Vital signs Flashcards
A nurse has implemented interventions for a client experiencing hypotension. Which of the following actions should the nurse take next to evaluate the effectiveness of the interventions?
Recheck the client’s blood pressure after having them relax and take slow, deep breaths.
Rechecking the client’s blood pressure after relaxation and deep breathing exercises is an appropriate method to evaluate the effectiveness of interventions aimed at reducing anxiety-related increases in blood pressure. If the blood pressure is within the expected reference range, the nurse can determine that the interventions were effective. Instructing the client to avoid drinking fluids may exacerbate hypotension and is not an appropriate action for evaluating the effectiveness of interventions aimed at increasing blood pressure. Advising the client to remain seated for an extended period may increase the risk of orthostatic hypotension and is not a recommended action for evaluating the effectiveness of interventions for hypotension. While it is important to report significant findings to the provider, the nurse should first recheck the blood pressure after interventions to determine if there has been a change before reporting. This allows the nurse to provide the provider with updated information on the client’s response to the interventions.
Name each corresponding heart anatomy.
- Superior Vena Cava.
- Right Atrium.
- Pulmonary valve.
- Tricuspid valve.
- Right Ventricle.
- Inferior vena cava.
- Aorta.
- Left Atrium.
- Mitral valve.
- Aortic valve.
- Left Ventricle.
Identify the direction of blood flow through the heart after it enters the right atrium. (Match the options in the left column with the numbers in the right to order them.)
Blood passes through the tricuspid valve > blood collects int he right ventricle > blood passes through the pulmonary artery > blood enters the left atrium > Blood passes through the mitral valve > Blood collects in the left ventricle > Blood passes through the aorta.
Name the four stages of hypertension, including the blood pressure values that define each stage. (Enter your response and submit to compare to an expert’s response.)
Elevated: when the systolic pressure is 120 to 129 mm Hg and the diastolic pressure is less than 80 mm Hg Stage I hypertension: when the systolic pressure is 130 to 139 mm Hg, or the diastolic pressure is 80 to 89 mm Hg Stage II hypertension: when the systolic pressure is 140 mm Hg or greater or the diastolic pressure is 90 mm Hg or greater Hypertensive crisis: when the systolic pressure is greater than 180 mm Hg and/or the diastolic pressure is greater than 120 mm Hg
Tachycardia is
Heart rate above the expected reference range.
Adult blood pressure expected reference range
Systolic 90 to 119; Diastolic 60 to 79 mm Hg
Bradycardia is
Heart rate below the expected reference range.
A nurse is planning care for a client with bradycardia. Which of the following interventions should the nurse include in the client’s plan of care?
Teach the client how to count the radial pulse and when to notify the provider.
When you obtained Mr. Ricci’s initial vital signs, his temperature via temporal scan was 39° C (102.2° F). His skin was warm to palpation and he was visibly shivering.
What are some nursing interventions you can implement to address his fever? (Enter your response and submit to compare to an expert’s response.)
Nursing interventions to address Mr. Ricci’s fever include the following. Remove blankets, hats, and clothing except for a single light layer. Encourage Mr. Ricci to drink cool fluids or eat ice chips frequently. Administer an antipyretic medication. Sponge Mr. Ricci’s skin with tepid water. Enhance heat loss via convection by placing a fan near Mr. Ricci. Administer antibiotics. Administer IV fluids. Decrease the temperature of the room.
Adult Pulse Expected reference range
60 to 100 beats per minute
Adult body temperature expected reference range
36c-38c (96.8f to 100.4f)
Adult respiration expected reference range
12 to 20 breaths/minute
Adult Oxygen saturation expected reference range
95% to 100%
Sites for measuring blood pressure
Upper Arm and Thigh
Expected location of an adult’s apical pulse
Over the apex of the heart; at the 5th intercostal space to the left of the sternum
