vitals check off - temperature, pulse, respirations, O2 sat

Question 1

expected temperature ranges:

Answer 1

96.4ºF to 99.1º (38.5ºC to 37.7º)

Question 2

average temperature range:

Answer 2

98.6ºF (37ºC)

-this is stable core temperature at which cellular metabolism is most efficient

Question 3

does temperature increase or decrease during menstruation?

Answer 3

increase

-begins at ovulation & remains elevated until menses cease because of progesterone secretion

Question 4

does temperature increase or decrease during exercise?

Answer 4

increase

Question 5

when is body temperature the lowest?

Answer 5

in the morning

Question 6

when is body temperature the highest?

Answer 6

in the late afternoon/evening

Question 7

oral temperature

Answer 7

safe & relatively accurate

Question 8

how long should you wait to take an oral temperature if patient ingested hot or cold liquid OR smoked?

Answer 8

10 minutes

Question 9

where is the thermometer (sheathed) placed during oral temperature reading?

Answer 9

under tongue in sublingual pocket for 15 to 30 seconds

Question 10

sublingual pocket

Answer 10

under the tongue - receives blood supply from carotid artery, thus indirectly reflects core temperature

Question 11

oral temperature is safe for what kind of patients?

Answer 11

school-aged children & confused adults

Question 12

temporal artery temperature

Answer 12

forehead to ear - used in children & adults in critical care setting

Question 13

when taking tympanic membrane temperature in children, do you pull the ear up or down?

Answer 13

pull the ear down

Question 14

when taking tympanic membrane temperature in adults, do you pull the ear up or down?

Answer 14

pull the ear up & out

Question 15

tympanic membrane temperature

Answer 15

probe covered with protective sheath, place in external ear canal for 2 to 3 seconds

Question 16

axillary temperature

Answer 16

measurement has questionable accuracy

Question 17

axillary temperature is used most commonly on what patients?

Answer 17

pediatric patients

Question 18

rectal temperature

Answer 18

most accurate temperature measurement BECAUSE closest to core temp

Question 19

why is rectal temperature used less frequently?

Answer 19

because newer methods exist & its less comfortable

Question 20

rectal temperature is safe to use in what patients?

Answer 20

adults

Question 21

before inserting rectal thermometer, what should you have patient do?

Answer 21

have patient lay on their side with upper leg flexed

Question 22

before inserting rectal thermometer, what should you do with thermometer?

Answer 22

place sheath on probe & apply water-soluble lubricant

Question 23

normal ranges of pulse

Answer 23

60-100 BMP

Question 24

what does pulse determine?

Answer 24

heart rate & rhythm

Question 25

heart rate

Answer 25

number of times in a minute pulsation is felt

Question 26

rhythm

Answer 26

refers to regularity of pulsations or time between each beat

Question 27

how do you take a pulse?

Answer 27

place fingers over artery & feel for pulsations + rhythm

Question 28

what fingers do you use to take a pulse?

Answer 28

finger pads of index & middle fingers

Question 29

how much pressure do you apply when taking a pulse?

Answer 29

firm pressure, but not so hard that pulsation is occluded

Question 30

how long do you count pulsations if rhythm is regular?

Answer 30

30 seconds x 2 OR 15 seconds x 4

Question 31

how long do you count pulsations if pulse rate is irregular?

Answer 31

one full minutes

-document irregular pulse

Question 32

what area is most commonly used to count pulse and why?

Answer 32

radial pulse BECAUSE accessible & easily palpated

Question 33

radial pulse

Answer 33

found at radial side of forearm at wrist

Question 34

which side of wrist do you take radial pulse?

Answer 34

thumb side

Question 35

brachial pulse

Answer 35

found in groove between biceps & triceps muscles, in bend of elbow

Question 36

carotid pulse

Answer 36

found along medial edge of sternocleidomastoid muscle in lower 3rd of neck

Question 37

normal ranges of respirations

Answer 37

12-20 breathes/minute

Question 38

respiratory rate

Answer 38

involves counting number of ventilatory cycles & inhalation + exhalation, each minute

Question 39

men & children usually breathe how?

Answer 39

diaphragmatically AKA increasing movement of abdomen

Question 40

women usually breathe how?

Answer 40

in their chest AKA thoracic

Question 41

when do you count respirations and why?

Answer 41

when patient is unaware to prevent self-conscious changing of breathing rate/pattern

Question 42

what factors increase respiratory rate?

Answer 42

1. fever
2. anxiety
3. exercise
4. higher altitude

Question 43

how is depth of respirations assessed?

Answer 43

by observing excursion or movement of chest wall

Question 44

depth is described as:

Answer 44

normal or shallow

-shallow breathing is small movement & may be hard to observe

Question 45

oxygen saturation

Answer 45

measured by pulse oximeter which estimates oxygen saturation of hemoglobin in blood

Question 46

where is the probe of a pulse oximeter taped or clipped on a patient?

Answer 46

1. fingertip
2. toe
3. earlobe
4. nose

Question 47

normal range of oxygen saturation:

Answer 47

95%-100%

Question 48

what oxygen saturation levels are considered abnormal & require further evaluation?

Answer 48

90%