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30 Cards in this Set
- Front
- Back
What would be the appropriate times to take vital signs in te clinical settings?
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on admission,
routine schedule according to Dr. orders when assessing client in home care settings before and after invasive procedures before and after medication administration when client's physical condition changes before, during and after nursing interventions when client reports symptoms of physical distress feeling ill or different nurse feels it is necessary |
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What is the leading cause of inaccurate BP readings?
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an improperly fitting BP cuff
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What are some cultural considerations to consider when taking vital signs?
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provide privacy,
use gender congruent providers, consult physician and family decision maker of abnormal vital signs, determine client's understanding of new procedures, use interpreter if necessary |
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What are the guidelines for assessing vital signs?
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the nurse is responsible for vital sign measurements,
equipment must be functional and chosen based on client's condition and physical characteristics, knowing the standard range for all vital signs, client's normal range may be different from the standard, know medical history, therapies, and prescribed medication, control environmental factors that may effect vital signs, use and organized and systematic method, nurse collaborates with physician to decide minimum frequency of vital sign assessment, analyze results of vital sign measurements, nurse verifies and communicates significant changes in vital signs, in an out patient setting vital signs are taken before health care provider examines client |
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What are the normal temperature ranges for each site?
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oral(96.8-100.4)
rectal (97.7-101.3) axillary (95.9-99.5) *same site should be used when repeating measurements* no single temp is normal for all people |
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What are the core temperature measurement sites?
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Rectum
Tympanic membrane Esophagus Pulmonary artery Urinary bladder |
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What are the surface sites for taking temp.?
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skin
oral cavity axilla |
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What is the most accurate site for taking an accurate temp.?
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rectal is the most accurate site and is best post-oral surgery
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What are some things to take into consideration when determining potential alterations in body temperature?
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fever
age exercise hormones stress environmental temperature medications daily fluctuations |
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What are the steps for taking and oral temperature?
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1) remove thermometer and attach probe cover
2)ask client to open mouth; then gently place thermometer probe under tongue 3) hold in place with lips closed |
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What are the steps for taking rectal temperature?
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1) draw curtain
2) insert into anus in direction of umbilicus approximately 1 1/2 inches |
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What are the steps for taking axillary temperature?
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1) draw curtain
2)raise are away from torso 3) insert thermometer probe into center of axilla, lower are over probe, place arm across client's chest |
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What are the steps for taking tympanic membrane?
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1) place disposable cover over the otoscope-like lens tip
2) adults: pull ear up and back Child less than 2: pull ear down and back |
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What are the nursing measures to take if client's temperature is above normal range?
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1) cool room temperature
2) reduce external covering 3) keep clothing and bed linen dry 4) apply hypothermia blanket as ordered 5) limit physical activity and sources of emotional stress 6) administer antipyretics as ordered 7) increase fluid intake to at least 3L daily 8) initiate measure to stimulate appetite, and provide nutrients to meed increase energy needs 9) prevent or contro spread of infection |
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What are nursing measures to take if client't temp. is below normal range?
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1) initiate measures to increase body temperature
2) heat room 3) cover client with warm blankets 4) apply hyperthermia blankets 5) close room doors or control drafts 6) encourage warm liquids |
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What are factors to consider when determining alterations in pulse?
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1) history of heart disease
2) cardiac dysrhythmia 3) sudden onset of chest pain or acute pain from any site 4) invasive cardiovascular 5) surgery 6) sudden infusion of large volume of IV fluids 7) internal or external hemorrhage 8) or administration of medications that alter cardiac functions 9) history of peripheral vascular disease 10) age 11) exercise 12) position changes 13) cool extremities 14) thin, shiny skin with decreased hair growth 15) thickened nails 16) poor cardiac circulation 17) high pain rate |
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What are the locations of pulse site?
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1) temporal
2) radial 3) ulnar 4) carotid 5) popliteal 6) petal 7) brachial 8) femoral 9) posterior tibial 10) dorsalis pedis |
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What are the normal ranges of the pulse for all age groups?
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1) birth: 100-160
2) infant: 70-110 3) adolescent: 60-90 4) adult: 60-90 |
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What is the correct procedure for taking and recording the radial pulse?
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if pulse is regular count rate for 30 seconds and multiply by 2. If it is irregular count for 1 whole minute. Record pulse on flow sheet and recor any accompanying signs and symptoms of pulse alterations. Report abnormal findings
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What is the correct procedure for taking and recording the radial pulse?
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locate the PMI(point of maximal impulse) in the 5th intercostal space. count for one full minute if pt is on cardiovasular medication or if it is irregular. report any abnormal findings. Record alterations in nurse's notes.
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What are some nursing interventions to implement if an adult pt's radial pulse if high?
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Identify related data: pain, fear, anxiety, recent activity, low BP, blood loss, elevated temp., inadequate oxygenation
Observe symptoms associated with abnormal cardiac function: dyspnea, fatigue, chest pain, jugular vein distention, cyanosis, pallor of the skin, and edema |
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What are some nursing interventions to implement if and adult pt's radial pulse is low?
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ausculate the apical pulse
confer with the physician and be prepared to order an electrocardiogram |
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What are some nursing interventions to implement if pt's apical pulse if high?
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identify related data
observe symptoms assosiciated with abnormal cardiac function |
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What are some nursing interventions to implement if apical pulse is low?
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observe for signs associated with altered tissue perfusion
have another nurse assess apical pulse report findings to charge nurse/physician |
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What are some nursing interventions if apical rhythm is irregular?
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assess for pulse deficit
an electrocardiogram may be ordered |
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What are some nursing interventions to implement if athere are occasional premature ventricular contractions in a pt with heart disease?
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numerous PVCs or PVCs that alternate with normal heartbeat repeatedly should be reported to Dr.
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What are the implications of a pulse deficit?
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1) an inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pusle sites
2) frequently associated with dysrhythmias and warn of potential alteration to cardiac output 3) to assess for a pulse deficit the nurse and a colleague assess the radial and apical pulse simultaneously and compare measurements 4) the difference between the rates is the pulse deficit 5) both nurses count for a full min. 6) it reflects the number of ineffective cardiac contractions in 1 min. |
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What are some factors that determine a potential for alteration in respirations?
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pain
fever anxiety disease of the chest wall constrictive dressing abdominal incision chronic pulmonary disease cyanosis irritablity confusion labored or difficult breathing adventitious breath sounds |
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What is the correct procedure for taking and recording respirations?
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1) provide privacy
2) chest must be visible 3) observe complete respiratory cycle 4) count normal respirations for 30 seconds and multiply by 2, if irregular count for full min. 5) note shallow, normal, or deep breaths 6) note rhythm 7) record on flow sheet, record abnormal finding in nurses notes, report abnormal findings to Dr. or charge nurse |
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What are the normal parameters for respirations in each age group?
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Adult: 12-20 respiration per min
Newborns: 35-40 Infant (6 months-1yr): 30-50 Toddler(2yrs): 25 3-12yrs: 18-23 |