Written Midterm - Vital Signs and Interpretation

Question 1

Vital signs

Answer 1

Blood pressure
Heart rate (pulse)
Temperature
Respiratory rate

Question 2

Blood pressure measurement: prior to measurement

Answer 2

Seated and rested for 5 minutes

No caffeine, nicotine, or alcohol for 30 minutes prior

Back against the chair, feet flat on the floor, and arm at heart rate level on a flat surface

Verify correct fit

Question 3

How do you verify the correct fit of a blood pressure cuff

Answer 3

Index line should fall between the two range lines

The bladder inside the cuff encircles 80% of the adult arm

The width of bladder is at least 1/2 arm circumference

Question 4

Blood pressure measurement: Placing the cuff on the arm

Answer 4

Should fit snug, but not tight

DO NOT take BP through a shirt

Place cuff 1 inch above the antecubital space and center it over the brachial artery

Palpate the brachial artery to ensure that cuff is positioned correctly

Question 4

What should be done prior to using a stethoscope on the patient?

Answer 4

Clean the diaphragm

Question 5

When placing the stethoscope on the brachial artery, what should you ensure?

Answer 5

Diaphragm is making contact with the skin

Place diaphragm above and medial to the antecubital space

Keep diaphragm just below edge of the cuff

Question 5

How do you determine how far to inflate a BP cuff?

Answer 5

1. Find the radial pulse
2. Inflate the cuff to where the pulse is no longer felt - this is typically ~ 30 mmHg above usual systolic BP
3. Deflate cuff
4. Wait 30 seconds before taking measurement

Question 6

Blood pressure measurement: Remaining steps

Answer 6

Ensure you can see the gauge

Determine how far to inflate the cuff

Place stethoscope in ears

Place stethoscope on brachial artery

Close valve

Inflate cuff to 30 mmHg above usual systolic pressure where the radial pulse disappears

Gently deflate the cuff by 2-3 mmHg/second

Measure korotkoff sounds to obtain the systolic and diastolic BP

Immediately record measurement

Wait 1-2 minutes, then repeat measurement in same arm

Average the readings

Question 7

What HR signifies tachycardia?

Answer 7

> 100 bpm

Question 8

What is a normal HR?

Answer 8

60-100 bpm

Question 9

What is a normal respiratory rate?

Answer 9

8-16 bpm

Question 9

What HR signifies bradycardia?

Answer 9

< 60 bpm

Question 10

What respiratory rate signifies tachypnea?

Answer 10

> 16 bpm

Question 11

What respiratory rate signifies bradypnea?

Answer 11

< 8 bpm

Question 11

One respiration =

Answer 11

One inhalation + one exhalation

Question 12

What cannot occur for at least 5 minutes prior to taking oral temperature?

Answer 12

• smoking
• drinking hot or cold beverages

Question 12

How is respiratory rate measured?

Answer 12

In respirations per minute (rpm)

Assessed by watching the chest rise and fall

Do NOT let the pt know you are watching them so they don’t adjust their breathing