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Pretest
Question 1
The clients temperature at 8:00 AM using an oral electronic thermometer is 36.1C (97.2F). If the respiration, pulse, and blood pressure are within normal range, what would the nurse do next?
1. 2. 3. 4.
Wait 15 minutes and retake it. Check what the clients temperature was the last time. Retake it using a different thermometer. Chart the temperature; it is normal.
Question 2
Which of the following clients meets the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse? A client is in shock The pulse changes with body position changes A client with an arrhythmia It is less than 24 hours since a client's surgical operation
1. 2. 3. 4.
Question 3
It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP?
1. 2. 3. 4.
A patient being prepared for elective facial surgery with a history of stable hypertension. A patient receiving a blood transfusion with a history of transfusion reactions. A client recently started on a new antiarrhythmic agent. A patient who is admitted frequently with asthma attacks.
Question 4
A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by which one of the following: Bounding radial pulse Irregular apical pulse Carotid pulse stronger on the left side than the right Absent posterior tibial and pedal pulses
1. 2. 3. 4.
Question 5
The nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following?
1. 2. 3. 4.
Rationales 1
1. 2.
3.
4.
Depending on that finding, you might want to retake it in a few minutes (no need to wait 15 minutes). Correct. Although the temperature is slightly lower than expected for the morning, it would be best to determine the clients previous temperature range next. This may be a normal range for this client. There is no need to take temperature again with another thermometer to see if the initial thermometer was functioning properly. Chart after determining that the temperature has been measured properly.
Rationales 2
For clients in shock, use the carotid or femoral pulse. 2. The radial pulse is adequate for determining change in orthostatic heart rate. 3. Correct. The apical rate would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm; a radial pulse would only reveal the heart rate and suggest an arrhythmia. 4. The radial pulse is appropriate for routine postoperative vital sign checks for clients with regular pulses.
1.
Rationales 3
1.
2. 3.
4.
Correct. Vital signs measurement may be delegated to UAP if the client is in stable condition, the findings are expected to be predictable, and the technique requires no modification. Only the preoperative client meets these requirements. This client is unstable and vital signs measurement cannot be delegated. In addition to the client being unstable, UAP are not delegated to take apical pulse measurements for the client with an irregular pulse as would be the case with the client newly started on antiarrhythmic medication. This client is unstable and vital signs measurement cannot be delegated.
Rationales 4
Abounding radial pulse is more indicative that perfusion exists. 2. Apical pulses are central and not peripheral. 3. Carotid pulses are central and not peripheral. 4. Correct. The posterior tibial and pedal pulses in the foot are considered peripheral and at least one of them should be palpable in normal individuals.
1.
Rationales 5
1. 2. 3.
4.
Shallow respirations are seen in tachypnea (rapid breathing). Wheezing is a high-pitched breathing sound that may or may not occur with dyspnea. Correct. Dyspnea, difficult or labored breathing, is commonly related to inadequate oxygenation. Therefore, the client is likely to experience shortness of breath, that is, a sense that none of the breaths provide enough oxygen and an immediate second breath is needed. The medical term for coughing up blood is hemoptysis and is unrelated to dyspnea.
Vital Signs
Temperature, Pulse, Respiration, Blood Pressure and Pain Monitor functions of the body Should be a thoughtful, scientific assessment
On admission Change in clients health status Client reports symptoms such as chest pain, feeling hot, or faint Pre and post surgery/invasive procedure Pre and post medication administration that could affect CV system Pre and post nursing intervention that could affect vital signs
TEMPERATURE
Body Temperature
center in the hypothalamus regulates temperature receives messages from cold and warm thermal receptors in the body initiates responses to produce or conserve body heat or increase heat loss
Heat Production
Primary
source is metabolism
Hormones,
muscle movements, and exercise increase metabolism and norepinephrine are released and alter metabolism production decreases and heat production increases
Epinephrine Energy
(primary source) of sweat and humidifying inspired air urine and feces
Evaporation Warming
Eliminating
Radiation
The
uncovered surfaces.
Convection
The
Evaporation
The
Conduction
The
Equipment
Electronic digital or infrared thermometer or tympanic thermometer or glass thermometer. Water-soluble lubricant (for rectal temp.) Gloves (for rectal temp) Facial tissue Disposable thermometer sheath or probe Alcohol pad
Types of Thermometers
Children
Oral 37.0C, 98.6F Rectal 37.5C, 99.5F Axillary 36.5C, 97.6F Tympanic 37.5C, 99.5F Forehead 34.4C, 94.0F
TC = 5/9(TF 32)
STEP-BY-STEP PROCEDURE
PULSE
PULSE
Pulse rate = number of contractions over a peripheral artery in 1 minute
Equipment
Watch
with second hand Stethoscope (for auscultating apical pulse) Doppler ultrasound blood flow detector Alcohol pad
Auscultating
stethoscope
Assessing
apical-radial pulse
Medial antecubital fossa (hollow in front of elbow) Thumb side of the forearm at wrist
Behind knee in the popliteal fossa Inner side of the ankle slightly below the medial malleolus Dorsum of the foot with the foot plantar flexed
Age Gender Exercise Fever Medications Hypovolemia Stress Position changes Pathology
Elders
Pulse Sites
Radial Temporal Carotid Apical
Readily accessible When radial pulse is not accessible During cardiac arrest/shock in adults Determine children up to 3the brain Infants and circulation to years of
age Discrepancies with radial pulse Monitor some medications
Pulse Sites
Brachial Blood pressure Cardiac arrest in infants Cardiac arrest/shock Circulation to a leg; Circulation to lower leg Circulation to the foot Circulation to the foot
Rate
Beats per minute Tachycardia Bradycardia
Rhythm
Equality of beats and
Volume
Strength or amplitude Absent to bounding
STEP-BY-STEP PROCEDURE
RESPIRATION
Respiration
Interchange
Respiratory centers
Medulla oblongata Pons
Chemoreceptors
Medulla Carotid and aortic bodies
Inhalation
Diaphragm contracts (flattens) Ribs move upward and outward Sternum moves outward Enlarging the size of the thorax
Exhalation
Diaphragm relaxes Ribs move downward and inward Sternum moves inward Decreasing the size of the thorax
Blood Circulation
Children
Elders
Rate
Breaths per minute Eupnea Bradypnea Tachypnea
Depth
Normal Deep Shallow
Rhythm
Regular Irregular
Effectiveness
Uptake and transport
of O2
Transport and
Quality
Effort Sounds
elimination of CO2
Assessing Respirations
Inspection Listening
with stethoscope Monitoring arterial blood gas results Using a pulse oximeter
STEP-BY-STEP PROCEDURE
BLOOD PRESSURE
of the blood against arterial walls Controlled by a variety of mechanisms to maintain adequate tissue perfusion Pressure rises as ventricle contracts and falls as heart relaxes
Highest pressure is systolic Lowest pressure is diastolic
Age Exercise Stress Race Gender Medications Obesity Diurnal variations Disease process
Children
Elders
Systolic
Contraction of the
ventricles
Diastolic
Cardiac Cycle.mpg
Korotkoffs Sounds
Korotkoffs Sounds
Phase 1
First faint, clear tapping or thumping
Phase 2
Muffled, whooshing, or swishing sound
Korotkoffs Sounds
Phase 3
Blood flows freely Crisper and more intense sound Thumping quality but softer than in phase 1
Phase 4
Muffled and have a soft, blowing sound
Phase 5
Pressure level when the last sound is heard Period of silence Diastolic pressure
Auscultatory Palpatory
Sites
Upper arm (brachial artery) Thigh (popliteal artery)
diastolic pressure
The
Parts of Sphygmomanometer
Blood pressure monitors register systolic and diastolic blood pressures and often other vital
temperature 37.0C, 98.6F Pulse rate 60 to 100 (80 average) Respirations 12 to 20 breaths/minute Blood pressure 130/85
Delegating to UAP
Body temperature
Routine measurement may be delegated to
UAP UAP reports abnormal temperatures Nurse interprets abnormal temperature and determines response
Delegation to UAP
Pulse
Radial or brachial pulse may be delegated
to UAP Nurse interprets abnormal rates or rhythms and determines response UAP are generally not responsible for assessing apical or one person apical-radial pulses
Delegating to UAP
Respirations
Counting and observing respirations may
Delegation to UAP
Blood pressure
May be delegated to UAP Nurse interprets abnormal readings and
determines response
Oxygen saturation
Application of the pulse oximeter sensor and
Post Test
1. The proper time frame for waiting to check a temperature for the patient who has just had a drink of water is a. 2 minutes. b. 5 minutes c. 10 minutes d. 15 minutes 2. The best thing to do when you get a reading on a digital thermometer that does not seem quite right is to a. record that temperature b. do nothing c. repeat the temperature measurement d. report the measurement immediately
1.
2.
3.
1.
2.
Which of these factors can affect blood pressure? (Choose all that apply)
a. b. c. d. Age Height Recent activity Position
3.
The point which the heart is beating and exerting its greatest force is called
a. b. c. d. Systolic pressure Diastolic pressure Pulse pressure Basal pressure
Answers
1. 2. 3. 4. 5. 6. 7. 8.
d c b d c b a, c, d a
TOTAL POINTS = 10