Week One Flashcards
1
Q
Why is it important to establish a clinent’s baseline vitals?
A
Find any significant changes or any effectiveness by interventions
2
Q
What is the difference surface body temp and core body temp?
A
Core body temperature is the temp on the skin and and the core body temp is the temperature of the body and regulated by the cold and warm receptors that send messages to the thermoregulatory centers of the body
3
Q
What is a normal core body temperature range?
A
96.8 and 100.4 (36-38 C)
4
Q
What should I measure temp with in a normal setting?
A
Chemical or electronic
5
Q
What is the best type of thermometers for comatose patients?
A
Tympanic and electronic
6
Q
What is the best type of temperature taking method for infectious patients?
A
Chemical as single use temps
7
Q
What is contraindicated for the oral route for temperature with a glass instrument?
A
Oral diseases
Surgery
Oxygen via mask and they cannot remove
Unconscious
Combative
Seizure-prone
8
Q
How long should one wait if a patient has consumed a hot or cold food or fluid?
A
15 to 30 minutes
9
Q
What are pyrexia manifestations
A
Loss of appetite
Delirium
Seizure
Malaise
Thirst
Hot, dry skin
10
Q
What are dangerous s/s of fever?
A
Dehydration
Rapid HR
Decreased urinary output
11
Q
What can I do to reduce fever?
A
Cooling room
Remove bedding and clothing and keep dry
Increase fluids
12
Q
When is it important to continue checking temperature?
A
Infection
Open wound
Burn
WBC less than 5K or greater than 12K/mm
Post op
Hypothalamus injury
Hypo/hyperthermia therapy
13
Q
What are the manifestations of fever, hyperthermia and heatstroke?
A
Fever (temp more than 100.4 (38 c)
Tacycardia
Muscle/join pain
14
Q
Hyperthermia differs from fever how?
A
Fever is an upward shift of body temp and hyperthermia is an overload of the body’s thermoregulatory mechanisms
15
Q
What are some s/s of hyperthermia?
A
Tachycardia
Decreased skin turgor
Hypotension
Concentrated urine
Decreased venous filling
16
Q
S/s of heatstroke?
A
Dry skin hot to the touch
Tachycardia
Hypotension
Excessive thirst
Muscle cramps
Confusion
Hallucination
Visual disturbance
17
Q
What is the body temp for hypothermia?
A
Core body temp drop to 96.8 F or 36 C
18
Q
What are some hypothermia s/s
A
Uncontrolled shivering
Reduced LOC
Shallow respirations
Bradycardia
Dysrhythmias
19
Q
What is a pulse deficit?
A
Difference b/w apical and radial pulse rate. They the peripheral pulse site might not be heard because the heart’s pulsations are not reaching the peripheral arteries or the pulses are too weak to be palpated
20
Q
Wha happens in the S1 pulse?
A
Low pitched and dull should when the tricuspid and mitral valves
21
Q
How the does the S2 sound and what does it do?
A
Higher pitches and shorter sound when the pulmonic and aortic valves close a the end of ventricular ejection
22
Q
When should I expect alterations in the apical pulse?
A
HD
Dysrhythmias
Acute chest pain
Bleeding
Surgery
Invasive CV Disagnostics
23
Q
Difference between ventilation, diffusion, and perfusion
A
Respiration is ventilation, diffusion, and perfusion
Ventilation- gases into and out of the lungs
Diffusion- moving oxygen and CO2 between alveoli and RBC
Perfusion- blood distribution to and from the blood-gas barrier in the pulmonary capillaries
24
Q
Wha is the number for orthostatic hypotension?
A
Drop in BP of 15 mm HG or more when a client rises from a recumbent position to standing or sitting
25
What is the number for hypertension?
130 mmHG+ and/or 80 mmHG
26
What are the BP cuff sizing guidelines?
40% of circumference or 20% wider than the diameter
27
What kind of reading does a too wide bladder give you?
Falsely low reading
28
What happens if you don’t wrap the BP cuff evenly or too loosely?
Falsely high reading
29
What happens if the BP cuff is deflated or inflated too slowly?
Falsely night diastolic reading
30
What are the best paces to obtain core temps?
Esophagus
Tympanic membrane
Urinary bladder
Pulmonary artery
31
What are the best places to measure the surface body temps?
Mouth
Rectum
Skin
Axilla
32
What does the P stand for in a pain assessment?
Provoke- What caused or causes the pain?
33
What does the Q stand for in a pain assessment?
Quality or type of pain
34
What does the R stand for in a pain assessment?
Region or radiation- Where is the pain and does it travel anywhere?
35
What does the S stand for in a pain assessment?
From a scale from 0-10, can you rate your pain level?
36
What does the T stand for in a pain assessment?
When did the pain start? Is it constant or intermittent?
37
What are some objective indicators of pain with vital signs?
Elevated BP, HR, and RR
38
What are some non-vital sign objective indicators of pain?
muscle tension or rigidity
pallor
nausea
vomiting
fainting
withdrawal to pain
restlessness
guarding
39
What is an objective indicator to severe pain?
Decrease in BP and HR
40
What is the term for how much of a stimulus the client is willing to accept?
Pain tolerance
41
What is the term for the point at which a stimulus causes the client to perceive pain?
Pain threshold
42
What is a moderate number on the pain scale?
4-7
43
What pain scale uses six faces with different expressions?
Wong-Baker FACES
44
What are the three types of nociceptive pain?
Somatic, visceral, and cutaneous
45
What are some factors that can affect perception of pain?
Cultural, ethnic, and religious beliefs
family
support systems
gender/ age
environment
past experiences with pain
anxiety
46
What are the two origins of pain?
Nociceptive and neuropathic
47
What are some drugs to treat neuropathic pain?
Usually adjuvant meds such as antidepressants, antispasmodic agents, skeletal muscle relaxants
48
What are some non pharmacological pain interventions?
Positioning
cutaneous stimulation
heat/cold therapy, touch
massage, acupuncture
hypnosis
acupressure
TENS
Distraction
49
What are some populations at risk for under treatment of pain?
Infants,
children,
older adults,
those with substance abuse disorder
50
What are some type of cancer pain?
Tumor invasion,
Nerve compression
Bone metastases
Associated infections
Immobility
Radiation-induced pain
Postsurgical pain
51
What kind of pain may be common in people in their 30’s 40’s and 50’s?
Headaches
Jaw pain
Abdominal
Back
52
What is the FLACC scale? And who is it used for?
Faces
Legs
Activity
Cry
Consolability
For children from 2 months to 7 years old or who are unable to communicate their pain observed for 1-5 minutes if always and more than 5 minutes
53
What is the CRIES scale used for?
Post-op neonates 38 weeks gestational or less
Crying
Respiration
Increase in vital signs
Expression
Sleep
54
What is the nonverbal PAin scale used for?
A pain scale for people who are so impaired that that they cannot verbally express their pain level or location.
55
A nurse is discussing the challenges of assessing pain in kids with a group of parents. What statements should the nurse include?
They may deny pain to avoid IM injection or bad tasting oral meds.
56
What are some risks for opioids?
Sedation
Respiratory depression
Constipation
Orthostatic hypotension
Urinary retention
Nausea/vomiting
57
Wha take some types of opioids? (6)
Hydrocodone (Vicodin)
Oxycodone (OxyContin)
Morphine
Codeine
Fentanyl
Hydromorphone
Dilantin
58
What are some types of non-opioids?
Acetaminophen
Ibuprofen
Aspirin
59
What are some influencing factors of pain?
Client risk factors
Anxiety
Client trends
Type of pain medication used
60
What major organ does acetaminophen affect?
Liver
61
What medication is bad for those with kidney disease?
Ibuprofen
62
What are some examples of adjuvant analgesics?
Anti depressants
Anticonvulsants
Corticosteroids
Biophosphonates
63
What are some adverse effects of NSAIDS?
Tinnitus
Vertigo
Decreased hearing acuity
Bleeding: long-term NSAID use
64
How often should patients be turned to avoid bedsores?
Every two hours
65
What are some examples of CBT?
Distraction
Relaxation
Imagery
Music therapy
66
Antidepressants work well for what kind of physical pain?
Nerve-related pain, migraines, and arthritis.
67
What is the mnemonic method to screen clients for opioid addiction?
Screening
Brief
Intervention
Referral to
Treatment
68
What are some vitals that should be monitored when patients are on pharmacological pain interventions?
Baseline first
RR quality
O2 levels
69
What is the most critical time for PACU patients?
First hour, and then 24 hour monitoring afterwards
70
What are some considerations a nurse must take into account when carrying out orders?
How much the patient has taken before if any
Any adverse effects of any prior times the medication has been taken
71
A charge nurse is reviewing factors that can affect a client’s perception of pain with a newly licensed nurse. What should the nurse include?
Stress
Culture
Social support
Disease severity
72
Clients who have a healthy liver should take no more that’s how many grams of acetaminophen a day?
Four grams
73
How long should a nurse apply heat therapy to a client’s knee?
No more than 20 minutes with 20 min break
74
A nurse is assisting with a staff in -service regarding pain control. Which of the following statements indicates an understanding of the information - all of them
Client’s religious belief may affect response to pain
Client’s past pain experiences are not related to their current pain management?
If a client can rate their pain, then they may also need to note non verbal findings
Pain control may be harder to achieve if the nurse and client speak different primary languages.
75
A nurse is monitoring a client who is 2 hour post op and is receiving morphine via PCA pump. Which of the following findings should the nurse plan to monitor to detect OIVI?
RR rate
Capnography
O2 sat
76
A nurse is reviewing discharge instructions for a client who has a prescription for morphine oral solution 10 to 20 mg every four hours PRN. What is an indicator of good understanding?
Morphine must be stowed in a safe space
77
What are some non verbal indicators of increased level of pain and discomfort?
Grimacing
Restlessness
Increased sweating
78
What does the ethical principle of justic an dhow it relates to pain management for clients?
Justice requires that all clients be treated fairly in regard to their pain management regardless of age, ethnicity, or history, such as substance use disorder or limited social and economic resources. Pain relief should be available to all clients
79
What are barriers to end-of life pain management?
Fever of addiction
Believe that pain is expected
Inadequate pain assessment
80
If a nurse takes vitals, for a standard precaution, do they need to wear gloves?
No, only if they thing there is a possibility of coming in contact with a client’s bodily fluids
81
If an RN asks another RN or LPN or AP to take vitals, what happens next?
The person obtaining vitals need to report the measurements to the nurse who delegated the tasks
82
What is the formula for Cardiac Output?
The amount of blood pumped into the circulatory system by the heart within one minute
CO= SV X HR
83
What is a common cause of increased afterload?
Hypertension
84
What is the amount of resistance or constriction that the heart must overcome to eject the blood into the systemic circulation ?
Afterload
85
What is the path of flow of blood through the heart?
Superior and inferior vena cava, right atrium, tricuspid valve, right ventricle, pulmonary artery, lungs, pulmonary vein, left atrium, mitral valve, left ventricle
86
What ages should BP be obtained? Any exceptions?
Patients less than three years of age or younger ones with a preexisting condition.
87
When should a nurse use a manual BP measurement? (3)
When the blood pressure is outside of the normal things for the patient.
When a client has a history of elevated or decreased blood pressure
Has manifestations of hypertension on hypotension or is critically ill 
88
How big should a blood pressure cuff be?
About 80% of the cuff
89
How should the client be taking a blood pressure reading?
Patient lying down or seated, but Min need to stand if ortho static measurements are required. If seated, feet must be flat on the floor. Palm rests on the table and palm up
90
What happens if a client cannot have their blood pressure measured on their upper arm?
They can use the upper thigh
91
What are some reasons not to use the arm for BP measuring?
Breast surgery that involves removal of lymph nodes, on that same side
Those with an intravenous catheter
Those with an arteriovenous shunt for hemodialysis
92
When measuring the blood pressure in the thigh, what difference is there in the reading between the sign and brachial reading?
The blood pressure in the thigh is several mmHg higher than in the arm
93
What happens if a blood pressure cuff is too large or applied to loosely?
The bread, pressure reading can give a falsely low reading
94
What are some extrinsic factors that contribute to blood pressure? (8)
Weight,
stimulants, such as caffeine
nicotine
medication
sodium intake
stress
activity novels
anxiety or fear can cause a temporary elevation in blood pressure
95
What are some health status? Is that affect blood pressure?
Pain and fever
96
What health status can cause a decrease in blood pressure?
Hypoglycemia; it can also cause heart failure, which can decrease what pressure
97
How many measurements of elevate pressure is needed to diagnose hypertension?
At least two readings
98
What is the blood pressure reading for stage one hypertension?
When the systolic blood pressure is 130 to 139 mm pressure is 80 to 89 mmHg
99
What is the body’s normal blood pressure?
Systolic is less than 120 and diastolic is less than 80 mmHg
100
What is considered elevated blood pressure levels?
Systolic pressure of 100 to 129 mmHg and diastolic pressure medicine and 80
101
What is considered a high blood pressure or stage two level?
140 or higher for or diastolic is 90 or higher
102
What is a hypertensive crisis? What pressure level?
Higher than 180 for and/or higher than 120 for diastolic
103
What are some manifestations of hypotension? (5)
Dizziness, nausea, blurred vision, increase, and fatigue
104
What are the levels of hypertension, blood pressure?
Systolic reading is less than 90 mmHg or diastolic pressure reading less than 60 mmHg
105
What are some causes of low pressure? (3)
Dehydration, blood loss shock, such as sepsis
106
What are some causes of orthostatic hypotension? (4)
Dehydration, hypertension, heart, failure, or disorder of the CNS
107
What are some blood pressure readings indicative of orthostatic hypotension
A drop in systolic pressure of at least 20 mmHg or a drop in diastolic pressure of at least 10 mmHg moving to a position, but they can also have it up to 3 minutes
108
What are some medications that affect blood pressure? (3)
beta blockers
Calcium channel blockers
Ace inhibitors
109
What are some manifestations of hypertension? (4)
Dizziness
headache
chest pain
tachycardic
110
What are some ways? The nurse should document the findings of blood pressure readings? (3)
location
Measurement
Body position
111
What can give a falsely high measurement when measuring blood pressure
Applying the blood pressure too tightly attaining the measurements immediately after a client has been smoked a cigarette
112
What are some factors that can lead to falsely low blood pressure measurements? (4)
Leaving the clients arm unsupported, using a cuff that is too large, using a cuff that is too small based on the kinds arm circumference, apply the blood pressure cuff too loosely
113
What are some nursing interventions for hypertension? (6)
Increase fluid, place in an upright position, unless medically contraindicated, client about risk for dizziness and falling, encourage slow position changes, avoid extreme temperatures, stay well hydrated
114
What are some factors that affect the pulse rate? (7)
Body position, or age, activity levels, health condition, body temperature, medications or hypertension
115
What are some causes of tachycardia? (5)
Exercise, anxiety, some medication, caffeine, nicotine
116
What is the Valsalva maneuver used fo?
It is used to elicit a vasovagal response to decrease the heart rate
117
What are some physical manifestations of bradycardia and people who are not fit? (5)
Dizziness, fatigue, shortness of air, chest pain, confusion
118
What are some causes of bradycardia? (5)
Heart Failure, Heart muscle damage, congenital abnormalities, heart muscle damage, hypothyroidism
119
How should the pulse be graded?
0= no pulse, 1= pulse that is weak/diminished (trauma or hemorrhage); 2= normal; 3= pulse that is increased/strong (moderate/strenuous activity); 4= bounding (fluid volume overload b/c HF and fluid overload)
120
Where is the apical pulse of people older than seven y.o.
This is located at the fifth intercostal space on the left side of the chest at the midclavicular line
121
Where can the nurse auscultate the apical pulse in patients younger than seven years old?
Intercostal space on the left of the sternum
122
Where are some common areas to measure the pulse in the body?
Temporal, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial
123
What are some medication’s that can lead to tachycardia?
Epinephrine, levothyrixine, beta adrenergic agonist
124
When should the nurse assess peripheral pulses?
If the client is undergoing a procedure that could affect circulation
125
What can cause a pulse deficit? (3)
Aortic rupture, coronary artery disease, atrial fibrillation
126
Older adults temperatures are expected to have higher or lower body temps than younger adults?
Lower
127
Body temperature is difference between what and what?
Show me the potty and heat loss to the environment
128
When is body temp the highest and lowest?
It is highest in the late afternoon and lowest in the morning
129
What is the most common cause of fever?
Infection
130
What temperature is considered a fever?
I need temperature greater than 38°C for 104°F
131
What are some simple manifestations of? (5)
Tachycardic, increased RR, Flushed face, diaphoretic, and skin that feels hot on palpitation
132
What are some manifestations of hyperthermia? (5_
Hypotension, syncope, confusion, tachycardia, and impaired coordination
133
What are some nursing interventions to deal with hyperthermia? (5)
Removal of clothing, fan, IV, fluids, cold packs
134
What are some early signs of hypothermia? (3)
Poor concentration, pupil dilation , and loss of consciousness
135
What are some serious signs of severe hypothermia? (4)
Loss of deep, tendon, reflexes, and high risk for cardiac arrest
136
What are some side effects of Tylenol?(4)
hepatotoxicity, jaundice, elevated ALT and AST
137
What are some contraindications of acetaminophen? (2)
Alcoholism, liver disease 
138
What are some advantages to taking an oral temperature? (2)
Easily accessible, and accurately measure surface temperature
139
What is a risk for taking an oral temperature? (3)
There’s a risk of exposure to body fluids, and accurate at the time previous 30 minutes, as well as those who are in a coma have altered mental status
140
What are some advantages of using a tympanic membrane temperature? (4)
It is easily accessible, rapid in less than five seconds, accurate, and not altered by environmental temperature
141
What are some disadvantages to taking a tympanic membrane temperature?(3)
It is in accurate, and those who have lots of earwax infection, it is difficult to obtain in newborns infants and children younger than three years old, because of the angle of their ears, it requires the removal of hearing aids
142
What are some disadvantages to using temporal artery temperatures? (5)
Easy access, rapid result, no risk of injury, accurate for all age groups, and reflects rapid changes within the body score temperature
143
What is a disadvantage to using temporal artery temperature measurements? (2)
Affected by moisture on the skin, such as sweat, inaccurate if a client has a head cover or hair on the forehead
144
What is an advantage of taking an axillary temperature? (2)
There is no risk of injury in accurate for all age groups
145
What is an advantage of taking an axillary temperature? (3)
It takes more time to obtain a reading, and other methods, temperature does not reflect rapid changes, and four temperature, and maybe altered by environmental temperature
146
What is an advantage of rectal temperature taking?
Reliable
147
What is the risk of rectal temperature taking?
There is a risk for rectal mucosa injury, can be altered by husbands, unpleasant, cannot be used when the client had diarrhea, hemorrhoids, textile surgery, or coagulation disorders
148
What patients should you not use a rectal temperature on?
Newborns or young children
149
Where should a patient have their temperature taken in their mouth?
The tip of the probe should be put in the pocket lateral to the frenulum and under the clients tongue
150
How should a rectal temperature be taken?
The probe should be covered in lubricant, and then inserted towards the umbilicus one inch for adults and half an inch for infants and young children until the temperature shows
151
How should the pinna be pulled for clients younger than three years and older than three years?
The pinna should be called up and back for those older than three years and down and back for years
152
Where can a temperature sensitive patch be placed in the body?
On the abdomen or forehead 
153
When is it ok to count the RR for one minute?
When the patient has an altered respiratory status or ill
154
What is eupnea?
RR that falls within the expected range
155
What kind of manifestations are associated with tachypnea? (2)
Dizziness, tingling in the hands
156
What are some factors that affect breathing and lead to tachypnea?
Pain, anxiety, increased, physical activity, respiratory infection, pneumonia, and other chronic lung diseases
157
What are some common symptoms of bradypnea? (5)
Dizziness, fatigue, weakness, confusion, impaired coordination
158
What are some possible causes of bradypnea?
Health conditions and medication, such as opioids and sedatives
159
What are some medication that lead too bradypnea?
Opioids, sedatives, General anesthetics, bronchodilators
160
What do amphetamines and cocaine do to breathing?
Increased respiratory rate and depth
161
What can cause apnea?
Hope you weren’t toxicity, trauma, neurologic dysfunction
162
What are respirations that are irregular consist of a cycling pattern of breaths, ranging from shallow to hyperventilation
Cheyne- stokes
163
What kind of respirations are regular in rhythm, but abnormally, deep and rapid- labored breathing
Kussmaul respirations
164
what type of patients usually have Kussmaul respiration?
Diabetics in metabolic acidosis and severe kidney disease
165
SaO2 is estimated amount of oxygen bound to what?
Hemoglobin molecule in RBC
166
SpO2 is an indication of the amount of oxygen being transported to what?
Body tissues
167
What are some additional signs to watch for when monitoring oxygen levels?
Kapilina Beach Homes clients, mental status, skin color and respiratory rate 
168
What are some other respiratory signs to watch for?
Rate, respiratory rhythm, and quality.
169
When is a disposable thermometer probe needed?
Rectal, oral, and tympanic
170
What are the steps to assessing and data collection of vital signs? (16)
1. Review the clients medical records
2. Obtain supplies
3. Provide privacy
4. Introduce yourself to the client
5. Perform hand hygiene and apply any other PPE
6. Identify the client using two unique identifiers
7. Provide client education
8. Check indications of alterations in thermoregulation
9. Select a site
10. Prepare the site if needed
11. Turn on the thermometer and apply the disposal switch cover if needed
12. Obtain the clients temperature
13. Determine if the temperature is within the expected reference range
14. Compare the current finding with previous vitals and identify trends
15. Discuss findings with a client has indicated
16. Ensure client safety before leaving the room
171
Why should the patient be instructed to lift the tongue?
It allows for access to the sublingual pocket
172
Why should we hold an oral thermometer probe?
To stabilize temperature in the oral cavity and stabilize the thermometer
173
What are common sites for temperature taking for young infants?
Axillary and temporal
174
What is the expected upper reference range for temperatures in lower adults?
It is typically lower in older adults because they can have a reduced ability to respond to infection with the fever. Temperature elevation of greater than 37.2°C or 99.0°F or greater than 1.1°C or 2°F above a client’s normal body temperature is suspicious 
175
What are some severe alterations in body temperature manifestation? (2)
Brain damage
Circulatory collapse
176
What are some interventions for unexpected oxygen saturation outcomes? (5)
Positions of client, upright, or elevator head to allow for maximum extension of the clients thoracic cavity
Encourage the client to cough
Administer supplemental oxygen, and prescribed
Notify the provider of findings outside of the expected reference range
Comparative Bernhard emergency interventions is the client has persistently low, oxygenation levels
177
What is the positioning for eight patient who is in bed to assess blood pressure?
Lying in bead with their head slightly elevated
178
What does good capillary refill look like what does it indicate?
Indicates good perfusion. Warm hand would be great.
No dark nail polish
179
How does a diabetic’s blood affect blood pressure?
They have thicker blood due to increased sugar content, so blood pressure goes up
180
What are some causes of fall risk?
Age
Post stroke
Opioid use
Steroids?
