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Nursing Essentials > Vital Signs > Flashcards

Vital Signs Flashcards

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1
Q

What causes normal vital signs to change

A

Age, sex, weight, exercise tolerance, and condition

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2
Q

What should you do if you have an abnormal result?

A

If they have abnormal results do they physically look like they have abnormal results or was their a mistake or is that their baseline.

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3
Q

What are the 4 things you need to do as the nurse relative to vital signs?

A

measure correctly, understand and interpret, communicate, and intervene

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4
Q

What is a patients baseline

A

1st set of vitals

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5
Q

Why is the patient’a baseline important?

A

It allows the nurse to see changes in the patient

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6
Q

How frequent should you take vital signs on stable pts

A

Q4-6 hours

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7
Q

How frequent should you take vital sings on postsurgical pts

A

Q15 minutes

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8
Q

How frequent should you take vital signs on critical pts

A

Q15 minutes

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9
Q

How should you interpret a pts vital signs

A

compare with their normal or baseline values

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10
Q

What do you need to know about the pt to understand their vital signs

A

The pts medical history and possible diagnosis

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11
Q

What are some cases in which you should take vital signs?

A

On ADMISSION, physical ASSESSMENT, MORNING routines, change in health STATUS, before and after SURGERY or administration of MEDICATION or INTERVENTIONS.

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12
Q

What is the normal tamperature

A

97.6-99.6

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13
Q

What is the average oral temperature?

A

98.6

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14
Q

What is hyperthermia

A

> 104F

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15
Q

If a patient is afebrile what does that mean

A

They have no fever

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16
Q

If a patient has a fever of >100.4 how would you describe them

A

febrile

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17
Q

Why might doctors wait a couple of hours to give antifebrile medication

A

A fever is a defense mechenism of the body to destroy bacteria

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18
Q

What sight gives the highest reading?

A

Rectal>oral>axiallary

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19
Q

Which age populations run on the cooler side. Are they more susceptible to environmental temperature extremes

A

Infants and elderly people, yes.

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20
Q

Can newborns regulate their tempurature

A

No they have immature regulatory mechanisms

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21
Q

How does exrcise effect body temp

A

in increases

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22
Q

A college student just got broken up with right before her finals and she’s very stressed. What do we predict her temp to be

A

higher

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23
Q

It’s a hot day outside and your patient just got to the doctor’s office and you took their temp right away. What do you expect it will be.

A

Higher

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24
Q

Your patient is a 40 year old male who has been smoking for 20 years. What do you expect his temp to be and why?

A

Coller becuase smoking constricts the blood vessels.

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25
Q

Your patient just exercised or bathed how long should you wait to take their temp

A

1 hour

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26
Q

what patient just smoked or consumed cold or hot food or drink how long should you wait

A

30 minutes

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27
Q

What is the most common way to measure temperature

A

oral (mouth)

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28
Q

What is the least accurate way to measure temp

A

exillary (armpit)

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29
Q

You have a child and need to get their temp. Which way are you using?

A

tympanic (ear)

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30
Q

What is the last resort way to get a newborns temp, its also the most accurate

A

rectal (anus)

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31
Q

You have a critical patient and need an advanced way to get their temp what can you use

A

Foley catheter and esophageal

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32
Q

You have a 3 year old who needs their temp, can you use the oral way?

A

No, only 4 years old and up

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33
Q

Where do you put the oral themometer

A

In the sublingual pocket

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34
Q

Your patient has a history of seizures, just got an oral surgery, and is unconscious should you use the oral way to get their temp

A

NO

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35
Q

How far should you insert a lubricared rectal bulb?

A

1-1.5 inches

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36
Q

What may happen if you use the recatl method on a newborn

A

You may puncture their bowels

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37
Q

Why shouldn’t you use the rectal method to get a temp for quesriplegic patients?

A

They can’t feel anything below the neck, throughfore they can’t tell you if it hurts

38
Q

Which way do you pull the ear for adUlt patients

A

Up and back

39
Q

Which way do you pull the ear for chilDren

A

Down and back

40
Q

What is the last resort method to get a temp other than rectal, and why

A

Temporal, it’s very inaccurate

41
Q

What should you use when oral and rectal sites are inaccessible

A

Avillary, it’s the least accurate

42
Q

What is the normal HR

A

60-100 BPM

43
Q

You have a female patient, what do you expect about their HR

A

Females have higher HR than males

44
Q

What causes bradycardia

A

<60 BPM, RESTING, heart BLOCK, AGE, ATHLETE

45
Q

What causes tachycardia

A

> BPM, SHOCK, HEMORRHAGE, FEVER, acute PAIN, DRUGS

46
Q

You need to get the central pulse of a patient, what is that

A

The apical pulse

47
Q

When you are getting a pts HR from their radial or pedial pulse what are those considered

A

Peripheral pulses, they are located away from the heart

48
Q

You have a 98 year old male compared to a 15 year female, their HR is higher or lower

A

Slower

49
Q

You just ran a mile your HR will be higher or lower

A

higher

50
Q

You girlfriend just dumped you and you are stressed out, is your HR higher or lower

A

higher

51
Q

Does medication increase or decrease your HR

A

both

52
Q

You pt comes in with their arm chopped off and they are losing a lot of blood (hypocolemic), is their HR higher or lower

A

higher

53
Q

You have a child under 2 how should you get their HR

A

auscultate the apical pulse for a full minute

54
Q

You feel an irregular pulse, what should you do

A

assess the apical pulse for a full minute

55
Q

When assessing the HR how do you describe the rhythm

A

regular or irregular

56
Q

When assessing the HR how do you describe the intensity

A

weak, normal, strong, or bounding (0-4)

57
Q

You have an obese pt that has edema and poor circulation. When getting their HR what should you keep in mind

A

It will be difficult to palpate

58
Q

How does HR change over the life spand

A

high, decreasing, normal, decrease

59
Q

You have an older patient what should you understand about their HR

A

They are more at risk for arrhythmias and heart disease, and the heart can’t beat as fast during exercise

60
Q

If your patient has an abnormally low or high heart rate, what questions should you ask your patient?

A

Their history, activites, if they are an athlete, or if they take any meds that could effect that heart

61
Q

What is a full respiration cycle

A

an inhale and exhale

62
Q

What is the average respiration range

A

12-20

63
Q

What can affect respirations

A

AGE, EXERCISE, respiratory DISEASE, MEDS, PAIN, EMOTIONS

64
Q

What is bradypnea and what can cause it

A

<12, head TRAUMA, MEDS (opioids, sedativies)

65
Q

What is tachypnea and what can cause it

A

> 20, FEVER, ILLNESS

66
Q

What you are getting your pts respirations what should you not tell them, and what should you do

A

don’t tell them you are counting their breaths, put your hand on their shoulder

67
Q

When assesing a pts respirations what three things are you looking at

A

rate (how fast), rhythm (regular or irregulat), quality (even, unlabored)

68
Q

If the patient is short of breath what is your first action

A
  1. sit them up (tripod position)
  2. Get another set of vitals
  3. interventions if needed
69
Q

How does respirations change over the life span

A

higher, decreasing, normal, increased

70
Q

What should you keep in mind about your 98 year olds respirations

A

their lung ELASTICITY decreses, and their respiratory MUSCLES are weakened

71
Q

What is blood pressure measured in

A

mmHg

72
Q

What is the average BP for an adult

A

120/80

73
Q

What affects BP

A

AGE, EXERCISE, MEDS, PAIN, EMOTIONS

74
Q

How is hypertension described

A

in stages

75
Q

What is hypotension

A

<90 systolic

76
Q

Describe systolic and diastolice pressures

A

Systolic: pressure when the heart CONTRACTS
Diastolic: pressure when heart is RELAXED

77
Q

Your patient has a limb alert and a pulse oximeter on their left arm. Which arm should you use for their BP

A

The right arm

78
Q

You have a pt who had a mastectomy, has a dialysis shunt, and an IV all in their left arm. What can you assume about that arm.

A

It’s likely on limb alert

79
Q

Why shouldn’t you put the BP cuff on the side of the pulse oximete

A

It cuts off the blood flow and can effect the results

80
Q

What is stage one hypertension, and what inventions are there

A

130-139/80-89, no meds, life style modifications

81
Q

What is stage two hypertension

A

> 140/90

82
Q

Your pt has primary hypertension, what does that mean

A

there is no known cause

83
Q

Your pt has secondary hypertenion, what does that mean

A

caused by a known illness

84
Q

Your patient is coming in to get their BP what should you tell them to avoid

A

They should avoid COFFEE, SMOKING, or EXERCISE

85
Q

Where should your patients feet and arm be when getting their BP

A

they should be SITTING, feet should be on the FLOOR, and their arm should be at the same height as their HEART

86
Q

If your patient’s arm is too high or the cuff is too big how will the BP read

A

The BP will read lower

87
Q

If your patient’s arm is too low or the cuff is too small how will the SP read

A

The BP will read lower

88
Q

How does the BP change over the years

A

lower, cardiovasular system improves, increases, normal, then increases

89
Q

Why does BP increase in older adults

A

natural stiffening of arteries and changes in blood vessel elasticity

90
Q

What must you think about when deciding to delegate vital signs to an aide or not

A

the patient must be stable, the techs must know the proper technique, and it must be accurate

Nursing Essentials (16 decks)

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