Vitals

Question 1

what is the importance (frequency) of checking vitals?

Answer 1

check pt as per provider orders or a sudden change in the patient

Question 2

what interventions should the RN do or anticipate doing if vital signs are abnormal?

Answer 2

• assess the patient
• assess the device they are using to take patients vitals to make sure the device is working correctly

Question 3

what are some clinical findings of orthostatic hypotension?

Answer 3

a change in the patients BP due to the laying, sitting and standing position

Question 4

what vital signs can be delegated to assistive personnel?

Answer 4

temperature, pulse, BP, respirations, oxygen saturation and pain level

Question 5

hypothermia vs. hyerthermia

Answer 5

hypo: below the average temp (36.0 C or 96.8 F)
hyper: above the temp of 100.4 F

Question 6

febrile vs afebrile

Answer 6

febrile: having a fever
afebrile: free from fevers

Question 7

bradycardia vs. tachycardia

Answer 7

brady: pulse below 60 bpm
tachy: pulse above 100 bpm

Question 8

bradypnea vs tachypnea

Answer 8

brady: respirations lower than 12
tachy: respirations above 20

Question 9

hypotension vs hypertension

Answer 9

hypo: BP below 120/80
hyper: BP above 120/80

Question 10

what scale is used for infants pain?

Answer 10

FLACC

Question 11

when is the Wong Baker Faces Pain Scale used? (for what ages)

Answer 11

3+

Question 12

Is pain subjective or objective?

Answer 12

subjective because it’s what the patient says

Question 13

acute vs chronic pain

Answer 13

acute: <6 months
chronic: >6 months

Question 14

what is the nursing priority to measure and intervene when dealing w/ pain?

Answer 14

measure the pain and do a continuous pain assessment (what makes it worse/better?)

Question 15

pharmacological vs non-pharmacological pain interventions?

Answer 15

• pharmacological: review provider orders for mild, moderate and severe pain, educate patient on misconceptions about pain meds (medicate patient as per providers order)
• non-pharmacological: position and re-position patient frequently, educate pt on the use of strategies to reduce pain, distraction, cognitive behavior (no medication is necessary)

Question 16

when is non-opiod medication used?

Answer 16

for mild to moderate pain (monitor for salicylism and gastric upset)

Question 17

when is opioid medication used?

Answer 17

for moderate to sever pain (monitor for sedation, respiratory depression and constipation)

Question 18

what objective patient findings may be associated with pain?

Answer 18

facial expressions, moaning, crying, decreased attention span

Question 19

what is the max L/min you can give to a patient per mask?

Answer 19

1. nasal cannula: 1-6 L/min
2. simple mask: 6-12 L/min
3. partial rebreather: 6-11 L/min
4. non rebreather mask: 10-15 L/min

Question 20

what should you do if a patient is a chronic user of oxygen airway?

Answer 20

humidify patient (anything above 6 will dry a patient out)

Question 21

what is cardiac output made up of?

Answer 21

HR, contractility, blood volume, venous return

Question 22

what are the respiration complications?

Answer 22

• bradypnea
  -hypoventilation
• apnea
• tachypnea
• hyperventilation
• cheyne: stokes respiration
• kussmaul respirations

Question 23

who is more likely to experience bradycardia, especially during the night?

Answer 23

athletes (no action needs to be taken)

Question 24

what pulse can a PCA NOT take on a patient?

Answer 24

apical pulse

Question 25

what is a baseline temp?

Answer 25

what the patients temp is when they are admitted so you can compare data

Question 26

what 2 systems work together to regulate temp?

Answer 26

neurologic and cardiovascular

Question 27

core temp vs surface temp

Answer 27

core: inside (oral, rectal, temporal, urinary)
surface: skin, mouth, axillary

Question 28

vital signs are considered to be what kind of data?

Answer 28

objective because they can be seen

Question 29

oxygen saturation is what kind of measurement of the blood?

Answer 29

noninvasive measurement

Question 30

low hemoglobin can result in what?

Answer 30

low O2

Question 31

early vs late signs of hypoxia

Answer 31

early: tachycardia, confusion, restlessness, anxiety, tachypnea, excessive muscle use, nasal flaring
late: cyanosis, hypotension, bradypnea, cardiac dysrhythmias