nursing funds > week 4--book ch 29 & 44 > Flashcards
week 4--book ch 29 & 44 Flashcards
average body temp
96.8-100.4
*axillary (surface temp) = 97.7
*oral = 98.6
*rectal = 99.5
normal pulse pressure range
30-50 mmhg
neonates increase body heat through
nonshivering thermogenesis
radiation
transfer of heat from surface of one object to surface of another object w/o direct contact
conduction
transfer of heat w/ direct contact
convection
transfer of heat away by air movement
evaporation
transfer of heat away when a liquid is changed to a gas
diaphoresis
visible perspiration
*forehead & upper thorax
factors of behavioral control of body temp
- degree of temp
- control
- mentality/emotions
- mobility
fever temp
greater than 100.4
recording temp in children younger than 6 mo
no ear tempp
intermittent fever
fever spikes & returns to normal
Remittent fever
fever spikes & falls w/o returning to normal
heat stroke symptoms
104+
no sweat
fixed & nonreactive pupils
unconscious
hypothermia
<95
severe = <82
antipyretics
meds that reduce fever
acetaminophen
NSAID’s
salicylates
indomethicin
corticosteroids & fevers
mask symptoms of infection
In children
measure respirations FIRST before vitals
Biot’s respiration
abnormally shallow respirations for 2-3 breaths followed by irregular apnea
capnography
measures exhales co2
35-45 mmhg
hematocrit
% of RbC in blood
*determines viscosity
Antihypertensives
*diuretics (-ide & -one)
*Beta Blockers (-olol)
*vasodilators
*CCB (-ide & -ine)
*ACE inhibitors (-pril)
*ARB’s (-sartan)
A 52-year-old woman is admitted with pneumonia, dyspnea, and discomfort in her left chest when taking deep breaths. She has smoked for 35 years and recently lost over 10 lb. She is started on intravenous antibiotics, high-protein shakes, and 2 L O2 via nasal cannula. Her most recent vital signs are HR 112, BP 138/82, RR 22, tympanic temperature 37.9°C (100.2° F), and oxygen saturation 94%. Which vital signs reflect a positive outcome of the treatment interventions? (Select all that apply.)
- Temperature: 37° C (98.6° F)
- Radial pulse: 98
- Respiratory rate: 18
- Oxygen saturation: 96%
- Blood pressure: 134/78
- Temperature: 37° C (98.6° F)
- Radial pulse: 98
- Respiratory rate: 18
- Oxygen saturation: 96%
The licensed practical nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient does the nurse need to assess first?
- 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%
- 54-year-old woman admitted after surgery for repair of a fractured arm, BP 160/86 mm Hg, HR 72
- 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84
- 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62
- 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%
A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7°C (101.6°F) at 0400, 36.6°C (97.9°F) at 0800, 36.9°C (98.4°F) at 1200, 37.6°C (99.6°F) at 1600, and 38.3°C (100.9°F) at 2000. How would the nurse describe this pattern of temperature measurements?
- Usual range of circadian rhythm measurements
- Sustained fever pattern
- Intermittent fever pattern
- Resolving fever pattern
- Intermittent fever pattern
A patient presents in the clinic with dizziness and fatigue. The assistive personnel (AP) reports a slow but regular radial pulse of 44. Place the following care activities in priority order.
- Direct the AP to obtain a blood pressure.
- Request that the patient lie on the clinical stretcher.
- Assess the patient’s apical pulse for a full minute.
- Prepare to administer cardiac-stimulating medications.
- Request that the patient lie on the clinical stretcher.
- Direct the AP to obtain a blood pressure.
- Assess the patient’s apical pulse for a full minute.
- Prepare to administer cardiac-stimulating medications.
Which of the following patients are at most risk for tachypnea? (Select all that apply.)
- Patient just admitted with four rib fractures
- Woman who is 9 months’ pregnant
- A patient admitted with hypothermia
- Postoperative patient waking from general anesthesia
- Three-pack–per-day smoker with pneumonia
- Woman who is 9 months’ pregnant
- Patient just admitted with four rib fractures
- Three-pack–per-day smoker with pneumonia
point of max impulse
5th intercoastal space
4th for kids
During admission of an obese patient with heart failure the assistive personnel (AP) reports to the nurse that the blood pressure (BP) is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? (Select all that apply.)
- Notify the health care provider immediately.
- Repeat the measurements on both arms using a stethoscope.
- Ask the patient if she has taken her blood pressure medications recently.
- Obtain blood pressure measurements on lower extremities.
- Verify that the correct cuff size was used during the measurements.
- Review the patient’s record for her baseline vital signs.
- Compare right and left radial pulses for strength.
- Repeat the measurements on both arms using a stethoscope.
- Review the patient’s record for her baseline vital signs.
The assistive personnel (AP) informs the nurse that the electronic blood pressure machine on the patient who has recently returned from surgery after removal of her gallbladder is flashing a blood pressure of 65/46 and alarming. Place the care activities in priority order.
- Press the start button of the electronic blood pressure machine to obtain a new reading.
- Obtain a manual blood pressure with a stethoscope.
- Check the patient’s pulse distal to the blood pressure cuff.
- Assess the patient’s mental status.
- Remind the patient not to bend her arm with the blood pressure cuff.
- Assess the patient’s mental status.
- Press the start button of the electronic blood pressure machine to obtain a new reading.
- Check the patient’s pulse distal to the blood pressure cuff.
- Obtain a manual blood pressure with a stethoscope.
- Remind the patient not to bend her arm with the blood pressure cuff.
A healthy adult patient tells the nurse that he obtained his blood pressure in “one of those quick machines in the mall” and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/92? (Select all that apply.)
- Cuff too small
- Arm positioned above heart level
- Slow inflation of the cuff by the machine
- Patient did not remove his long-sleeved shirt
- Insufficient time between measurements
- Cuff too small
- Insufficient time between measurements
A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The assistive personnel reports his admitting vital signs to the nurse. Which measurements should the nurse reassess? (Select all that apply.)
- Right arm BP: 118/72
- Radial pulse rate: 72 and irregular
- Temporal temperature: 37.4°C (99.3°F)
- Respiratory rate: 28
- Oxygen saturation: 99%
- Radial pulse rate: 72 and irregular
- Respiratory rate: 28
- Oxygen saturation: 99%
Which of the following signs or symptoms in a patient who is opioid-naïve is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid?
- Oxygen saturation of 95%
- Difficulty arousing the patient
- Respiratory rate of 12 breaths/min
- Pain intensity rating of 5 on a scale of 0 to 10
- Difficulty arousing the patient
A health care provider writes the following order for a patient who is opioid-naïve who returned from the operating room following a total hip replacement: “Fentanyl patch 100 mcg, change every 3 days.” On the basis of this order, the nurse takes the following action:
- Calls the health care provider and questions the order
- Applies the patch the third postoperative day
- Applies the patch as soon as the patient reports pain
- Places the patch as close to the hip dressing as possible
- Applies the patch the third postoperative day
A patient is being discharged home on an around-the-clock (ATC) opioid for postoperative pain. Because of this order, the nurse anticipates an additional order for which class of medication?
- Opioid antagonists
- Antiemetics
- Stool softeners
- Muscle relaxants
- Stool softeners
A new medical resident writes an order for oxycodone CR 10 mg PO q2h prn. Which part of the order does the nurse question?
- The drug
- The time interval
- The dose
- The route
- The time interval
The nurse reviews a patient’s medical administration record (MAR) and finds that the patient has received oxycodone/acetaminophen (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most?
- The patient’s level of pain
- The potential for addiction
- The amount of daily acetaminophen
- The risk for gastrointestinal bleeding
- The amount of daily acetaminophen
When using ice massage for pain relief, which of the following is correct? (Select all that apply.)
- Apply ice using firm pressure over the skin.
- Apply ice for 5 minutes or until numbness occurs.
- Apply ice no more than 3 times a day.
- Limit application of ice to no longer than 10 minutes.
- Use a slow, circular steady massage.
- Apply ice using firm pressure over the skin.
- Apply ice for 5 minutes or until numbness occurs.
- Use a slow, circular steady massage.
A patient with a 3-day history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The patient had been taking hydrocodone/APAP 5/325 up to four tablets/day before her stroke for the past year to manage her arthritic pain. The health care provider’s order reads as follows: “Hydrocodone/APAP 5/325 1 tab, per gastrostomy tube, q4h, prn.” Which action by the nurse is most appropriate?
- No action is required by the nurse because the order is appropriate.
- Request to have the order changed to around the clock (ATC) for the first 48 hours.
- Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3h, prn.
- Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of pain.
- Request to have the order changed to around the clock (ATC) for the first 48 hours.
- Place the following steps in the correct order for administration of patient-controlled analgesia:
- Insert drug cartridge into infusion device and prime tubing.
- Wipe injection port of maintenance IV line vigorously with antiseptic swab for 15 seconds and allow to dry.
- Demonstrate to patient how to push medication demand button.
- Secure connection and anchor PCA tubing with tape.
- Instruct patient to notify a nurse for possible side effects or changes in the severity or location of pain.
- Insert needleless adapter into injection port nearest patient.
- Apply clean gloves. Check infuser and patient-control module for accurate labeling or evidence of leaking.
- Program computerized PCA pump as ordered to deliver prescribed medication dose and lockout interval.
- Attach needleless adapter to tubing adapter of patient-controlled module.
- Demonstrate to patient how to push medication demand button.
- Instruct patient to notify a nurse for possible side effects or changes in the severity or location of pain.
- Apply clean gloves. Check infuser and patient-control module for accurate labeling or evidence of leaking.
- Insert drug cartridge into infusion device and prime tubing.
- Attach needleless adapter to tubing adapter of patient-controlled module.
- Wipe injection port of maintenance IV line vigorously with antiseptic swab for 15 seconds and allow to dry.
- Insert needleless adapter into injection port nearest patient.
- Secure connection and anchor PCA tubing with tape.
- Program computerized PCA pump as ordered to deliver prescribed medication dose and lockout interval.
When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which of the following represent an accurate description of the nonpharmacological therapy? (Select all that apply.)
- Turn TENS on before patient feels discomfort.
- TENS works peripherally and centrally on nerve receptors.
- TENS does not require a health care provider order.
- Remove any skin preparations before attaching TENS electrodes.
- Placing electrodes directly over or near the pain site works best.
- TENS works peripherally and centrally on nerve receptors.
- Remove any skin preparations before attaching TENS electrodes.
- Placing electrodes directly over or near the pain site works best.
Acute Pain
Has a protective effect
Usually has identifiable cause
Eventually resolves with or without treatment
chronic pain
Lasts more than 3 to 6 months
Dramatically affects quality of life
Viewed as a disease
Nociception
- transduction
- transmission
- perception
- modulation
a-fibers
sharp & localized
c-fibers
dull, achy, & poorly localized
A.B.C.D.E pain assessment
A– ask
B– believe
C–choose
D– deliver
E–empower
multimodal analgesia
combines drugs w/ at least 2 different mechanisms of action to optimize pain control
clinical signs of heat exhaustion
low blood pressure
normal pulse rate, diaphoresis,
weakness
The appropriate site for taking the pulse of a 2-year-old is:
apical
measuring the blood pressure in the legs
systolic pressure is 10-40mmHg higher than the brachial artery.
diastolic pressure is the same as that in the brachial artery
An 84-year-old client with diabetes is admitted for insulin regulation. Which of the following blood pressure, pulse, and respiration measurements, respectively, is considered to be within the expected limits for a client of this age?
a. BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/min
b. BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min
c. BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min
d. BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min
a. BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/min
norma vitals for a 10-year-old
75-100 beats/min
respiratory rate is 20-30 breaths/min.
110/65 mm Hg
The nurse is working in the newborn nursery. In planning for temperature measurement, the nurse will obtain the reading on the infants by using the:
Axillary site
The client’s apical pulse will be taken by a student. According to the nurse the stethoscope should be placed along the left clavicular line at the:
Fourth to fifth intercostal space
irregular respiratory rate, with periods of apnea and increases in respiration, followed by a reversal of the pattern.
Cheyne-Stokes respirations
