Vital Signs

Question 1

Why do nurses take vital signs?

Answer 1

Part of physical examination, determine abnormalities in any body systems

Question 2

When do nurses take vital signs (6)?

Answer 2

1. Admission into faculty
2. Before/after surgical procedure
3. Before/during/after administration of medications
4. Physician’s order
5. Any changes in condition of patient
6. Before/after procedures affecting vitals

Question 3

What are the vital signs (5)?

Answer 3

• Temp.
• Pulse
• Respiration
• Oxygen saturation
• Blood pressure

Question 4

What is the normal range for body temp?

Answer 4

35.9°C - 38.1°C

Question 5

Rectal & temporal artery temps are ____ than oral, while axillary temp is ____ than oral

Answer 5

higher, lower

Question 6

What are the 4 characteristics of a pulse?

Answer 6

• Rate
• Rhythm
• Amplitude
• Elasticity

Question 7

What is the normal heart rate for adults?

Answer 7

60-100 bpm

Question 8

Name some common pulse sites:

Answer 8

• Temporal
• Carotid
• Apical
• Brachial
• Radial
• Ulnar
• Femoral
• Popliteal

Question 9

What is the normal respiration rate for adults?

Answer 9

12-20 breaths/min`

Question 10

What is the normal oxygen saturation for adults?

Answer 10

> 92%

Question 11

BP is ____ pressure / ____ pressure

Answer 11

systolic, diastolic

Question 12

What are the 5 factors that contribute to BP?

Answer 12

• Cardiac output
• Peripheral vascular resistance
• Circulating blood volume
• Viscosity
• Elasticity of vessel walls

Question 13

Which artery is commonly used for measuring BP?

Answer 13

Brachial artery

Question 14

In children, what additional vital signs should be taken (2)?

Answer 14

• Length

- Head circumference

Question 15

How to calculate pulse pressure:

Answer 15

Systolic pressure - diastolic pressure

Question 16

How to calculate mean arterial pressure:

Answer 16

1/3 systolic + 2/3 diastolic

Question 17

[PRACTICE]
You are preparing to assess the vital signs of a 62-year-old woman following hip surgery. When you arrive, the patient is sitting in her chair having just finished breakfast. What is the appropriate nursing action?

A) Take vital signs as planned
B) Wait 20-30 mins and then take vital signs
C) Assess vital signs
D) Take rectal temp.

Answer 17

B

Question 18

[PRACTICE]
The pulse pressure for a patient with a BP of 144/86 is:

A) 58
B) 86
C) 144
D) 230

Answer 18

A

Question 19

[PRACTICE]
You are caring for a patient who is elderly and confused. When assessing temp., you will obtain a reading using a(n):

A) Oral thermometer
B) Rectal thermometer
C) Tympanic thermometer
D) Mercury thermometer

Answer 19

C

Question 20

[PRACTICE]
Which actions will result in an accurate BP reading? Select all that apply.

A) Applying the centre of the bladder of the cuff directly over the brachial artery
B) Raising the arm to the level of the heart
C) Using the bell to assess the BP
D) Pumping the cuff 60mm Hg above the estimated BP

Answer 20

A, B, C

Question 21

What is the normal BP for adults?

Answer 21

120/80 mm Hg

Question 22

What are the 3 components of Cushing’s Triad?

Answer 22

• Increasing BP with widening PP
• Bradycardia
• Irregular respiration

Question 23

What sounds are heard when listen to BP?

Answer 23

Korotkoff

Question 24

What is the BP range for hypertension?

Answer 24

> 140/90