sounds as the blood flows freely through an increasingly open artery

Question 19

Korotkoff sounds

PHASE 4

Answer 19

• distinct, ABRUPT, muffling sound with soft blowing quality

Question 20

Korotkoff sounds

PHASE 5

Answer 20

• The last sound heard

- Diastolic pressure

Question 21

How many routes can you assess patient’s temp?

Answer 21

5 Routes to access temp
• Oral
• Tympanic membrane- ear
• Temporal Artery- Right or left side of the forehead
• Axillary- under the armpit
• Rectal

Question 22

Which one is the most accurate

route?

Answer 22

Rectal Temp- Core body temp and is most accurate

Question 23

Are there any contraindications for assessing temp?

Answer 23

👷‍♂️🚧

Question 24

Why do you, as a nurse, need to assess patient’s V/S?

Answer 24

Nurses assess vital signs and compare findings with accepted normal values. Vital signs have been identified as the best indicator of cardiopulmonary arrest, unplanned ICU admission, and unexpected death.

Question 25

When do you check a patient’s V/S?

Answer 25

As often as patient’s condition requires. Frequency of Assessment is based on patient’s medical diagnosis, comorbidities, types of treatments received, and the patient’s level of acuity.

Question 26

What are your responsibilities to a patient’s V/S?

Answer 26

It’s the nurses responsibility to ensure the accuracy of the data, interpret vita sign findings, and report abnormal findings.