RN Engage 2.0: Vital Signs (Foundational Concepts of RN Practice)
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Questions and Answers

A patient's blood pressure consistently reads 140/90 mmHg. Which physiological process is most likely contributing to this elevated reading?

  • Increased vasodilation, reducing peripheral resistance.
  • Increased sympathetic nervous system activity, causing vasoconstriction. (correct)
  • Enhanced kidney function, promoting fluid excretion.
  • Decreased blood volume, leading to lower pressure.

When assessing a patient's pulse, a nurse notes an irregular rhythm. What is the most appropriate next step?

  • Document the finding and continue with routine vital sign assessment.
  • Notify the provider of the irregular pulse after completing the initial assessment.
  • Auscultate the apical pulse for a full minute to assess for discrepancies. (correct)
  • Immediately administer oxygen to improve tissue perfusion.

A patient's oral temperature is 101.5°F (38.6°C). Which nursing intervention is most appropriate?

  • Apply a cooling blanket to rapidly reduce the patient's temperature.
  • Encourage the patient to increase activity to promote heat dissipation.
  • Administer an antipyretic medication as prescribed and reassess temperature in 30 minutes. (correct)
  • Increase the room temperature to prevent shivering.

A patient is breathing rapidly and shallowly (tachypnea) with a respiratory rate of 28 breaths per minute. What underlying physiological factor is most likely contributing to this?

<p>Increased need for oxygen due to metabolic demands or respiratory distress. (C)</p> Signup and view all the answers

A patient's oxygen saturation (SpO2) is 88% on room air. Which action should the nurse take first?

<p>Administer oxygen via nasal cannula and reassess SpO2. (B)</p> Signup and view all the answers

A nurse is caring for a patient with a known history of hypertension. Which vital sign measurement is most critical to monitor for potential complications?

<p>Blood pressure (C)</p> Signup and view all the answers

During the admission assessment, a patient reports feeling anxious. How might anxiety impact the patient's vital signs?

<p>Increase heart rate and blood pressure (D)</p> Signup and view all the answers

A patient presents with a fever, rapid heart rate (tachycardia), and decreased blood pressure (hypotension). Which condition is most likely indicated by this combination of vital sign abnormalities?

<p>Infection or sepsis (B)</p> Signup and view all the answers

How does increased blood viscosity primarily affect blood pressure?

<p>By increasing resistance to blood flow, leading to higher blood pressure. (A)</p> Signup and view all the answers

A patient's blood vessels have become less elastic due to aging. Which of the following is a likely consequence of this change?

<p>Increased blood pressure due to vessel wall rigidity. (C)</p> Signup and view all the answers

A patient is diagnosed with atherosclerosis, a condition that hardens the arteries. How does this condition typically affect peripheral vascular resistance and blood pressure?

<p>Increases peripheral vascular resistance and raises blood pressure. (C)</p> Signup and view all the answers

If a patient's heart contractility decreases, what is the most direct effect on their cardiac output (CO) and blood pressure?

<p>Decreased CO and decreased blood pressure. (D)</p> Signup and view all the answers

A patient experiencing significant blood loss is likely to have decreased preload. How will this change in preload affect their stroke volume and blood pressure?

<p>Decreased stroke volume and decreased blood pressure. (D)</p> Signup and view all the answers

Chronic hypertension increases afterload on the heart. What is a potential long-term consequence of this increased afterload on the heart's structure and function?

<p>Hypertrophy of the heart muscle and decreased contractility. (B)</p> Signup and view all the answers

Following oxygenation in the lungs, through which vessel does blood return to the heart?

<p>Pulmonary vein (B)</p> Signup and view all the answers

What is the primary advantage of manual blood pressure measurement compared to electronic methods, especially in certain patient populations?

<p>Manual measurements are generally more accurate, particularly in children, older adults, and critically ill patients. (D)</p> Signup and view all the answers

When measuring blood pressure on a patient's arm, what is the recommended cuff width in relation to the limb circumference for accurate readings?

<p>Approximately 80% of the limb circumference. (A)</p> Signup and view all the answers

In the palpation method of blood pressure measurement, what physiological event corresponds to the palpable estimated systolic blood pressure?

<p>The appearance of a pulsatile thrill. (A)</p> Signup and view all the answers

Which of the following scenarios would most likely necessitate the use of manual blood pressure measurement over an electronic device?

<p>When a patient's electronic blood pressure reading is significantly outside the expected range. (B)</p> Signup and view all the answers

Deoxygenated blood enters the right atrium of the heart. Through which valve does it then pass to enter the right ventricle?

<p>Tricuspid valve (D)</p> Signup and view all the answers

During exercise, preload often increases. What is the primary mechanism by which increased preload enhances stroke volume?

<p>By increasing the stretch on ventricular muscle fibers, leading to a more forceful contraction. (D)</p> Signup and view all the answers

If a patient's blood pressure is measured using a cuff that is too small for their arm, what is the most likely effect on the blood pressure reading?

<p>The reading will be falsely higher than the actual blood pressure. (A)</p> Signup and view all the answers

Which of the following represents the correct sequence of blood flow after blood leaves the right ventricle?

<p>Pulmonary artery → Lungs → Pulmonary vein (B)</p> Signup and view all the answers

A nurse observes a client post-surgery who is stable but slightly drowsy. Considering typical postoperative monitoring, what would be the MOST appropriate frequency for vital sign checks for this client?

<p>Every 15 minutes for the first hour, then hourly. (C)</p> Signup and view all the answers

A registered nurse (RN) is caring for several clients. Which task related to vital signs can be MOST appropriately delegated to assistive personnel (AP)?

<p>Measuring routine vital signs for a stable client in long-term care. (A)</p> Signup and view all the answers

During blood product administration, a client suddenly develops chills and a noticeable increase in heart rate. In addition to stopping the transfusion, what is the MOST immediate nursing action related to vital signs?

<p>Immediately measuring and documenting the client's current vital signs. (D)</p> Signup and view all the answers

A nurse notes a client's blood pressure is significantly lower than their baseline. Which physiological factor directly contributes to blood pressure and is MOST likely affected in this scenario?

<p>Decreased cardiac output. (D)</p> Signup and view all the answers

Which statement BEST describes systolic blood pressure?

<p>The maximum pressure exerted against arterial walls during ventricular contraction. (B)</p> Signup and view all the answers

A client's blood volume has significantly decreased due to dehydration. How would this MOST directly affect their blood pressure?

<p>Blood pressure would decrease due to reduced circulatory volume. (D)</p> Signup and view all the answers

An increase in which factor would MOST directly lead to an elevation in blood pressure, assuming other factors remain constant?

<p>Increased blood viscosity. (D)</p> Signup and view all the answers

A client presents with a rapid heart rate and a decreased stroke volume. What is the MOST likely initial effect on their cardiac output?

<p>Cardiac output may remain unchanged or slightly decrease. (A)</p> Signup and view all the answers

When assessing Mr. Ricci, the nurse notes his temperature is 39°C (102.2°F). Which of the following is an expected physiological response to this elevated temperature?

<p>Increased pulse rate. (A)</p> Signup and view all the answers

Mr. Ricci's oxygen saturation (SpO2) is 94% on room air. For a previously healthy adult, how should the nurse interpret this finding?

<p>Slightly below normal, warrants further assessment and potential intervention. (A)</p> Signup and view all the answers

Mr. Ricci reports a productive cough with thick, yellow sputum. This finding is MOST indicative of which condition?

<p>Bacterial infection. (A)</p> Signup and view all the answers

Mr. Ricci’s respiratory rate is 23 breaths per minute. Considering his elevated temperature and cough, how should the nurse interpret this respiratory rate?

<p>Slightly elevated, possibly compensatory due to his condition. (C)</p> Signup and view all the answers

Mr. Ricci states he took acetaminophen about 8 hours prior to assessment. Knowing acetaminophen's typical duration of action, what effect, if any, might this have on his current temperature reading of 39°C (102.2°F)?

<p>Acetaminophen's effect may be diminished, and the current temperature reflects a persistent fever. (D)</p> Signup and view all the answers

The nurse prioritizes interventions for Mr. Ricci based on his immediate needs. Considering his vital signs and symptoms, which nursing intervention is of HIGHEST priority?

<p>Assessing lung sounds and respiratory effort. (D)</p> Signup and view all the answers

Which action demonstrates the nurse applying critical thinking when analyzing Mr. Ricci's vital signs?

<p>Comparing Mr. Ricci's vital signs to established normal ranges and his reported symptoms. (D)</p> Signup and view all the answers

Which of the following is an extrinsic factor that can influence a client's blood pressure?

<p>Sodium intake (C)</p> Signup and view all the answers

A client's blood pressure reading is 125/75 mm Hg. How would this blood pressure be classified?

<p>Elevated (D)</p> Signup and view all the answers

A nurse is assessing a client whose blood pressure consistently reads above 180/120 mm Hg. What condition is the client likely experiencing?

<p>Hypertensive crisis (D)</p> Signup and view all the answers

Which of the following blood pressure readings would be considered Stage 1 hypertension in an adult?

<p>134/84 mm Hg (B)</p> Signup and view all the answers

A school-age male child with a healthy BMI has a blood pressure reading at the 96th percentile for his age on three separate visits. Based on the provided information, how should this child's blood pressure be interpreted?

<p>Pediatric hypertension (C)</p> Signup and view all the answers

A client with hypertension is prescribed antihypertensive medications. What essential information should the nurse provide to the client?

<p>All of the above (D)</p> Signup and view all the answers

A nurse assesses a client and obtains a blood pressure reading of 85/50 mm Hg. The client reports feeling dizzy. What condition is the client likely experiencing?

<p>Hypotension (A)</p> Signup and view all the answers

Which of the following manifestations is indicative of shock due to extreme hypotension?

<p>Cold, pale skin and a rapid breathing rate (A)</p> Signup and view all the answers

A nurse is preparing to measure a client's blood pressure using a thigh cuff. Where should the nurse auscultate to obtain an accurate reading?

<p>Popliteal artery behind the knee (D)</p> Signup and view all the answers

Which statement best describes the trend of blood pressure throughout the lifespan?

<p>Blood pressure gradually increases throughout childhood, reaching adult levels during adolescence. It then tends to increase slightly throughout adulthood until older adulthood, when it decreases slightly. (C)</p> Signup and view all the answers

A client reports regularly using a wrist monitor to track their blood pressure at home. Which statement reflects the most appropriate guidance a nurse should provide?

<p>Individuals should only use technology validated for accuracy and wrist monitors are unsuitable for clinical use unless other blood pressure measurements are not feasible. (A)</p> Signup and view all the answers

Which of the following physiological responses can result in an increase in blood pressure?

<p>Pain (D)</p> Signup and view all the answers

A nurse is reviewing lifestyle modifications with a client diagnosed with stage II hypertension. Which of the following recommendations is most appropriate?

<p>Incorporate regular exercise, stress reduction techniques, a low-sodium diet, and weight loss if needed. (A)</p> Signup and view all the answers

A diagnosis of hypertension is typically based on:

<p>At least two elevated blood pressure readings taken on two or more separate occasions. (C)</p> Signup and view all the answers

What is the primary reason that thickening of arterial vessel walls and decreased elasticity contribute to hypertension?

<p>They increase peripheral vascular resistance. (B)</p> Signup and view all the answers

A nurse obtains a blood pressure reading of 140/90 mm Hg using a cuff that is too narrow for the client's arm. What type of error is most likely present in this reading?

<p>Both systolic and diastolic pressures are falsely elevated. (C)</p> Signup and view all the answers

When measuring blood pressure, at which point on the manometer does the nurse identify the diastolic pressure?

<p>The point at which the Korotkoff sounds disappear completely. (C)</p> Signup and view all the answers

A nurse needs to measure the blood pressure of a client who has a cast on their left forearm. Which alternative site is most appropriate for the nurse to use?

<p>The client's thigh, using a cuff of appropriate size. (C)</p> Signup and view all the answers

A client’s blood pressure is measured in their thigh and reads 130/85 mm Hg. If the blood pressure were measured in the arm, what would you expect the reading to be?

<p>Slightly lower than 130/85 mm Hg. (B)</p> Signup and view all the answers

A nurse palpates the popliteal artery when measuring blood pressure on the client's thigh. Where is the popliteal artery located?

<p>Behind the knee. (C)</p> Signup and view all the answers

What is the recommended rate at which the air pressure should be released from the blood pressure cuff during measurement?

<p>Approximately 2 mm Hg per second. (B)</p> Signup and view all the answers

A client has a history of breast surgery with lymph node removal on the left side. Which arm should the nurse avoid when measuring blood pressure and why?

<p>The left arm, to avoid complications related to altered lymphatic drainage. (A)</p> Signup and view all the answers

Which action by the nurse might cause a falsely elevated blood pressure reading?

<p>Failing to support the client's arm during the measurement. (D)</p> Signup and view all the answers

A nurse is preparing to measure a client's blood pressure. Which of the following actions is most important for the nurse to take prior to the measurement?

<p>Explaining the procedure to the client and ensuring they are resting comfortably. (D)</p> Signup and view all the answers

A client is known to have a large arm circumference exceeding the standard adult cuff size. What is the most appropriate nursing intervention to ensure an accurate blood pressure reading?

<p>Use a forearm cuff or a thigh cuff if the arm circumference is too large. (D)</p> Signup and view all the answers

What does the artery indicator label on a blood pressure cuff need to be aligned with?

<p>The brachial artery. (B)</p> Signup and view all the answers

A client consistently exhibits elevated blood pressure readings in a clinic setting but normal readings at home. This phenomenon is most likely due to what?

<p>White coat syndrome. (A)</p> Signup and view all the answers

What is the correct placement of the blood pressure cuff on the upper arm in relation to the antecubital fossa?

<p>Approximately 1 inch above the antecubital fossa. (B)</p> Signup and view all the answers

The nurse is unable to auscultate Korotkoff sounds while measuring a client's blood pressure after inflating the cuff. What should the nurse do first?

<p>Check the placement of the stethoscope over the brachial artery. (D)</p> Signup and view all the answers

What is the primary reason for advising a client to avoid crossing their legs during blood pressure measurement?

<p>Crossing legs may falsely elevate the blood pressure reading. (D)</p> Signup and view all the answers

A nurse is caring for a client experiencing shock. Which intervention is the priority?

<p>Initiating a rapid infusion of IV fluids or blood products. (B)</p> Signup and view all the answers

A client reports dizziness upon standing. After 1 minute of standing, the nurse observes a blood pressure change from 120/80 mmHg (lying) to 98/70 mmHg. What should the nurse do next?

<p>Recheck the blood pressure 3 minutes after the client has been standing. (D)</p> Signup and view all the answers

A nurse is teaching a client about managing orthostatic hypotension. Which of the following instructions should the nurse include?

<p>Elevate the head of the bed slightly while sleeping . (B)</p> Signup and view all the answers

A client with a history of falls is being assessed for orthostatic hypotension. Which of the following assessment techniques is most appropriate?

<p>Assess blood pressure while the client is lying, sitting, and standing. (B)</p> Signup and view all the answers

A client's blood pressure drops significantly when changing from a lying to a standing position. Besides non-pharmacological interventions, what should the nurse consider?

<p>Evaluate the client's current medications for potential hypotensive effects. (C)</p> Signup and view all the answers

A client reports chest pain and activity intolerance. The nurse recognizes that these symptoms can be associated with which blood pressure alteration?

<p>Decreased cardiac output from hypotension. (C)</p> Signup and view all the answers

After teaching a client about preventing falls related to orthostatic hypotension, which statement by the client indicates a need for further teaching?

<p>I will get out of bed quickly in the morning. (C)</p> Signup and view all the answers

A nurse is evaluating a client's blood pressure readings and notices a consistent downward trend. What is the most appropriate nursing action?

<p>Notify the provider and continue to monitor the client closely. (C)</p> Signup and view all the answers

A nurse documents a client's blood pressure as 110/70 mmHg, right arm, sitting. What additional documentation is essential for a comprehensive record?

<p>Any interventions used and the client’s response. (B)</p> Signup and view all the answers

A nurse is caring for an older adult client at risk for orthostatic hypotension. Which of the following interventions is least appropriate for this client?

<p>Promoting rapid position changes to maintain balance. (A)</p> Signup and view all the answers

A client with hypotension is being discharged. Which discharge instruction is most important for the nurse to emphasize to ensure client safety at home?

<p>Arise slowly from a lying or sitting position. (A)</p> Signup and view all the answers

A nurse observes a drop in a client's systolic blood pressure by 25 mm Hg upon standing. What is the priority nursing intervention based solely on this finding?

<p>Contact the provider to report the change. (C)</p> Signup and view all the answers

A nurse provides care for several clients. Which client is at greatest risk for development of orthostatic hypotension?

<p>An older adult client prescribed diuretics for hypertension. (D)</p> Signup and view all the answers

A client being treated for shock is prescribed medication to increase heart muscle contractility. The nurse understands that this medication is intended to primarily improve which parameter?

<p>Blood pressure. (D)</p> Signup and view all the answers

Which blood pressure readings, taken sequentially, would indicate possible orthostatic hypotension?

<p>120/80 mm Hg sitting, which changes to 110/70 mm Hg standing. (D)</p> Signup and view all the answers

A nurse is caring for a client with hypotension. Which intervention should be implemented first?

<p>Elevate the client’s legs. (D)</p> Signup and view all the answers

Using a blood pressure cuff that is too small for the client's arm would result in what type of blood pressure measurement?

<p>Falsely high measurement. (C)</p> Signup and view all the answers

After gathering supplies, what is the next step a nurse should take when manually measuring a client's blood pressure?

<p>Position the client's arm at heart level. (C)</p> Signup and view all the answers

Which of the following is considered an intrinsic (nonmodifiable) risk factor for hypertension?

<p>Family history of hypertension. (C)</p> Signup and view all the answers

What part of the heart is known as the intrinsic pacemaker?

<p>Sinoatrial (SA) node. (C)</p> Signup and view all the answers

Which of the following pulse rates would be considered within the expected reference range for a 15-year-old adolescent?

<p>65/min (A)</p> Signup and view all the answers

A client's pulse rate increases after walking up stairs. Which factor is most directly influencing this change in pulse rate?

<p>Activity Level. (A)</p> Signup and view all the answers

Which of the following physiological responses would be expected in a client experiencing tachycardia?

<p>Feeling as if their heart is racing. (A)</p> Signup and view all the answers

A nurse is caring for a client experiencing tachycardia. Which intervention should the nurse implement first?

<p>Encourage the client to use relaxation techniques. (C)</p> Signup and view all the answers

The nurse instructs a client with tachycardia to perform the Valsalva maneuver. What is the primary physiological effect the nurse anticipates from this action?

<p>Stimulation of the vagus nerve, leading to decreased heart rate. (C)</p> Signup and view all the answers

What is the expected outcome of stimulating the parasympathetic nervous system?

<p>Decreased heart rate. (A)</p> Signup and view all the answers

Which condition can cause bradycardia?

<p>Hypothyroidism. (B)</p> Signup and view all the answers

A physically fit client has a resting pulse rate of 55/min. What is the most likely explanation for this finding?

<p>The client's heart muscle pumps blood more efficiently. (B)</p> Signup and view all the answers

A client with bradycardia reports experiencing dizziness and fatigue. What is the priority nursing intervention?

<p>Advise the client to change positions slowly. (A)</p> Signup and view all the answers

A nurse assesses a client's pulse and notes an irregular rhythm. What term is used to describe this finding?

<p>Arrhythmia (D)</p> Signup and view all the answers

When auscultating the apical pulse of an adult, where should the nurse place the stethoscope?

<p>Fifth intercostal space, midclavicular line on the left. (D)</p> Signup and view all the answers

A nurse assesses a client's radial pulse and finds it to be weak and thready. What numerical rating would the nurse use to document this finding?

<p>+1 (B)</p> Signup and view all the answers

During an assessment, a nurse identifies an irregular radial pulse. What is the MOST appropriate next step?

<p>Auscultate the apical pulse for one full minute. (C)</p> Signup and view all the answers

A nurse palpates a client's radial pulse and documents it as 'bounding'. What numerical value corresponds with this finding?

<p>+4 (C)</p> Signup and view all the answers

To accurately assess for a pulse deficit, what is required?

<p>Two nurses, one assessing the apical pulse and the other the radial pulse simultaneously. (C)</p> Signup and view all the answers

A nurse is unable to palpate the dorsalis pedis pulse on a client. What is the most appropriate INITIAL action?

<p>Use a Doppler ultrasound stethoscope to assess the pulse. (A)</p> Signup and view all the answers

What is the correct technique for auscultating the apical pulse?

<p>Auscultate for one full minute. (C)</p> Signup and view all the answers

When auscultating heart sounds, which characteristic differentiates S1 from S2?

<p>S1 is a dull, low-pitched sound. (A)</p> Signup and view all the answers

To palpate a peripheral pulse accurately, what technique should the nurse employ?

<p>Use the pads of two or three fingers to apply gentle pressure over the pulse site. (A)</p> Signup and view all the answers

A nurse auscultates a client's apical pulse at 88 beats per minute and palpates the radial pulse at 76 beats per minute. What is the pulse deficit?

<p>12 (C)</p> Signup and view all the answers

Which anatomical location is used to auscultate the pulmonic valve?

<p>Second intercostal space on the left sternal border (A)</p> Signup and view all the answers

Before assessing a client’s pulse rate, what should the nurse ensure?

<p>The client has not exercised or used nicotine in the past few minutes. (C)</p> Signup and view all the answers

Which of the following pulses is NOT routinely assessed during vital sign measurement?

<p>Popliteal​ (C)</p> Signup and view all the answers

A nurse is assessing a 5-year-old child. Where would the nurse expect to find the apical pulse?

<p>Fourth intercostal space, left sternal border. (A)</p> Signup and view all the answers

When documenting pulse strength, what does a '0' indicate?

<p>Absent pulse (A)</p> Signup and view all the answers

Which of the following physiological mechanisms is the primary way the body loses heat through convection?

<p>Air currents moving across the body. (B)</p> Signup and view all the answers

A patient's temperature is 39°C (102.2°F). Given this finding, which of the following assessment findings would the nurse most likely expect?

<p>Tachycardia (A)</p> Signup and view all the answers

A nurse is caring for a client experiencing hyperthermia. Which intervention is most important for the nurse to implement?

<p>Removing excess clothing. (A)</p> Signup and view all the answers

Which statement best differentiates fever from hyperthermia?

<p>Fever involves an upward shift in the hypothalamic set point, while hyperthermia is due to impaired heat loss mechanisms. (A)</p> Signup and view all the answers

A nurse notes that a client who is afebrile begins to shiver. Which physiological process is most likely occurring?

<p>Vasoconstriction (D)</p> Signup and view all the answers

Which of the following clients is at highest risk for developing hyperthermia?

<p>An older adult wearing heavy clothing in hot weather. (C)</p> Signup and view all the answers

A patient is diagnosed with hyperthermia and is starting to show signs of confusion and impaired coordination. Which of the following complications is the patient at most immediate risk for?

<p>Hypotension (A)</p> Signup and view all the answers

A nurse plans to use cold packs to reduce a client's fever. Which location is most appropriate for applying the cold packs?

<p>Axillae (A)</p> Signup and view all the answers

When evaluating the effectiveness of interventions for hyperthermia, which assessment finding indicates improvement?

<p>Improved level of consciousness (A)</p> Signup and view all the answers

A nurse is teaching a client about preventing hyperthermia during exercise. Which instruction is most important?

<p>Drink plenty of fluids. (B)</p> Signup and view all the answers

A 4-year-old child has a temperature of 39.1°C (102.4°F). Which pulse rate would be considered within the expected reference range for this child?

<p>85 bpm (B)</p> Signup and view all the answers

An adolescent patient's pulse rate is 40 bpm. Which medication is most likely responsible for this finding, assuming no underlying cardiac conditions?

<p>A beta-blocker (C)</p> Signup and view all the answers

A newborn has a pulse rate of 158/min. Is this an expected or unexpected assesment finding?

<p>Expected (A)</p> Signup and view all the answers

A nurse is assessing an adult client who has bradycardia, Which of the following physical manifestations of bradycardia should the nurse expect?

<p>Dizziness (C)</p> Signup and view all the answers

A school nurse is reviewing the health records for a group of students who recently had a physical examination. Which of the following students should the nurse identify as having a pulse rate outside of the expected reference range?

<p>10-year-old who has a pulse rate of 118/min (C)</p> Signup and view all the answers

After scanning a temporal artery temperature, what is the next step a nurse should take to ensure an accurate reading?

<p>Touch the sensor to the skin behind the client's earlobe. (A)</p> Signup and view all the answers

For which temperature measurement route is a disposable cover required for a chemical dot thermometer?

<p>Rectal (B)</p> Signup and view all the answers

When using a temperature-sensitive patch, what is critical for the nurse to assess prior to application?

<p>Skin integrity and dryness at the application site. (D)</p> Signup and view all the answers

A client in the PACU has a temperature of 34.9°C (94.8°F). After applying a warming blanket, which assessment finding would indicate the intervention is becoming effective?

<p>The client reports feeling warmer and more alert. (B)</p> Signup and view all the answers

Mr. Ricci's temperature is 39°C (102.2°F), and he is shivering. Beyond antipyretics, which nursing intervention is most appropriate?

<p>Adjusting the room temperature and providing blankets. (D)</p> Signup and view all the answers

During inspiration, what physiological action directly causes air to enter the lungs?

<p>The diaphragm and intercostal muscles contract, expanding the thoracic cavity. (D)</p> Signup and view all the answers

Which nursing action is most important when administering warmed IV fluids to a client with significant hypothermia?

<p>Monitoring the client for signs of fluid overload or cardiac complications. (B)</p> Signup and view all the answers

Why should a nurse avoid informing a client that their respirations are being assessed?

<p>It may cause the client to voluntarily alter their breathing pattern. (D)</p> Signup and view all the answers

A nurse is caring for a newborn at risk for hypothermia. Which intervention is most appropriate to prevent heat loss through radiation?

<p>Moving the newborn away from cold windows. (B)</p> Signup and view all the answers

A newborn has a respiratory rate of 45 breaths per minute. How should the nurse interpret this finding?

<p>As eupnea, indicating a respiratory rate within the expected range. (B)</p> Signup and view all the answers

A client with mild hypothermia is shivering uncontrollably. What is the physiological rationale for this manifestation?

<p>Shivering is the body's attempt to generate heat through muscle activity. (C)</p> Signup and view all the answers

When assessing a client with hypothermia, which neurological change requires the most immediate intervention?

<p>Loss of consciousness (B)</p> Signup and view all the answers

An adult patient is breathing at a rate of 24 breaths per minute. What term should the nurse use to document this?

<p>Tachypnea (A)</p> Signup and view all the answers

A patient reports feeling dizzy and experiencing tingling in their hands. Upon assessment, the nurse notes a respiratory rate of 30 breaths per minute. Which of the following is the most likely cause of these symptoms?

<p>Tachypnea causing excessive carbon dioxide excretion. (C)</p> Signup and view all the answers

A nurse is taking the temperature of a 4-year-old child. Which temperature-taking method would be least appropriate?

<p>Oral (C)</p> Signup and view all the answers

For a client experiencing tachypnea due to anxiety, which intervention is most appropriate?

<p>Providing a calm environment, reassurance, and encouraging slow, deep breaths. (A)</p> Signup and view all the answers

Which factor should a nurse consider when selecting the most appropriate method for measuring a client's body temperature?

<p>The client's age, health status, and any environmental factors. (D)</p> Signup and view all the answers

A client who has just consumed a cup of hot coffee asks the nurse to take their oral temperature. What is the most appropriate action by the nurse?

<p>Wait 15 to 30 minutes before measuring the oral temperature. (A)</p> Signup and view all the answers

When assessing a client's respiratory rate, what is the recommended duration for counting respirations in a stable adult?

<p>30 seconds (A)</p> Signup and view all the answers

Which of the following clients would be most suitable for assessing temperature using the temporal artery method?

<p>A client who is diaphoretic with no head covering. (C)</p> Signup and view all the answers

A nurse observes a client's chest movement while assessing respiration. What is the purpose of this action?

<p>To assess the depth and symmetry of breaths (D)</p> Signup and view all the answers

Why is a rectal temperature contraindicated for a client with a coagulation disorder?

<p>There is a risk for injury to the rectal mucosa, leading to bleeding. (B)</p> Signup and view all the answers

What is the correct term for respirations that fall within the expected reference range?

<p>Eupnea (A)</p> Signup and view all the answers

What underlying mechanism allows for the exchange of gases in the alveoli?

<p>Diffusion (B)</p> Signup and view all the answers

What is the benefit of using a temporal artery thermometer compared to an axillary thermometer?

<p>The temporal artery thermometer takes less time to obtain a reading and reflects rapid changes in core temperature. (A)</p> Signup and view all the answers

Which of the following is a limitation of using a tympanic thermometer for temperature measurement?

<p>The measurement can be inaccurate in clients who have cerumen or an ear infection. (B)</p> Signup and view all the answers

Which of the following conditions may lead to tachypnea?

<p>Metabolic acidosis (B)</p> Signup and view all the answers

A nurse is using an electronic thermometer with separate probes for oral and rectal use. What precaution must the nurse take to ensure an accurate result?

<p>Ensure the correct probe is used and covered with a disposable probe cover prior to each use. (A)</p> Signup and view all the answers

A client is prescribed a rectal temperature, but has a history of hemorrhoids. What should the nurse do?

<p>Consult the healthcare provider about an alternative method for temperature measurement. (B)</p> Signup and view all the answers

Which statement accurately describes the advantage of using an axillary temperature measurement?

<p>It poses no risk of injury to the client. (B)</p> Signup and view all the answers

When using a temporal artery thermometer, what is the most important initial step to ensure accurate temperature measurement?

<p>Ensuring the forehead and temple are free from hair and moisture. (B)</p> Signup and view all the answers

A nurse is preparing to take a tympanic temperature on a 2-year-old child. How should the nurse correctly position the child's ear?

<p>Pull the pinna down and back. (C)</p> Signup and view all the answers

What is the primary reason for applying a disposable cover to a thermometer probe before measuring a patient's temperature?

<p>To prevent the spread of infection. (D)</p> Signup and view all the answers

A client with chronic lung disease has an oxygen saturation of 85%. Besides administering oxygen, which intervention is MOST appropriate initially?

<p>Place the client in an upright position and encourage coughing and deep breathing. (C)</p> Signup and view all the answers

A newborn has a pulse oximeter probe on their foot. What is the MOST important nursing consideration regarding the probe application?

<p>Checking the foot's skin integrity and circulation regularly. (B)</p> Signup and view all the answers

When taking a rectal temperature on an adult, how far should the nurse insert the thermometer probe?

<p>1 inch, angled towards the umbilicus. (D)</p> Signup and view all the answers

When performing oral temperature measurement, what is the primary reason for instructing the client to close their lips around the thermometer probe?

<p>To stabilize the probe and minimize temperature fluctuations. (B)</p> Signup and view all the answers

Which type of thermometer relies on liquid crystals that change color based on temperature and is affected by environmental temperature?

<p>Adhesive patch or tape thermometer. (C)</p> Signup and view all the answers

A client's oxygen saturation drops suddenly from 95% to 88%. They appear anxious and are breathing rapidly. What is the FIRST action the nurse should take?

<p>Assess the client's airway, breathing, and circulation. (C)</p> Signup and view all the answers

A patient with diarrhea needs a temperature taken, what is the best route?

<p>Tympanic (A)</p> Signup and view all the answers

Why is it important to support the arm when taking an axillary temperature of an infant or young child?

<p>To keep the probe from becoming displaced and affecting the accuracy of the measurement. (A)</p> Signup and view all the answers

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted for an exacerbation. Their oxygen saturation is 89% on 2L of oxygen. What is the MOST appropriate intervention?

<p>Titrate oxygen to maintain SpO2 between 88-92%. (A)</p> Signup and view all the answers

Which finding would be MOST concerning in a client with a decreased oxygen saturation level?

<p>Confusion and decreased level of consciousness. (D)</p> Signup and view all the answers

During rectal temperature measurement on an adult client, at what angle and depth should the nurse insert the probe?

<p>Toward the umbilicus, 1 inch. (B)</p> Signup and view all the answers

What is the recommended waiting period before taking an oral temperature on a patient who has just consumed a cup of hot coffee?

<p>30 minutes to allow the oral temperature to return to baseline. (D)</p> Signup and view all the answers

Why is it important to apply lubricant to the temperature probe before inserting it into the rectum?

<p>To reduce friction and prevent rectal mucosa injury. (A)</p> Signup and view all the answers

When measuring an axillary temperature, where should the nurse place the thermometer probe for accurate measurement?

<p>In the center of the axilla, ensuring skin contact. (C)</p> Signup and view all the answers

A client with a history of opioid use presents with bradypnea. Besides administering naloxone, what other vital sign assessment is MOST critical for the nurse to monitor during the intervention?

<p>Skin color, to detect changes in oxygenation. (D)</p> Signup and view all the answers

To ensure an accurate oxygen saturation reading using a finger probe, what should the nurse assess PRIOR to applying the probe?

<p>Skin integrity, moisture, and temperature. (B)</p> Signup and view all the answers

A client is experiencing dyspnea. Which question is MOST important for the nurse to ask when assessing the client's dyspnea?

<p>What activities make your shortness of breath worse? (C)</p> Signup and view all the answers

Following the measurement of a rectal temperature, what is the correct procedure for cleaning the thermometer probe?

<p>Disinfect per facility policy. (D)</p> Signup and view all the answers

When measuring a tympanic temperature on a client older than 3 years, in which direction should the nurse pull the pinna?

<p>Upward and backward. (A)</p> Signup and view all the answers

A client is exhibiting Cheyne-Stokes respirations. Which combination of underlying conditions is MOST likely contributing to this breathing pattern?

<p>Brain tumor and increased intracranial pressure. (C)</p> Signup and view all the answers

A postoperative client has a respiratory rate of 10 breaths per minute. Which term BEST describes this respiratory rate?

<p>Bradypnea (C)</p> Signup and view all the answers

For a child younger than 3 years old, what is the correct technique for positioning the pinna when using a tympanic thermometer?

<p>Pull the pinna down and back. (C)</p> Signup and view all the answers

A nurse is using a chemical dot thermometer. What is a key consideration when using this type of thermometer compared to a digital thermometer?

<p>Chemical dot thermometers may be single-use, reducing the risk of cross-contamination. (C)</p> Signup and view all the answers

A client with diabetic ketoacidosis (DKA) is exhibiting Kussmaul respirations. Which physiological mechanism is the primary driver of this respiratory pattern?

<p>The body's attempt to compensate for metabolic acidosis by blowing off excess carbon dioxide. (A)</p> Signup and view all the answers

Which of the following clients is least suitable for oral temperature measurement?

<p>A confused patient who is unable to follow directions. (A)</p> Signup and view all the answers

An assistive personnel (AP) reports a client's apical pulse is 130 bpm. What action should the nurse take FIRST?

<p>Recheck the apical pulse and assess the client. (A)</p> Signup and view all the answers

When assessing a client's respiratory effort, the nurse notes the presence of subcostal retractions. What does this finding indicate about the client's respiratory status?

<p>The client is experiencing increased work of breathing and respiratory distress. (A)</p> Signup and view all the answers

After inserting the tympanic thermometer probe into the ear canal, why should the probe be gently rotated?

<p>To improve contact with the tympanic membrane for a more accurate reading. (B)</p> Signup and view all the answers

A nurse is assessing a client with heavily pigmented skin and notes an SpO2 reading of 92%. What is the MOST appropriate next step for the nurse?

<p>Check the client's capillary refill and compare SpO2 reading to other clinical signs. (B)</p> Signup and view all the answers

Following the procedure, why is it important for the nurse to assist the client in cleaning the perianal area after taking a rectal temperature?

<p>To remove any remaining lubricant or feces for comfort and hygiene. (B)</p> Signup and view all the answers

A nurse is assessing a client's temperature using a temporal artery thermometer. The reading is significantly higher than previous measurements. What is the most appropriate first action?

<p>Retake the temperature on the other side of the forehead. (B)</p> Signup and view all the answers

What should the nurse do when the reading displayed on the pulse oximeter does not correlate with the client's clinical presentation?

<p>Assess the client's perfusion, probe placement, and compare with other vital signs. (D)</p> Signup and view all the answers

When would it be MOST appropriate for a nurse to avoid delegating the task of assessing a client's body temperature to assistive personnel (AP)?

<p>For a client whose condition is unknown or unstable. (A)</p> Signup and view all the answers

A nurse is preparing to measure a child's oxygen saturation. Which site is MOST appropriate for accurate measurement in this population?

<p>The child's earlobe. (B)</p> Signup and view all the answers

Why should the nurse use their non-dominant hand to separate the client's buttocks when preparing to insert a rectal thermometer?

<p>To have better control with the dominant hand for inserting the probe. (D)</p> Signup and view all the answers

What is the most important consideration when selecting a temperature measurement site for a patient?

<p>The patient's age, condition, and the appropriateness of the site. (C)</p> Signup and view all the answers

What is the primary rationale for cleaning the thermometer according to the facility's policy after taking a patient's temperature, regardless of the method used?

<p>To decrease the risk of microorganism transmission between patients. (C)</p> Signup and view all the answers

A nurse assesses a client and obtains a respiratory rate of 30 breaths per minute. What condition is the client MOST likely experiencing?

<p>Tachypnea (A)</p> Signup and view all the answers

A nurse is having difficulty obtaining a consistent SpO2 reading on a client's finger. Which intervention should the nurse implement first to improve the accuracy of the reading?

<p>Ensure the finger is dry, without nail polish, and reposition the probe. (D)</p> Signup and view all the answers

A nurse is teaching a new graduate nurse how to measure tympanic temperature accurately. Which statement by the new graduate indicates a need for further teaching?

<p>&quot;I should insert the thermometer straight into the ear canal without angling.&quot; (A)</p> Signup and view all the answers

A nurse confirms the pulse rate displayed on the oximeter by palpating the client's radial pulse and notes a significant discrepancy. What is the MOST appropriate initial action?

<p>Move the oximeter to a different site and re-evaluate pulses. (A)</p> Signup and view all the answers

What is the significance of performing hand hygiene both before and after the process of taking a client's temperature, regardless of the method used?

<p>To prevent the spread of microorganisms and maintain infection control. (B)</p> Signup and view all the answers

A client presents with frequent cough, tachycardia, and confusion. Which condition is MOST likely indicated by this combination of manifestations?

<p>Hypoxemia (A)</p> Signup and view all the answers

For which of the following patients would the nurse consider the rectal route to obtain the core temperature?

<p>A 6-month-old infant. (D)</p> Signup and view all the answers

What is the most important action for a nurse to take immediately after removing a rectal temperature probe from a patient?

<p>Discard the probe cover. (D)</p> Signup and view all the answers

The physician orders albuterol for a client experiencing tachypnea due to asthma exacerbation. What is the PRIMARY expected outcome?

<p>Decreased respiratory rate. (D)</p> Signup and view all the answers

A geriatric client has significant hypoxia. What findings should a nurse monitor for?

<p>A decrease in mental alertness and confusion (D)</p> Signup and view all the answers

A client presents with a respiratory rate of 10 breaths per minute. Which assessment finding would warrant immediate notification of the health care provider?

<p>Client reports feeling dizzy. (D)</p> Signup and view all the answers

Why is a disposable probe cover used for most temperature measurement methods?

<p>To decrease the risk of microorganism transmission. (C)</p> Signup and view all the answers

A client reports feeling short of breath or having difficulty breathing. Which condition is the client MOST likely experiencing?

<p>Dyspnea (A)</p> Signup and view all the answers

What should the nurse do immediately after removing the temperature probe from a patient's axilla?

<p>Discard the probe cover. (C)</p> Signup and view all the answers

An unresponsive client is found to have no respirations. What is the priority intervention?

<p>Initiate rescue breathing. (B)</p> Signup and view all the answers

A client with severe kidney disease is exhibiting Kussmaul respirations. What acid-base imbalance is most likely present in this client?

<p>Metabolic acidosis (D)</p> Signup and view all the answers

During tympanic temperature measurement, why is it important to gently insert the probe at a slightly anterior angle?

<p>To follow the natural shape of the ear canal for proper placement. (A)</p> Signup and view all the answers

A nurse is assessing a client's breathing pattern and observes periods of deep, rapid breaths followed by periods of apnea. Which respiratory pattern is the client exhibiting?

<p>Cheyne-Stokes respirations (B)</p> Signup and view all the answers

A nurse is preparing to apply a pulse oximeter to a client's finger. Which factor should the nurse consider to ensure an accurate reading?

<p>Edema (B)</p> Signup and view all the answers

A client has a respiratory rate of 30 breaths per minute. Which of the following conditions is the client most likely experiencing?

<p>Tachypnea (B)</p> Signup and view all the answers

What is the rationale behind discarding the probe cover of a thermometer after use?

<p>To decrease the risk of transmission of microorganisms. (C)</p> Signup and view all the answers

Why is it important to ensure a client's forehead is dry before using a temporal artery thermometer?

<p>Damp skin can lead to an inaccurate measurement. (C)</p> Signup and view all the answers

When using a temporal artery thermometer, why is it important to keep the button depressed while lifting the probe from the forehead and touching it to the skin behind the ear?

<p>To ensure continuous scanning for a more representative temperature. (A)</p> Signup and view all the answers

What action should a nurse take if a client has just finished drinking a cup of hot coffee prior to a scheduled oral temperature measurement?

<p>Wait at least 30 minutes before taking the oral temperature. (D)</p> Signup and view all the answers

An elderly patient has a slightly elevated temperature of 37.4°C (99.3°F). Considering age-related factors, how should the nurse interpret this finding?

<p>It may indicate an infection, warranting further assessment. (A)</p> Signup and view all the answers

Which temperature measurement site is generally avoided in young children due to the risk of injury?

<p>Rectal (A)</p> Signup and view all the answers

After obtaining a client's temperature, what is the next best step for the nurse to take?

<p>Compare the current findings with the client’s previous vital signs. (A)</p> Signup and view all the answers

What is the normal expected range in Celcius for an adult?

<p>36° C to 38° C (C)</p> Signup and view all the answers

Which action is most important for the nurse include before going to the next patient?

<p>Perform Hand Hygiene. (D)</p> Signup and view all the answers

Which of these is not an expected client safety measures.

<p>Dimming the lights. (B)</p> Signup and view all the answers

For a newborn baby, which is the most common site to monitor body temperature?

<p>Axillary or temporal (B)</p> Signup and view all the answers

If a client has eaten in the previous 30 minutes, which method should be avoided.

<p>Oral (C)</p> Signup and view all the answers

If the temperature is above the expected range what are the next steps.

<p>Monitor the client for additional manifestations and Notify the provider of findings outside of the expected reference range. (D)</p> Signup and view all the answers

A nurse is teaching a new graduate nurse on using the tympanic method. What is an important teaching point?

<p>It is difficult to perform accurately in children younger than 3 years of age. (D)</p> Signup and view all the answers

A client’s temperature has been consistently increasing over the past 24 hours. What might the nurse infer from this observation?

<p>A consistent increase in temperature can indicate infection or that previous interventions are no longer effective. (B)</p> Signup and view all the answers

A nurse is preparing to take a client's temperature. What is the MOST important reason for reviewing the client's medical record prior to the procedure?

<p>To identify potential allergies, conditions affecting the technique, and relevant lab results. (C)</p> Signup and view all the answers

A client has a history of a coagulation disorder and reports discomfort and visible hemorrhoids. Which temperature route should the nurse avoid, and why?

<p>Rectal, due to the risk of tissue trauma and bleeding. (C)</p> Signup and view all the answers

The nurse is preparing to use a tympanic thermometer on a client. What action is MOST important to ensure an accurate reading?

<p>Ensure the ear canal is free of excessive cerumen. (B)</p> Signup and view all the answers

When using a temporal artery thermometer, what should the nurse do to ensure an accurate temperature reading?

<p>Ensure the skin is dry and the hair is moved away from the forehead. (B)</p> Signup and view all the answers

Prior to taking an oral temperature, the nurse learns the client just finished a cup of hot coffee. What is the MOST appropriate course of action?

<p>Wait at least 30 minutes before taking the oral temperature. (C)</p> Signup and view all the answers

A nurse observes a client shivering and notes their skin is pale and cool to the touch. What condition should the nurse suspect, and what additional assessment is MOST important?

<p>Hypothermia; assess core temperature. (B)</p> Signup and view all the answers

A nurse is preparing to take a client's oral temperature. Which of the following instructions should the nurse provide to the client for proper placement of the thermometer?

<p>Place the tip of the thermometer under your tongue. (D)</p> Signup and view all the answers

A client reports feeling fatigued and has a documented fever. Given these manifestations, what additional signs and symptoms should the nurse monitor for as potential indicators of altered thermoregulation?

<p>Diaphoresis and irritability. (D)</p> Signup and view all the answers

The nurse closes the door and pulls the curtain before taking the client's temperature. What is the primary rationale for these actions?

<p>To maintain client confidentiality and respect physical privacy. (D)</p> Signup and view all the answers

What is the primary purpose of using a disposable probe cover when measuring a client's temperature, regardless of the route (oral, rectal, tympanic)?

<p>To decrease the risk of microorganism transmission between clients. (B)</p> Signup and view all the answers

A nurse is preparing to delegate temperature measurement to assistive personnel (AP). What information is MOST essential for the nurse to communicate to the AP before they take a client's temperature?

<p>Any contraindications for specific routes based on the client's condition. (B)</p> Signup and view all the answers

A nurse identifies that a client has a elevated temperature. What would be the most appropriate next step?

<p>Assess other vital signs and related symptoms. (A)</p> Signup and view all the answers

A patient has a history of seizures, which temperature taking method should be avoided?

<p>Rectal. (C)</p> Signup and view all the answers

A nurse is caring for a patient that has a low platelet count and is at risk for bleeding. Which method of taking temperature should be avoided?

<p>Rectal. (D)</p> Signup and view all the answers

A client reports breathing through their mouth, which method of assessing temperature should be avoided?

<p>Oral (D)</p> Signup and view all the answers

Flashcards

Vital Signs

Clinical measurements of body functions: blood pressure, pulse, temperature, respirations, and oxygen saturation.

Purpose of Monitoring Vital Signs

To provide a baseline for future comparisons, identify trends and inform treatment decisions.

Significance of Vital Signs

Objective data reflecting the body’s essential functions, crucial for client care across health settings.

Trends in Vital Signs

Consistent patterns in vital signs that indicate a change in a client’s condition.

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Analyzing Vital Signs

To assess the effectiveness of nursing interventions, medications, and treatments.

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Components of Vital Signs

Include blood pressure, pulse rate, body temperature, respiration rate, and oxygen saturation.

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Impact of Vital Signs on Care

Can lead to adjustments in nursing interventions and prescribed treatments.

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Vital signs within the nursing process

Information about vital signs is objective data that is used throughout the nursing process when providing client care.

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Critical Thinking in Nursing

Thinking critically to analyze findings and using clinical judgment to decide on appropriate nursing interventions.

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Institutional Policy

Policies and procedures set by institutions or units regarding frequency of vital sign measurements.

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Intuitive Sense

A nurse's sense of concern about a client, based on experience, even without obvious changes in health status.

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Infection Control

Following guidelines to prevent the spread of infection.

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Delegation

The process of transferring responsibility for a task to another qualified staff member.

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Blood Pressure

Amount of pressure exerted by blood on artery walls.

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Systolic Pressure

Maximum pressure when the heart contracts.

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Diastolic Pressure

Minimum pressure when the heart relaxes.

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Cardiac Output (CO)

Volume of blood pumped by the heart in one minute.

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Stroke Volume (SV)

Volume of blood ejected by the ventricle in one contraction.

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Cardiac Output Formula

CO = SV x HR

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Increase in Cardiac Output

An increase of cardiac output has what effect on blood pressure?

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Blood Volume

Amount of blood circulating in the body.

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Blood Viscosity

Thickness of the blood

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Decreased Blood Volume

What happens to blood pressue when blood volume decreases?

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Cuff too narrow

Blood pressure reading will be higher than the actual value.

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Cuff too wide

Blood pressure reading will be lower than the actual value.

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Cuff placement

Approximately 1 inch above the antecubital fossa.

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Artery indicator

Align with the brachial artery.

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Cuff inflation

Inflate cuff ~30 mm Hg above expected systolic pressure.

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Korotkoff sounds

Auscultate Korotkoff sounds during cuff deflation.

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Arm contraindications

Breast surgery with lymph node removal, recent surgery/injury, IV line, or AV shunt.

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Thigh as alternative site

Severe edema or bilateral arm contraindications.

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Thigh blood pressure

Palpate the popliteal artery or auscultate the pulse with a stethoscope.

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Thigh pressure vs. arm

In most adults, it is higher than in the arm.

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Alternative methods for inaccurate readings

Use forearm, thigh, or conical-shaped cuff.

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Cuff too small/tight

Falsely high reading.

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"White coat syndrome"

Anxiety-induced blood pressure elevation in a medical setting.

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Viscosity

Resistance to flow increases blood pressure.

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Elasticity

Vessel's ability to stretch and return to shape.

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Peripheral Vascular Resistance

Vessels' ability to accommodate blood flow.

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Contractility

Heart's ability to contract efficiently.

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Preload

Blood volume in ventricles before contraction.

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Afterload

Resistance heart overcomes to eject blood.

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Heart Blood Flow

Vena cavae → R atrium → tricuspid valve → R ventricle → pulmonary artery → Lungs → pulmonary vein → L atrium → mitral valve → L ventricle → aorta.

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Sphygmomanometer

Device for manually measuring blood pressure.

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Stethoscope

Instrument used for listening to body sounds.

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Palpating Blood Pressure

Estimating BP by feeling artery pulsations.

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Electronic Blood Pressure Machine

Cuff that automatically inflates to measure BP

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Appropriate Cuff Size

80% of the client's limb circumference.

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Preload

Amount of blood inside the ventricles before they contract.

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Vessel Elasticity

The ability of blood vessels to stretch, compress, and return to their original shape.

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Popliteal Artery Auscultation

Listen for blood flow sounds in the popliteal artery.

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Blood Pressure Factors

Dynamic; influenced by intrinsic (age, genetics) and extrinsic (weight, stimulants) factors.

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Hypertension

Blood pressure above the normal range, increasing risk of heart attack and stroke.

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Cause of Hypertension

Thickening and decreased elasticity of arterial walls, increasing peripheral vascular resistance.

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Diagnosing Hypertension

Requires multiple elevated readings on separate occasions for diagnosis.

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Elevated Blood Pressure

Systolic 120-129 mm Hg and diastolic less than 80 mm Hg.

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Stage I Hypertension

Systolic 130-139 mm Hg or diastolic 80-89 mm Hg.

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Stage II Hypertension

Systolic 140 mm Hg or greater, or diastolic 90 mm Hg or greater.

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Hypertensive Crisis

Systolic >180 mm Hg and/or diastolic >120 mm Hg; requires immediate medical attention.

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Pediatric Hypertension

Blood pressure at or above the 95th percentile for age on three separate visits.

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Hypertension Interventions

Exercise, stress reduction, low-sodium diet, and weight loss (if needed).

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Hypotension

Blood pressure below normal; systolic <90 mm Hg or diastolic <60 mm Hg.

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Causes of Hypotension

Dehydration, blood loss, shock, sepsis.

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Hypotension Symptoms

Dizziness, nausea, blurred vision, increased pulse, fatigue.

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Shock Symptoms

Cold, pale skin; rapid breathing; weak, rapid pulse.

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Arrhythmias

Irregular heart rhythms that can be harmless or cause symptoms like shortness of breath or dizziness.

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Auscultating Apical Pulse

Listening to the heart at the apex (bottom) to confirm irregularities detected in the radial pulse.

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Apical Pulse Location (Adults)

The fifth intercostal space on the left midclavicular line.

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S1 Heart Sound

Dull, low-pitched sound when the mitral and tricuspid valves close.

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S2 Heart Sound

Shorter, higher-pitched sound when the aortic and pulmonic valves close.

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Aortic Valve Auscultation Location

Second intercostal space on the right side of the chest.

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Determining Apical Pulse Rate

Count the number of "lub-dub" sounds heard in one minute.

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Peripheral Pulses

Pulse sites located away from the heart, such as temporal, radial, and dorsalis pedis.

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Radial Pulse

The most common site for routine pulse rate assessment.

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Pulse Deficit

Difference between apical and peripheral pulse rates.

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Palpating a Pulse

Using finger pads to apply gentle pressure over a pulse site.

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Pulse Rating Scale

0 = absent, +1 = weak, +2 = normal, +3 = strong, +4 = bounding.

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Bilateral Pulse Equality

Comparing pulse findings from both sides of the body.

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Doppler Ultrasound Stethoscope (DUS)

Using a Doppler ultrasound stethoscope to detect a pulse that is difficult to palpate.

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Manifestations of Impaired Circulation

Cool skin or changes in skin color in the extremities.

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Shock Interventions

Rapid interventions to increase blood pressure and heart contractility.

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Orthostatic Hypotension

Blood pressure drop upon standing/sitting; systolic decrease ≥20mmHg or diastolic ≥10mmHg.

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Assess for Orthostatic Hypotension

Lying, sitting, then standing.

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Orthostatic Hypotension - 3 Minute Recheck

Recheck blood pressure at 3 minutes for persistent symptoms/drops.

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Interventions for Hypotension

Increase oral fluid intake or administer IV fluids.

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Prevent Orthostatic Hypotension

Slow position changes, elevate head of bed, avoid prolonged sitting/lying.

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Medication Review for Hypotension

Review meds for hypotensive effects and discuss with provider.

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Hypotension Risks

Dizziness, falls, temperature extremes, and dehydration.

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Evaluate Hypotension Treatment

Reassess blood pressure after interventions.

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Anxiety-Induced Hypertension

Build rapport; instruct client to relax, breathe deeply and slowly.

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Data drives action.

Effectiveness and next steps in treatment.

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Persistent Increased BP

Continue effective interventions; if not effective, document and notify provider.

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Document BP Measurement

Measurements in mm Hg, site of measurement, and client position.

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Next step to evaluate effectiveness

Recheck the client's blood pressure after having them relax and take slow, deep breaths.

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Factors Increasing BP

Anxiety, use of nicotine, obesity, and fear.

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Pulse

Rhythmic dilation of arteries caused by left ventricle contraction.

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SA Node

Intrinsic pacemaker of the heart; generates electrical impulses.

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Tachycardia

Adult pulse rate greater than 100/min.

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Tachycardia Management

Relaxation techniques or the Valsalva maneuver.

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Bradycardia

Adult pulse rate less than 60/min.

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Bradycardia Management

Change positions slowly, take medications as prescribed, notify provider of changes.

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Normal Newborn Pulse

Newborn (birth to 28 days) pulse range.

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Normal Infant Pulse

Infant (1 month to 1 year) pulse range.

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Normal Toddler Pulse

Toddler (1 to 3 years) pulse range.

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Normal Preschooler Pulse

Preschooler (3 to 6 years) pulse range.

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Normal School-age Pulse

School-age (6 to 12 years) pulse range.

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Normal Adolescent Pulse

Adolescent (12 to 20 years) pulse range.

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Normal Adult Pulse

Adult (20 years and older) pulse range.

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Tachycardia Risk

Fever due to infection can cause this vital sign abnormality.

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Bradycardia Manifestation

Dizziness can result from a low heart rate, affecting blood flow to the brain.

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Core Temperature

Body temperature of deep tissues.

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Surface Temperature

Body temperature of skin, fat, and subcutaneous tissue.

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Expected Body Temperature Range

Normal body temperature range: 36° C to 38° C (96.8° F to 100.4° F).

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Fever

The increase of body temperature due to an upward shift of the body’s natural set point in the hypothalamus gland.

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Febrile

The state of having a fever.

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Afebrile

Without fever; body temperature within the normal range.

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Hyperthermia

Increase in temperature due to the body’s inability to stop heat production or stimulate heat loss.

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Hyperthermia Symptoms

Dizziness, weakness and thirst are initial signs.

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Hyperthermia Interventions

Move the client to a cooler environment, remove excess clothing.

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Conduction

Loss of heat due to direct contact with a cooler surface.

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Convection

Loss of heat due to air currents.

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Thermometer Disinfection

Disinfect the thermometer sensor probe after use, following facility policy.

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Rectal Thermometer Cover

Apply a disposable cover to a chemical dot thermometer before rectal use.

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Temperature Patch Prep

Ensure skin is dry and intact, and environment temperature is neutral.

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Inspiration

The intake of air into the lungs to oxygenate body tissues.

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Expiration

Expelling carbon dioxide, a waste product, from the lungs.

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Gas Exchange

Occurs via diffusion between alveolar air and pulmonary capillaries.

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Healthy Breathing

Breathing should be silent and require minimal effort.

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Respiratory Rate

Count inspirations and expirations to determine breaths per minute.

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Eupnea

Normal respiratory rate.

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Newborn Respiratory Rate

30-60 breaths per minute.

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Infant Respiratory Rate

25-60 breaths per minute.

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Toddler Respiratory Rate

25-30 breaths per minute.

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Preschooler Respiratory Rate

20-25 breaths per minute.

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School age Respiratory Rate

20-25 breaths per minute.

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Adolescent Respiratory Rate

16-20 breaths per minute.

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Adult Respiratory Rate

12-20 breaths per minute.

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Tachypnea

Respiratory rate above the expected reference range.

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Temporal Artery Thermometer

Uses infrared technology to measure temperature via the temporal artery on the forehead.

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Chemical Dot Thermometer

A thin plastic strip with chemical-filled dots that change color to indicate temperature.

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Adhesive Patch/Tape Thermometer

A patch or tape with liquid crystals that change color based on skin temperature.

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Oral Temperature

Temperature taken under the tongue using a thermometer.

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Sublingual Area

Area under the tongue where oral temperature is typically measured; lateral to the frenulum.

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Oral Temperature Delay

Wait 15-30 minutes after hot/cold drinks before temperature measurement.

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Axillary Temperature

Temperature taken in the armpit; probe placed in the center of the axilla.

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Rectal Temperature

Temperature taken rectally by inserting a lubricated probe into the rectum.

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Tympanic Temperature

Temperature taken in the ear canal using a tympanic thermometer.

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Tympanic Thermometer Use

Position head away, pull pinna up and back (adults) or down and back (child).

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Temporal Temperature

Temperature taken by sliding a temporal thermometer across the forehead.

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Temporal Temperature Prep

Ensure skin is dry and hair is brushed away from forehead.

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Temporal Thermometer Placement

Place sensor on forehead, slide toward hairline at the temple.

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Probe Cover Use

Disposable cover needed for temperature probe to avoid contamination.

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Oral Temperature Smoking Wait

Wait 15-30 minutes after smoking before oral temperature measurement.

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Early Hypothermia Symptoms

Shivering, decreased motor skills, and impaired peripheral perfusion.

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Advanced Hypothermia Symptoms

Confusion, poor concentration, dilated pupils, and potential loss of consciousness.

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Severe Hypothermia Risks

Loss of deep tendon reflexes and coma, requires immediate intervention.

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Severe Hypothermia Treatment

Warming mats/blankets and warmed IV fluids.

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Monitoring During Hypothermia Treatment

Continuously monitor core body temperature.

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Initial Response to Hypothermia (PACU)

First, apply a warming blanket then administer warmed IV fluids.

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Core Temperature Sites

Oral, tympanic membrane, temporal artery, axillary, and rectal.

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Oral Temperature Advantages

Easily accessible, accurately measures body surface temperature.

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Oral Temperature Limitations

Inaccurate if recent eating/drinking/smoking, risk of exposure to body fluids.

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Tympanic Temperature Advantages

Rapid result, measures core body temperature, not altered by environment.

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Tympanic Temperature Limitations

Inaccurate with cerumen or ear infection, difficult in young children, requires hearing aid removal.

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Temporal Artery Temperature Advantages

Rapid result, accurate for all ages, reflects changes in core temperature.

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Temporal Artery Temperature Limitations

Affected by moisture or head coverings.

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Lips around oral probe

Stabilizes the probe and minimizes temperature variations.

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Hold oral probe still

Prevents injury to the oral mucosa.

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Gentle probe removal

Prevents injury to the oral mucosa and discomfort.

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Discard probe cover

Decreases risk of spreading microorganisms.

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Clean thermometer

Decreases risk of spreading microorganisms.

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Hand hygiene

An important infection control measure.

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Probe in axilla center

Ensures accurate axillary temperature measurement.

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Support arm in axilla

Prevents probe dislodgement in infants and young children.

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Hand hygiene

Essential infection control measure.

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Side-lying position

Provides easy access to the rectum.

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Lubricate rectal probe

Decreases client discomfort during rectal temperature measurement.

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Separate buttocks

Allows access to the rectum.

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Probe towards umbilicus

Follows rectum's natural shape, reducing injury risk.

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Hold rectal probe still

Prevent accidental removal or movement during rectal temperature measurement.

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Scan tympanic membrane

Infrared scans tympanic membrane for temperature.

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Pulse Oximetry

Noninvasive method to measure blood oxygen saturation.

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Earlobe Pulse Oximetry Steps

Apply the probe to the earlobe, confirm pulse, observe reading.

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Skin Prep for Oximetry

Clean, dry, intact skin ensures accurate probe readings.

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Probe Application

Wrap snugly, avoiding circulation restriction.

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Causes of Decreased SpO2

Pneumonia, lung disease, hypothermia, or decreased perfusion.

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Dyspnea

Shortness of breath or difficulty breathing.

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Hypoxia

Not enough oxygen to body tissues.

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Hypoxemia

Decreased oxygen level in the blood.

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Manifestations of Low SpO2

Frequent cough, tachycardia, confusion.

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Interventions for Low SpO2

Upright position, deep breaths, cough, supplemental O2, bronchodilators.

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Monitoring Low SpO2

Monitor mental status, capillary refill, skin color.

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Assessing Respiratory Status

Closely watching respiratory rate, rhythm, and quality.

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Preparing for Respiratory Distress

Ensure intubation equipment is readily available.

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Verify Client Identity

Ensure correct procedure on correct client.

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Tachypnea Treatment (Asthma)

Administer bronchodilators and maintain an upright position.

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Evaluating Tachypnea Interventions

Reassess respiratory status after interventions.

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Bradypnea

Respiratory rate lower than expected reference range.

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Bradypnea Symptoms

Dizziness, fatigue, weakness, confusion, and impaired coordination.

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Causes of Bradypnea

Increased intracranial pressure, hypothyroidism, shock, overdose, obesity.

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Bradypnea Treatment

Administer naloxone for opioid toxicity; elevate head of bed for increased intracranial pressure.

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Evaluating Bradypnea Interventions

Monitor respiratory rate, skin color, and oxygen saturation.

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Apnea Consequences

Requires immediate intervention due to respiratory arrest.

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Cheyne-Stokes Respirations

Irregular respirations with shallow-to-deep breaths, followed by apnea.

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Causes of Cheyne-Stokes

Increased intracranial pressure, brain tumor, stroke, heart failure.

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Kussmaul Respirations

Deep and rapid respirations due to severe metabolic acidosis.

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Retractions

Use of accessory muscles, causing inward pulling during inspiration.

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Oxygen Saturation (SpO2)

Estimated amount of oxygen bound to hemoglobin in red blood cells.

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Holding Thermometer Still

Ensures accurate measurement and minimizes discomfort/injury.

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Discarding Probe Cover

Minimizes microorganism transmission.

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Cleaning Thermometer

Reduces the spread of microorganisms.

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Forehead Preparation

Allows easy access to site and increases accuracy.

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Disposable Probe Cover

Decreases microorganism transmission.

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Probe Placement (Forehead)

Ensures accurate measurement.

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Sliding the Probe

Initiates scanning across forehead to hairline/temple.

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Probe Behind the Ear

Ensures accuracy.

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Releasing the Button

Temperature displays on the thermometer.

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Expected Temperature Range

The expected reference range for body temperature.

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Previous Vital Signs Data

Determines baseline and tracks changes over time.

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Infant Temperature Site

The axillary and temporal methods for newborns and young infants.

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Older Adult Temperature

Older adults have decreased ability to respond to infection with a fever.

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Standard Precautions

Actions used with all clients to prevent infection transmission.

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Additional Infection Control Measures

Used for specific infections or situations in addition to standard precautions.

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PPE (Personal Protective Equipment)

Non-sterile gloves and other equipment like masks and gowns

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Disposable Thermometer Probe Cover

Decreases risk of microorganism transmission between clients.

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Review Client Medical Record

Reviewing records to check WBC count, temperature trends and allergies

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Provide Privacy

Respect a client’s right by closing doors and curtains.

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Identify the Client

Using two methods to verify you have the right client.

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Hypothermia Manifestations

Shivering, fatigue and confusion.

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Fever Manifestations

Fatigue and shivering

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Rectal Route Contraindications

Diarrhea or recent rectal surgeries.

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Oral Route Contraindication

Recent oral surgery

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Tympanic Membrane Considerations

Cerumen can obscure the ear canal, providing an erroneous measurement.

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Oral Temperature Interference

Consuming either hot or cold food or drinks.

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Oral Thermometer Placement

The probe should rest in the sublingual pocket, near the frenulum.

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Study Notes

Vital Signs Overview

  • Vital signs include blood pressure, pulse, body temperature, respiration, and oxygen saturation.
  • Vital signs are key indicators of a client’s health status.
  • Information about vital signs is objective data that is used throughout the nursing process when providing client care.
  • Vital signs can determine nursing interventions and other prescribed treatments.
  • Common situations for measuring vital signs include the start of a healthcare encounter, as directed by institutional/unit policies, post-surgery/procedures, change in health status, and during special situations like blood transfusions or medication administration.
  • Hand hygiene should be performed before and after obtaining a client’s vital signs.
  • Gloves should be worn if there is a possibility of coming in contact with a client’s body fluids.
  • RNs can delegate measurement of vital signs to other RNs, LPNs, or AP, and LPNs can delegate to other LPNs or AP, with the measurements reported back.

Blood Pressure

  • Blood pressure measures the pressure exerted by blood in the circulatory system.
  • It is measured in millimeters of mercury (mm Hg), expressed as systolic over diastolic pressure.
  • Systolic pressure is the maximum pressure during heart contraction (systole).
  • Diastolic pressure is the minimum pressure when the heart is relaxed (diastole).
  • Blood pressure reflects cardiac output, blood volume, blood viscosity, vascular elasticity, and peripheral vascular resistance.
  • Cardiac output (CO) is the amount of blood pumped by the heart per minute, calculated as stroke volume (SV) multiplied by heart rate (HR): CO = SV × HR.
  • Decreased blood volume decreases blood pressure.
  • Increased viscosity increases blood pressure.
  • Decreased elasticity increases blood pressure.
  • Increased peripheral vascular resistance increases blood pressure.
  • Contractility signifies the heart's efficiency, indicated by the ejection fraction from an echocardiogram.
  • A decrease in contractility causes a decreased CO, thereby decreasing blood pressure.
  • Preload refers to the amount of blood inside the ventricles before they contract
  • If preload is decreased, such as from blood loss or shock, both the stroke volume and blood pressure decrease.
  • Afterload is the resistance the heart must overcome to eject blood into systemic circulation; increased afterload can lead to hypertrophy.
  • Accurate blood pressure measurements are crucial for treatment decisions.

Measuring Blood Pressure

  • Manual measurement uses a sphygmomanometer (blood pressure cuff) and stethoscope.
  • Palpation method estimates systolic and diastolic blood pressure
  • Electronic devices can be used, but manual measurements are more accurate.
  • Manual measurement is recommended for children, older adults, clients with a history of abnormal blood pressure, those with signs of hypertension/hypotension, and critically ill clients.
  • Select a cuff width that encircles approximately 80% of the client’s limb.
  • Improperly fitted cuffs produce inaccurate blood pressure; if it is too narrow, blood pressure will be higher, and a cuff too wide will produce a lower blood pressure reading.
  • Explain the procedure, ask the client to remove restrictive clothing, and ensure the client is supine or seated with feet flat and arm supported at heart level.
  • Apply the cuff snugly about 1 inch above the antecubital fossa, aligning the artery indicator with the brachial artery.
  • Inflate the cuff to 30 mm Hg above the expected systolic pressure value.
  • Release pressure slowly at 2 mm Hg per second while listening for Korotkoff sounds over the brachial artery.
  • Systolic pressure is the point when the first Korotkoff sound is heard.
  • Diastolic pressure is the point when Korotkoff sounds disappear.
  • Avoid using an arm with lymph node removal, recent surgery/injury, or special medical equipment (central line, AV shunt).
  • If the arm cannot be used, measure blood pressure on the thigh, using a thigh cuff and auscultating over the popliteal artery; thigh pressure may be slightly higher than arm pressure.

Factors Affecting Blood Pressure

  • Factors include age, ethnicity, genetics, hormones, weight, stimulants, medications, sodium intake, stress, and activity level.
  • Anxiety, fear, pain, and fever can increase blood pressure, while hypoglycemia and heart failure can decrease it.
  • Digital devices are unsuitable for clinical use unless other blood pressure measurements are not feasible
  • White coat syndrome: elevated blood pressure due to anxiety in a healthcare setting.

Hypertension

  • Hypertension is blood pressure above the expected reference range, increasing the risk of heart attack and stroke.
  • Diagnosis requires multiple elevated readings on separate occasions.
  • Elevated: Systolic 120-129 mm Hg and diastolic <80 mm Hg.
  • Stage I: Systolic 130-139 mm Hg or diastolic 80-89 mm Hg.
  • Stage II: Systolic ≥140 mm Hg or diastolic ≥90 mm Hg.
  • Hypertensive Crisis: Systolic >180 mm Hg and/or diastolic >120 mm Hg.
  • Pediatric hypertension is diagnosed in a child who has a healthy body mass index (BMI) when the blood pressure is at or above the 95th percentile for age on three separate visits.

Hypertension Interventions

  • Lifestyle modifications include exercise, stress reduction, low-sodium diet, and weight loss.
  • Provide information about antihypertensive medications.

Hypotension

  • Hypotension is blood pressure below the expected reference range.
  • In the absence of baseline data, a systolic pressure less than 90 mm Hg or a diastolic pressure less than 60 mm Hg is typically considered hypotension in an adult.
  • Causes include dehydration, blood loss, shock, and significant illness (e.g., sepsis).
  • Manifestations include dizziness, nausea, blurred vision, increased pulse, and fatigue.
  • Extreme hypotension can lead to shock, with symptoms including cold, pale skin; rapid breathing; and weak, rapid pulse.
  • Interventions for shock include IV fluids/blood products and medications to increase blood pressure and contractility.
  • Orthostatic hypotension is a drop in blood pressure upon sitting or standing.
  • A drop in systolic pressure of at least 20 mm Hg, or a drop in diastolic pressure of at least 10 mm Hg, within 1 minute after moving to a sitting or standing position, is indicative of orthostatic hypotension.

Hypotension Interventions

  • Encourage increased fluid intake, administer IV fluids, and use compression stockings.
  • Encourage slow position changes, elevate the head of the bed, and avoid prolonged lying or sitting.
  • Evaluate medications for potential adverse effects on blood pressure.
  • Report any information regarding the medications to the provider.
  • Hypotension may cause activity intolerance or chest pain with exertion.

Evaluating and Documenting Blood Pressure

  • Recheck blood pressure after interventions (e.g., relaxation techniques).
  • Notify the provider if increased blood pressure persists or trends downward.
  • Document blood pressure in mm Hg with the site of measurement and the client’s position.

Pulse

  • Pulse is the rhythmic dilation of arteries from the heart's left ventricle contraction.
  • The sinoatrial (SA) node, located in the right atrium, serves as the heart's intrinsic pacemaker.
  • The SA node produces electrical impulses that travel to the atrioventricular (AV) node near the ventricles of the heart.

Expected Pulse Reference Ranges

  • Newborn (full term; birth to 28 days): 110 to 160/min
  • Infant (1 month to 1 year): 90 to 160/min
  • Toddler (1 to 3 years): 80 to 140/min
  • Preschooler (3 to 6 years): 70 to 120/min
  • School-age (6 to 12 years): 60 to 110/min
  • Adolescent (12 to 20 years): 50 to 100/min
  • Adult (20 years and older): 60 to 100/min

Factors Affecting Pulse Rate

  • Factors like body position, age, activity level, health conditions, body temperature, and medications influence pulse rate.
  • Pulse increases with exercise and fever, decreases with an underactive thyroid and in physically fit individuals.
  • Tachycardia is a pulse rate greater than 100/min in adults.
  • Causes may include exercise, anxiety, medications, caffeine/nicotine, or heart abnormalities.

Tachycardia Interventions

  • Use relaxation techniques (meditation, yoga, guided imagery).
  • Perform the Valsalva maneuver to stimulate the vagus nerve and slow heart rate.
  • Provide information on resources to assist the client in quitting smoking and the use of products that contain nicotine.
  • Instruct the client in how to count the radial pulse and when to notify the provider of the finding.
  • Reevaluate pulse after interventions and notify the provider if tachycardia persists.
  • Bradycardia is a pulse rate less than 60/min in adults.
  • It may be normal in physically fit individuals but can cause dizziness, fatigue, shortness of air, chest pain, or confusion in others.
  • Causes: congenital cardiac abnormalities, heart failure, heart muscle damage, or hypothyroidism.

Bradycardia Interventions

  • Encourage slow position changes, proper medication adherence, and regular medical appointments.
  • Instruct the client in how to count the radial pulse and when to notify the provider of the finding.
  • An arrhythmia is an irregular rhythm or rate outside the expected reference range.
  • Auscultate the apical pulse for 1 full minute to confirm irregularity and notify the provider.
  • Apical pulse is auscultated over the apex of the heart (fifth intercostal space at the midclavicular line for adults/older children, fourth intercostal space for children under 7).

Heart Sounds

  • S1 is a dull, low-pitched “lub” sound when the mitral and tricuspid valves close; it is more easily auscultated with the bell of the stethoscope.
  • S2 is a shorter, higher-pitched, “dub” sound when the aortic and pulmonic valves close; it is better auscultated using the diaphragm of the stethoscope.
  • The aortic valve is heard best at the second intercostal space (ICS) on the right side of the chest, and the pulmonic valve is best at the second ICS on the left side.
  • The tricuspid valve is loudest at the fourth ICS on the left, and the mitral valve at the midclavicular fifth ICS.
  • Peripheral pulses are palpated at sites like temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial.
  • The radial pulse is the most common site for routine assessment.
  • Assess peripheral pulses when circulation may be affected or if manifestations of impaired blood flow are present.
  • A pulse deficit is the difference between the apical and peripheral pulse rates (assessed by two nurses simultaneously); it can indicate heart conditions.

Pulse Assessment Technique

  • Ensure client is relaxed and hasn't exercised or used nicotine recently.
  • Apply gentle pressure with the pads of two or three fingers over the pulse site.
  • Note pulse strength (0 = absent, +1 = weak, +2 = normal, +3 = strong, +4 = bounding) and compare bilaterally.
  • Use a Doppler ultrasound stethoscope (DUS) for nonpalpable or difficult-to-palpate pulses from the wrist to auscultate the pulse.
  • Also, determine if the client has manifestations of impaired circulation, such as cool skin or an alteration in skin color.

Body Temperature

  • Body temperature is the balance of heat production and loss, measured in degrees.
  • Core temperature is the deep tissue temperature, while surface temperature is that of the skin and subcutaneous tissue.
  • Typical reference range: 36° C to 38° C (96.8° F to 100.4° F).
  • Varies throughout the day, with the lowest temperature in the early morning and highest in the late afternoon. It will also increase with exercise and stress, whereas a cool external environment will decrease temperature.
  • The body maintains a constant temperature through shivering, sweating, vasoconstriction, and vasodilation.
  • Heat is produced through metabolic processes, physical activity, and shivering.
  • Heat is lost through conduction, convection, evaporation, and radiation.

Fever and Alterations

  • A fever is an elevated body temperature above the expected reference range resulting from an upward shift of the body’s natural set point in the hypothalamus gland.
  • Above 38° C (100.4° F) indicates fever, often due to infection.
  • A client who has a fever is said to be febrile; when the fever dissipates and the body temperature returns to the expected reference range, the client is considered afebrile.
  • Hyperthermia: increased temperature due to the body's inability to stop heat production or stimulate heat loss.
  • Untreated hyperthermia may cause hypotension, syncope, confusion, tachycardia, impaired coordination, organ failure, and death.

Hyperthermia Interventions

  • Move the client to a cooler environment, remove excess clothing, and apply cold packs to the neck, axillae, and groin.
  • Use a fan to promote heat loss via convection.
  • Administer IV fluids to decrease temperature and maintain hydration.
  • Hypothermia is a decreased core body temperature due to cold exposure or the inability to produce heat.
  • Early signs include shivering, decreased motor skills, and impaired peripheral perfusion.
  • Severe hypothermia can lead to coma, loss of reflexes, and cardiac arrest.

Hypothermia Interventions

  • Use a warming mat or blanket, radiant warmer, and warmed IV fluids to increase the temperature.
  • Increase room temperature, add clothing layers, and use a cap.

Temperature Measurement Sites

  • Oral, tympanic membrane, temporal artery, axillary, and rectal.
  • Use clinical judgment to select the appropriate method; consider age, health status, and environmental factors.
  • Wait 15-30 minutes after eating, drinking, or smoking before taking an oral temperature.
  • Avoid rectal route in newborns/young infants unless prescribed.

Thermometer Types

  • Electronic thermometers with disposable probe covers.
  • Tympanic thermometers measure heat radiating from the tympanic membrane.
  • This handheld device uses infrared scanning from a small speculum that is inserted into a client’s auditory canal.
  • Temporal thermometers are handheld devices that measure temporal artery blood flow, an accurate reading of core body temperature.
  • Chemical dot thermometers use chemicals that change color based on temperature.
  • Temperature-sensitive patches/tape contain liquid crystals that change color based on temperature; environmental temperatures can alter the result.

Temperature Measurement Techniques

  • A disposable cover is applied on the temperature probe, with correct placement and removal.
  • When measuring an oral temperature, the nurse should place the tip of the probe under the client’s tongue (the sublingual area), in the pocket lateral to the frenulum, and instructs the client to close the lips around the probe.
  • Prior to obtaining an axillary temperature, the nurse raises the client’s arm to expose the axilla. The nurse then places the probe in the center of the axilla and lowers the client’s arm.
  • For an adult or adolescent rectal temperature, the probe is inserted approximately 1 inch, toward the umbilicus.
  • For infants and children rectal temperatures the probe is inserted approximately ½ inch, toward the umbilicus.
  • When measuring a tympanic temperature, the nurse gently pulls the pinna of the ear up and back for a client older than 3 years, or down and back for a client younger than 3 years.
  • To measure a client’s temporal temperature, the nurse places the sensor probe of the thermometer on the center of the client’s forehead, above the level of the eyebrows.
  • The nurse applies a disposable cover to a chemical dot thermometer prior to rectal use.

Respiration and Oxygen Saturation

  • Respiration includes inspiration (intake of air) and expiration (expulsion of carbon dioxide).
  • Respiration relies on diaphragm and intercostal muscle contraction for thoracic cavity expansion.
  • In a healthy client, breathing is silent and requires minimal effort.
  • Count respiratory rate when the client is relaxed; for healthy clients, count for 30 seconds and multiply by 2.
  • For clients with respiratory issues, count for 1 full minute.
  • Do not alert the client that you are counting respirations.
  • Respiratory rates are fastest in newborns and infants.

Expected Respiratory Reference Range

  • Newborn (full term; birth to 28 days): 30 to 60/min
  • Infant (1 month to 1 year): 25 to 60/min
  • Toddler (1 to 3 years): 25 to 30/min
  • Preschooler (3 to 6 years): 20 to 25/min
  • School-age (6 to 12 years): 20 to 25/min
  • Adolescent (12 to 20 years): 16 to 20/min
  • Adult (20 years and older): 12 to 20/min
  • Eupnea: respiratory rate is within expected range.
  • Tachypnea: respiratory rate is higher than the expected reference range; may be due to activity, pain, anxiety, or respiratory infection.
  • Bradypnea: respiratory rate is lower than the expected reference range in a client who is not very physically fit; may be caused by increased intracranial pressure, hypothyroidism, shock, alcohol toxicity, opioids, or obesity.
  • Apnea: cessation of respirations, potentially leading to respiratory arrest.
  • Cheyne-Stokes respirations: irregular, cycling pattern of breaths ranging from shallow to deep, followed by periods of hyperventilation, then by an episode of apnea; related to increased intracranial pressure or heart failure.
  • Kussmaul respirations: regular rhythm, abnormally deep and rapid; occurs due to severe metabolic acidosis.
  • The nurse should observe a client’s breathing effort with every respiratory assessment and report manifestations of increased effort to the provider.
  • Retractions: use of accessory muscles, pulling tissue inward during inspiration.

Oxygen Saturation (SpO2)

  • Arterial blood oxygen saturation, or SaO2, is the estimated amount of oxygen bound to the hemoglobin molecule in red blood cells. Measurement of SaO2 by pulse oximetry is referred to as SpO2.
  • SpO2 measures the amount of oxygen bound to hemoglobin and should range from 95% to 100%.
  • In variations the pulse oximetry accuracy can occur for clients with highly pigmented skin tones.
  • The nurse must choose a site that has adequate capillary refill.
  • Measurement is usually obtained via a finger probe (adults/children) or foot/wrist probe (newborns/infants).
  • Ensure the finger is dry and free from dark nail polish or artificial nails.
  • The nurse should confirm the pulse rate by palpating the client’s radial pulse.
  • An earlobe probe can be used with any age and is more reliable with decreased peripheral perfusion.
  • Adhesive probes can be applied to the forehead (children/adults) or foot/wrist (newborns/infants).
  • Dyspnea: the state of feeling short of breath or having difficulty breathing.
  • Hypoxia: insufficient oxygen supplied to body tissues. Significant hypoxia can cause a decrease in mental alertness and confusion.
  • Hypoxemia: decreased oxygen level in the blood.

Interventions for Low Oxygen Saturation

  • Place the client upright and instruct deep breathing/coughing.
  • The provider may prescribe supplemental oxygen and medications, such as bronchodilators, to increase the oxygen saturation level.
  • Monitor mental status, capillary refill, and skin color.
  • May require continuous monitoring, high-flow oxygen, and readiness for intubation.

Assessing Body Temperature

  • Assessing body temperature evaluates the client's overall health status.
  • The nurse can delegate this skill to AP only if the client is stable and has been seen by a licensed nurse/provider.
  • Allergies such as latex that might require the use of alternative equipment, should be noted.
  • Review the WBC count, which is frequently elevated during infection.
  • Obtains supplies and ensures they are clean and properly working.
  • The nurse should monitor the client for manifestations of fever, such as fatigue, shivering, diaphoresis, irritability, restlessness, or anxiety.
  • The nurse turn on the thermometer and apply the disposable probe cover if needed.

Temperature Taking Techniques

  • Ensure the client has not smoked or consumed hot or cold food or drinks in the previous 30 minutes.
  • In the Axillary Method Raises the client’s arm to provides access to the axilla, and places the probe in the center of the axilla.
  • In the Rectal Methods uses the dominant hand to insert the probe into the anus, toward the umbilicus
  • Turns the clients with the head facing away and use the nondominant hand to position the pinna of the ear to apply the Tympanic Method
  • When applying the Temporal Method removes any head scarf, covering, or hair from the client's forehead, and ensures the skin is dry

Monitoring Results

  • The nurse recognizes and considers the temperature based on the site used and environmental factors, client's age, health status, and recent activity level.
  • The nurse checks the client for the presence of an infection when an elevated temperature is detected.
  • The nurse should notify the provider of findings outside of the expected reference range, so that indicated prescriptions can be obtained.

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Learning Objectives:

For each vital sign (blood pressure, pulse, temperature, respirations, oxygen saturation):

  • Describe the physiology and expected reference ranges of vital signs.
  • Describe assessment techniques used to obtain vital signs.
  • Analyze alterations in vital signs.
  • Plan nursing interventions in response to an alteration in vital signs.
  • Evaluate the effectiveness of interventions to determine the extent to which client outcomes have been met.
  • Demonstrate accurate documentation of vital signs.

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