week 2

Question 1

PQRSTU mnemonic

Answer 1

Provocation and or Palliation
Quality and or Quantity
Region and or Radiation
Severity Scale
Timing Onset, duration, frequency
Understanding pts perception & or Unable to do

Question 2

factors affecting body temperature

Answer 2

-age
-hormonal level
-environment
-circadian rhythm
-temperature alterations

Question 3

different temperature sites

Answer 3

-oral (PO) = eaten or drank take 30 minutes after
-axillary (Ax)
-rectal (R)
-tympanic (ear) (TA)
-temporal (TM)

Question 4

average temp for adults

Answer 4

96.8-100.4℉

Question 5

average older adult (oral)

Answer 5

95-97℉

Question 6

average oral temp

Answer 6

98.6℉

Question 7

average rectal/tympanic

Answer 7

99.5℉

Question 8

average axillary

Answer 8

97.6℉

Question 9

sepsis & pyrexia (in regards to temp)

Answer 9

sepsis = very low or very high temp
pyrexia = fever (100.4℉)

Question 10

what does pulse measure & normal rate

Answer 10

palpable bounding of blood flow in a peripheral artery (circulatory status)
60-100 bpm = eucardia

Question 11

pulse tachycardia & bradycardia

Answer 11

tachycardia = >100 bpm
bradycardia = <60 bpm

Question 12

when pulse is concerning

Answer 12

greater than 120 and less than 50

Question 13

factors influencing pulse rate

Answer 13

-exercise
-temp
-emotions
-medications
-postural changes
-pulmonary conditions
-hemorrhage

Question 14

radial pulse strengths

Answer 14

3+, 2+, 1+, 0+
3 = strong
2 = normal
1 = weak

Question 15

heart rate (apical pulse rate) location and technique

Answer 15

5th ICS, MCL
-auscultate

Question 16

what is respiration and what 3 components involved

Answer 16

exchange gasses between atmosphere & the blood
ventilation, diffusion, perfusion

Question 17

define ventilation, diffusion, & perfusion

Answer 17

ventilation = movement of gas in environment & out of the lungs
diffusion = movement of oxygen & CO2 between alveoli & RBCs
perfusion = distribution of RBCs from pulmonary capillaries

Question 18

respiration: inspiration & expiration, active or passive?

Answer 18

inspiration = active process (expand chest wall)
expiration = passive process (chest wall recoil)

Question 19

factors affecting respiration

Answer 19

-exercise
-acute pain
-anxiety
-smoking
-body position
-meds
-neuro injury
-hemoglobin function

Question 20

normal respirations and abnormal values

Answer 20

-12-20 breaths per minute (eupnea)
-greater than 20 bpm = tachypnea
-less than 12 bpm = bradypnea

Question 21

blood pressure measures what? systolic & diastolic measures what?

Answer 21

blood pressure: force exerted on walls of artery by pulsing blood
*systolic = peak of max pressure
*diastolic = minimal pressure against arterial walls

Question 22

normal blood pressure value

Answer 22

less than 120 and less than 80

Question 23

hypotension value

Answer 23

less than 90 & less than 60

Question 24

common errors in BP

Answer 24

-anxious pt
-smoking or caffeine within 30 minutes
-position above or below heart
-too small or big of a cuff
-failure to wait between repeating readings (1-2 min)
-arm not supported

Question 25

what is a sphygmomanometer

Answer 25

blood pressure cuff

Question 26

what are korotkoff sounds

Answer 26

sounds heard over an artery distal to the blood pressure cuff when the cuff is deflated

Question 27

what is auscultatory gap? what does it cause?

Answer 27

a period of diminished or absent Korotkoff sounds during the manual measurement of blood pressure
causes underestimation of SBP or overestimation of DBP

Question 28

in what circumstances should we avoid taking blood pressure?

Answer 28

-hemodialysis pt w/ AV shunt
-masectomy pt
-PICC lines
-open wounds

Question 29

other blood pressure site

Answer 29

-brachial artery
-radial artery
-popliteal artery
-dorsalis pedis artery
-posterior tibial artery

Question 30

oxygen saturation measure what, normal range, and clinical emergency value

Answer 30

percent of hemoglobin bound with oxygen in the arteries
normal: 93-100%
clinical emergency: 90%

Question 31

factors affecting SpO2

Answer 31

-pt moving
-nail polish
-artificial nails
-hypothermia
-hypotension
-edema
-disease & medication

Question 32

should we rotate sites when using vital signs tools? why?

Answer 32

yes, to decrease the risk for skin breakdown