Vital signs

Question 1

What changes vital signs

Answer 1

age, gender, weight, exercise, tolerance, condition

Question 2

What is my job as a nurse relating to vital signs

Answer 2

measure correctly, understand + interpret, communicate, interventions

Question 3

why is the baseline important

Answer 3

identifies changes and establishes trends

Question 4

what is the frequency for stable pts?

Answer 4

Q4-8

Question 5

what is the frequency for post-surgical pts?

Answer 5

Q15

Question 6

what is the frequency for critical pts?

Answer 6

Q5

Question 7

when should VS be taken?

Answer 7

admission, physical assessment, routine monitoring, change in health status, before + after surgery, administration of meds, and interventions

Question 8

normal range for temperature

Answer 8

97.6-99.6 (98.6 average oral)

Question 9

what is hyperthermia

Answer 9

104+

Question 10

afebrile

Answer 10

no fever

Question 11

febrile

Answer 11

100.4+

Question 12

what is hypothermia

Answer 12

less than 95

Question 13

What is an important note relating to temperatures

Answer 13

rectal temps> oral> axillary

Question 14

What affects body temperature

Answer 14

age, exercise, stress, environment, smoking (only one that decreases temp)

Question 15

What are the ways to measure temperature

Answer 15

oral, axillary, tympanic, temporal, rectal

Question 16

what would you use to measure temp on critical care pts.

Answer 16

Foley catheter and esophageal

Question 17

when should temperature measurement occur

Answer 17

30 minutes after smoking or consuming food/beverages and 1 hour of exercise or bathing

Question 18

what are the advantages of oral thermometers

Answer 18

accessible, comfortable, sublingual pocket

Question 19

who cannot use an oral thermometer

Answer 19

infants + children, unconscious, post oral surgery, pts with seizure disorders

Question 20

what are the advantages of rectal thermometers

Answer 20

most accurate, lubricate tip and no more than 1-1.5 inches in

Question 21

who cannot use rectal thermometers

Answer 21

newborns, spinal cord injury, diarrhea/rectal disease, quadriplegic

Question 22

what are advantages of tympanic thermometers

Answer 22

easy access for all, confused or unconscious pts

Question 23

who cannot use tympanic thermometers

Answer 23

ear drainage and eardrum scarring

Question 24

who can use temporal temperature

Answer 24

children and adults not needing core body temp

Question 25

adUlt and chilD

Answer 25

adUlt: Up and back chilD: Down and back

Question 26

who can use axillary thermometer

Answer 26

oral and rectal sites not available, healthy newborns

Question 27

which is the least accurate thermometer

Answer 27

axillary

Question 28

Which thermometer would you use for a pt who needs an accurate temperature

Answer 28

rectal

Question 29

Which thermometer would you use for a pt with dementia who cannot follow directions well

Answer 29

tympanic

Question 30

Which thermometer would you use for a pt coming in for an office visit

Answer 30

oral

Question 31

Which thermometer would you use for a child with an ear infection

Answer 31

axillary

Question 32

what is bradycardia and what causes it

Answer 32

less than 60 bpm, resting, heart block, age, athlete

Question 33

what is tachycardia and what causes it

Answer 33

over 100 bpm, hemorrhage, shock, fever, acute pain, drugs

Question 34

what is the central pulse

Answer 34

apical

Question 35

what are peripheral pulses

Answer 35

can be palpated over arteries located away from heart

Question 36

what affects pulse rate

Answer 36

age, exercise, stress, meds, hypovolemia

Question 37

when do you use the carotid pulse

Answer 37

in emergency situations

Question 38

what makes it difficult to palpate pulse rate

Answer 38

edema, obesity, poor circulation

Question 39

what does heart rate do over the lifespan

Answer 39

high, decrease, normal, decrease

Question 40

what happens to heart rate in older adults

Answer 40

increase risk for arrhythmia and heart disease and can't be as fast during exercise

Question 41

what are respirations affected by

Answer 41

age, exercise, respiratory disease, meds, pain, exercise

Question 42

what is bradypnea and what causes it

Answer 42

less than 12, head trauma, meds (opioids and sedatives)

Question 43

what is tachypnea and what causes it

Answer 43

over 20, fever and illness

Question 44

what do you do when pt is SOB

Answer 44

elevate HOB, redo vitals, intervene if needed

Question 45

what do you assess for with respirations

Answer 45

rate, rhythm, and quality

Question 46

what happens to respirations across lifespan

Answer 46

high, decrease, normal, decrease

Question 47

what happens to respirations in old age

Answer 47

lung elasticity decrease and respiratory muscles weaken

Question 48

where do you not place BP cuff

Answer 48

same arm as pulse oximeter and extremity with limb alert

Question 49

what are the hypertension stages

Answer 49

stage 1: 130-139/80-89 stage 2: 140+/90 primary: no known cause secondary: caused by known illness

Question 50

if the arm is too high what happens to BP

Answer 50

low BP

Question 51

If arm is too low what happens to BP

Answer 51

high BP

Question 52

what happens to BP over lifespan

Answer 52

low, increase, normal, increase

Question 53

why is BP high in older adults

Answer 53

arteries stiffen naturally, changes in blood vessel elasticity

Question 54

when can you delegate VS to UAP

Answer 54

pt is stable, they know proper technique, accurate