vital signs

Question 1

temperature range

Answer 1

96.8-100.4 F

Question 2

pulse range

Answer 2

60-100 BPM

Question 3

respiration rate

Answer 3

12-20 BPM

Question 4

pulse oximetry range

Answer 4

95-100%

Question 5

blood pressure range

Answer 5

systolic - <120 mmHg
diastolic - <80 mmHg

Question 6

prehypertension

Answer 6

120-139 mmHg (systolic)
OR 80-89 mmHg (diastolic)

Question 7

stage 1 hypertension

Answer 7

140-159 mmHg (systolic)
or 90-99 mmHg (diastolic)

Question 8

stage 2 hypertension

Answer 8

greater or equal to 160 mmHg (systolic)
greater or equal to 100 mmHg (diastolic)

Question 9

when is temperature considered a fever?

Answer 9

once temp hits 100.4 F

Question 10

ways to take a temperature

Answer 10

oral thermometer, tympanic thermometer, TAT (temporal), rectal, axillary

Question 11

afebrile

Answer 11

no fever

Question 12

febrile

Answer 12

with a fever

Question 13

rectal temperature

Answer 13

usually 6 months or younger (we want the core temperature); use lubrication and gloves; usually has RED cap

Question 14

TMT

Answer 14

tympanic membrane, uses infrared

Question 15

temporal artery thermometer

Answer 15

sliding probe across forehead; takes multiple readings and produces an average result

Question 16

pulse

Answer 16

reflection of heart rate and rhythm

Question 17

tachycardia

Answer 17

pulse over 100 BPM

Question 18

bradycardia

Answer 18

pulse under 60 BPM

Question 19

technique for taking pulse

Answer 19

count for 30 seconds and multiply by 2

Question 20

technique for taking pulse if patient has irregular pulse

Answer 20

found for a FULL minute

Question 21

pulse amplitude on a 4 point scale

Answer 21

0 - none
1 - weak
2 - normal/expected
3 - bounding pulse
4 - extreme/tachycardic pulse

Question 22

where should you take pulse for vital signs

Answer 22

radial artery

Question 23

apical pulse

Answer 23

used when the radial pulse is difficult to palpate or irregular in rhythm, or when the patient’s condition requires a more accurate reading

Question 24

what should you note about respirations

Answer 24

respiratory rate, depth, effort, rhythm
example: RR 18, shallow, labored

Question 25

blood pressure (def)

Answer 25

reflects pressure in arteries during contraction and relaxation of heart

Question 26

korotkoff sounds

Answer 26

made by turbulent blood flow in partially occluded vessel

Question 27

systolic pressure

Answer 27

the maximum pressure felt on the artery during left ventricular contraction

Question 28

diastolic pressure

Answer 28

the resting pressure that the blood constantly exerts between contractions (diastole)

Question 29

where do you measure BP?

Answer 29

avoid taking BP in arms with IV’s, take it in leg if they have had a mastectomy

Question 30

how to avoid miscuffing

Answer 30

the width of the cuff should cover 2/3 of the upper arm

Question 31

orthostatic/postural vital signs

Answer 31

having to do with taking vital signs in different positions; position changed from supine to standing, normally slight decrease may occur

Question 32

orthostatic vital sign procedure

Answer 32

baseline readings while person is resting supine; repeat with person sitting up

Question 33

abnormal orthostatic vital signs

Answer 33

drop of 20 mmHg systolic or increase of 10 bpm of pulse upon standing

Question 34

reasons for elevated BP

Answer 34

stress, exercise, sympathetic stimulation, medications

Question 35

reasons for decreased blood prssure

Answer 35

major bleeding, dehydration, shock, medication

Question 36

pulse oximetry

Answer 36

assesses arterial oxygen saturation; normal range is 95-100%
must include whether the patient is on room air or has oxygen applied (ex: ventilator)