Vital signs

Question 1

Baseline

Answer 1

take vital signs at rest prior to treatment and following exercise or activities.

Question 2

Pulse

Answer 2

 Indirect measure of contraction of the left
ventricle of the heart
 Movement of blood in an artery
 Children over 10 years and adults: 60 -100
 Newborn (0 to 3 months): 100
-150
 Infants (3 to 6 months): 90 to 120
 Children (1 to 10 years of age): 70 -130

Question 3

Temp

Answer 3

96.8 to 99.3°F
no treatment

Question 4

Assessment of Pulse

Answer 4

temporal, carotid (more common), brachial, radial (more common), femoral,
popliteal, pedal, and posterior tibial arteries

Question 5

Pulse Oximetry

Answer 5

measures blood oxygen levels,
monitors pulse rate, and calculates heart rate
 Placed over index or ring finger
 Normal blood oxygen saturation: 95% to 100%

Question 6

Blood Pressure (BP)

Answer 6

sphygmomanometer
and stethoscope
 Systolic pressure: contraction of left ventricle;
Korotkoff’s Level I sound
 Diastolic pressure: rest period of the heart;
Korotkoff’s Level V sound

Question 7

Mean Arterial Pressure (MAP)

Answer 7

 Average pressure during a single cardiac cycle
 (Systolic pressure + [diastolic pressure × 2])/3
 A MAP of 60 or greater is necessary to perfuse
organs.

Question 8

Assessment of BP

Answer 8

 Most common site: brachial artery
 Tools: properly fitting blood pressure cuff,
stethoscope, chair and arm support for patient,
alcohol wipes, recording materials

Question 9

Respiration (Pulmonary Ventilation)

Answer 9

 Components: inspiration (inflow) and expiration
(outflow) of air between the environment and
lungs
 Normal values: 12 to 18 for adults; 30 to 50 for infants

Question 10

Assessment of Respiration

Answer 10

 Careful observation or tactile assessment of rate, rhythm, depth, and character
Depth: volume of air exchanged with each
respiration
 Rhythm: regularity of pattern
 Character: deviations from normal
 Rate: breaths per minute

Question 11

Apnea

Answer 11

absence of breathing

Question 12

Dyspnea

Answer 12

labored breathing

Question 13

Orthopnea

Answer 13

condition in which breathing is easier when a person is seated or standing

Question 14

Rale

Answer 14

abnormal discontinuous nonmusical sound
heard on auscultation of the chest; crackle

Question 15

Stridor

Answer 15

inspiratory musical wheeze heard over the
trachea; secondary to tracheal or laryngeal
obstruction (medical emergency)

Question 16

Wheezes and rhonchi

Answer 16

secondary to restricted
airway and heard during expiration

Question 17

Pulmonary Auscultation

Answer 17

 Listening for breath sounds in the lungs
 Listening for the characteristics of breath
sounds: pitch, qualities, intensity, and duration of
phases

Question 18

Adventitious (Abnormal) Breath
Sounds

Answer 18

 Discontinuous or nonmusical—crackles (rales),
or pleural friction rubs
 Continuous or musical—wheezes, rhonchi, and
stridor
 Indication of Lung Disease

Question 19

Pain Assessment

Answer 19

 Location
 Intensity
 Duration
 Aggravating or relieving factors
 Effects on performing activities of daily living
 Sleep patterns
 Psychosocial effects

Question 20

Pain Management

Answer 20

 Pharmacologic interventions
 Nonpharmacologic interventions

Question 21

Nonpharmacologic Interventions

Answer 21

 Application of physical agent modalities, for
example, heat, TENS
 Positioning
 Massage
 Distraction techniques
 Relaxation techniques

Question 22

Comprehensive Pain Management

Answer 22

 Interprofessional medical teams
 Interdisciplinary approach
 Specific goals/outcomes

Question 23

Automated BP machines Cannot be used in patients with:

Answer 23

 Seizures, shaking, or shivers
 Weak pulses
 Agitation
 Any situation where the arm cannot be kept still

Question 24

Right Cuff in the Right Place

Answer 24

*Cuff width = 20% more than upper arm diameter
*Cuff width = 2/3 of upper arm length
*Cuff bladder length encircles 80% of upper arm
*Cuff arrow aligned with brachial artery
 Inside of the elbow