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Quiz 2 Fundamental > Vitals > Flashcards

Vitals Flashcards

1
Q

6 Vital Signs

A 
Temperature
Pulse
Respiratory rate
Blood pressure
Pain 
Oxygen saturation
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2
Q

Average oral temp? Range?

A
  1. 6

96. 4 - 100

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3
Q

Advantages to oral temp? Disadvantages?

A

Convenient, accessible

Safety, physical abilities, accuracy

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4
Q

Average axillary temp? Range?

A

.9-1 degree lower than oral

  1. 6
  2. 8-99

Takes 5-10 min manual

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5
Q

Rect temperature average? Range?

A

1 degree higher than oral
.7 - .9

97.3 - 101

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6
Q

Tympanic temperature average? Range?

A

Set to either oral or rectal

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7
Q

How to do a tympanic temperature? Child? Adult?

A

Point towards tympanic membrane

Child: pull down and back
Adult: pull up and back

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8
Q

Variables affecting temperature

A

Circadian rhythms - lowest 1st thing in the morning

Hormones
Age
Exercise
Stress

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9
Q

Afebrile vas. Febrile

A

No fever

Fever

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10
Q

Hyperthermia

A

Above normal temperature reading

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11
Q

Hypothermia

A

below normal temperature reading

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12
Q

What does pulse measure?

A

Speed and strength of heart contractions, peripheral artery pressures, rhythm

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13
Q

Normal pulse range

A

60 -100 bpm

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14
Q

Pulse rating scale (volume)

A

4 point scale for measuring

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15
Q

0 for pulse means

A

weak or absent

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16
Q

+1

A

weak

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17
Q

+2

A

normal

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18
Q

+3

A

strong/increased

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19
Q

+4

A

bounding

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20
Q

6 places to check pulse

A

carotid, brachial, radial, femoral, popliteal, pedal

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21
Q

8 factors affecting heart rate

A 
age
gender
activity
emotional status
pain
environmental factors
stimulants
medications
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22
Q

how to check the apical pulse

A 
most direct
5th intercostal space
midclavicular line (mid clavicle)
regular: 30sec x2
irregular: 60 seconds
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23
Q

Tachycardia

A

greater than 100 bpm

24
Q

Bradycardia

A

less than 60 bpm

25
Q

asystole

A

without heart beat

26
Q

What would you do first if your patient has a radial pulse of 120 bpm

A

take an apical pulse

27
Q

Normal respiration range

A

12-20 per minute

28
Q

Eupnea

A

normal

29
Q

tachypnea

A

fast over 20

30
Q

bradypnea

A

less than 12

31
Q

apnea

A

not breathing

32
Q

dyspnea

A

difficulty/irregular breathing

33
Q

orthopnea

A

upright have easier time breathing

34
Q

what is blood presure

A

force exerted by the flow of blood pumped into the large arteries

35
Q

factors that determine blood pressure (5)

A

cardiac output
peripheral vascular resistance
volume of circulating blood
elasticity of blood vessel walls (increase)

36
Q

Measuring BP - sytole

A

contraction

37
Q

Measuring BP - diastole

A

relaxation

38
Q

pulse pressure

A

difference between systole and diastole

39
Q

BP sites

A

brachial

thigh

40
Q

avoid what for bp

A

av shunts or fistulas

affected arm of post-mastectomy patient

41
Q

BP at Brachial Site

A

palpate brachial pulse

auscultation of BP

42
Q

Normal BP - systolic/diastolic

A

systolic < 120

diastolic < 80

43
Q

hypotension (orthostatic)

A

drop in systolic bp of at least 20 or at least 10 for diastolic BP within three minutes of standing

drop in bp from sitting to standing

44
Q

Hypertension

A

high blood pressure

45
Q

Elevated BP (pre-hypertension)

A

120 - 129/<80

46
Q

Hypertension Stage 1

A

130-139 or 80-89

47
Q

Hypertension stage 2

A

greater than or equal to 140

greater than or equal to 90

48
Q

Common errors in BP measurements

A 
incorrect cuff size
unrecognized ausculatory gap
incorrect cuff placement
above the heart
legs dangling
49
Q

Factors influencing BP

A 
age, sex, race
diurnal rhythm
weight
exercise
emotion/stress/pain
white coat syndrome
medications
hypervolemia, hypovolemia
50
Q

5th vital sigh

A

pain

asses treat evaluate pain (0-10)

51
Q

pulse oximetry

A

measurement of the oxygen saturation of the hemoglobin molecule

normal is greater than 95%

52
Q

you measure pulse ox on your patient having a routine physical exam, and it is 90%. What do you do first

A

recheck the reading at another site

have them take a deep breath

53
Q

thready pulse

A

feeble, weak

difficult to feel or once felt is obliterated easily with slight pressure

54
Q

When assessing a clients pulse the nurse is able to palpate for some time before losing it when exerting more pressure. The pulse is beating at 80 bpm, Which of these should the nurse document as the character of the clients pulse?

A

thready pulse

55
Q

an athlete wants to increase her intake of complex carbs and asks the nurse about potential sources. Which food is considered a complex carb?

A

bread

56
Q

polypharmacy

A

use of many medications at the same time, can pose many hazards for older adults.

57
Q

a nurse in a clinic is caring for a female client who is of chidlbearing age. Which vitamins or minerals should the nurse recommend to prevent neural tube defects during pregnancy?

A

folic acid

Quiz 2 Fundamental (7 decks)

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