Podcast
Questions and Answers
A patient's blood pressure consistently reads 140/90 mmHg. Which physiological process is most likely contributing to this elevated reading?
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?
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?
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?
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?
A patient's oxygen saturation (SpO2) is 88% on room air. Which action should the nurse take first?
A patient's oxygen saturation (SpO2) is 88% on room air. Which action should the nurse take first?
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?
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?
During the admission assessment, a patient reports feeling anxious. How might anxiety impact the patient's vital signs?
During the admission assessment, a patient reports feeling anxious. How might anxiety impact the patient's vital signs?
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?
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?
How does increased blood viscosity primarily affect blood pressure?
How does increased blood viscosity primarily affect blood pressure?
A patient's blood vessels have become less elastic due to aging. Which of the following is a likely consequence of this change?
A patient's blood vessels have become less elastic due to aging. Which of the following is a likely consequence of this change?
A patient is diagnosed with atherosclerosis, a condition that hardens the arteries. How does this condition typically affect peripheral vascular resistance and blood pressure?
A patient is diagnosed with atherosclerosis, a condition that hardens the arteries. How does this condition typically affect peripheral vascular resistance and blood pressure?
If a patient's heart contractility decreases, what is the most direct effect on their cardiac output (CO) and blood pressure?
If a patient's heart contractility decreases, what is the most direct effect on their cardiac output (CO) and blood pressure?
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?
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?
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?
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?
Following oxygenation in the lungs, through which vessel does blood return to the heart?
Following oxygenation in the lungs, through which vessel does blood return to the heart?
What is the primary advantage of manual blood pressure measurement compared to electronic methods, especially in certain patient populations?
What is the primary advantage of manual blood pressure measurement compared to electronic methods, especially in certain patient populations?
When measuring blood pressure on a patient's arm, what is the recommended cuff width in relation to the limb circumference for accurate readings?
When measuring blood pressure on a patient's arm, what is the recommended cuff width in relation to the limb circumference for accurate readings?
In the palpation method of blood pressure measurement, what physiological event corresponds to the palpable estimated systolic blood pressure?
In the palpation method of blood pressure measurement, what physiological event corresponds to the palpable estimated systolic blood pressure?
Which of the following scenarios would most likely necessitate the use of manual blood pressure measurement over an electronic device?
Which of the following scenarios would most likely necessitate the use of manual blood pressure measurement over an electronic device?
Deoxygenated blood enters the right atrium of the heart. Through which valve does it then pass to enter the right ventricle?
Deoxygenated blood enters the right atrium of the heart. Through which valve does it then pass to enter the right ventricle?
During exercise, preload often increases. What is the primary mechanism by which increased preload enhances stroke volume?
During exercise, preload often increases. What is the primary mechanism by which increased preload enhances stroke volume?
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?
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?
Which of the following represents the correct sequence of blood flow after blood leaves the right ventricle?
Which of the following represents the correct sequence of blood flow after blood leaves the right ventricle?
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?
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?
A registered nurse (RN) is caring for several clients. Which task related to vital signs can be MOST appropriately delegated to assistive personnel (AP)?
A registered nurse (RN) is caring for several clients. Which task related to vital signs can be MOST appropriately delegated to assistive personnel (AP)?
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?
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?
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?
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?
Which statement BEST describes systolic blood pressure?
Which statement BEST describes systolic blood pressure?
A client's blood volume has significantly decreased due to dehydration. How would this MOST directly affect their blood pressure?
A client's blood volume has significantly decreased due to dehydration. How would this MOST directly affect their blood pressure?
An increase in which factor would MOST directly lead to an elevation in blood pressure, assuming other factors remain constant?
An increase in which factor would MOST directly lead to an elevation in blood pressure, assuming other factors remain constant?
A client presents with a rapid heart rate and a decreased stroke volume. What is the MOST likely initial effect on their cardiac output?
A client presents with a rapid heart rate and a decreased stroke volume. What is the MOST likely initial effect on their cardiac output?
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?
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?
Mr. Ricci's oxygen saturation (SpO2) is 94% on room air. For a previously healthy adult, how should the nurse interpret this finding?
Mr. Ricci's oxygen saturation (SpO2) is 94% on room air. For a previously healthy adult, how should the nurse interpret this finding?
Mr. Ricci reports a productive cough with thick, yellow sputum. This finding is MOST indicative of which condition?
Mr. Ricci reports a productive cough with thick, yellow sputum. This finding is MOST indicative of which condition?
Mr. Ricci’s respiratory rate is 23 breaths per minute. Considering his elevated temperature and cough, how should the nurse interpret this respiratory rate?
Mr. Ricci’s respiratory rate is 23 breaths per minute. Considering his elevated temperature and cough, how should the nurse interpret this respiratory rate?
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)?
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)?
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?
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?
Which action demonstrates the nurse applying critical thinking when analyzing Mr. Ricci's vital signs?
Which action demonstrates the nurse applying critical thinking when analyzing Mr. Ricci's vital signs?
Which of the following is an extrinsic factor that can influence a client's blood pressure?
Which of the following is an extrinsic factor that can influence a client's blood pressure?
A client's blood pressure reading is 125/75 mm Hg. How would this blood pressure be classified?
A client's blood pressure reading is 125/75 mm Hg. How would this blood pressure be classified?
A nurse is assessing a client whose blood pressure consistently reads above 180/120 mm Hg. What condition is the client likely experiencing?
A nurse is assessing a client whose blood pressure consistently reads above 180/120 mm Hg. What condition is the client likely experiencing?
Which of the following blood pressure readings would be considered Stage 1 hypertension in an adult?
Which of the following blood pressure readings would be considered Stage 1 hypertension in an adult?
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?
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?
A client with hypertension is prescribed antihypertensive medications. What essential information should the nurse provide to the client?
A client with hypertension is prescribed antihypertensive medications. What essential information should the nurse provide to the client?
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?
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?
Which of the following manifestations is indicative of shock due to extreme hypotension?
Which of the following manifestations is indicative of shock due to extreme hypotension?
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?
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?
Which statement best describes the trend of blood pressure throughout the lifespan?
Which statement best describes the trend of blood pressure throughout the lifespan?
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?
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?
Which of the following physiological responses can result in an increase in blood pressure?
Which of the following physiological responses can result in an increase in blood pressure?
A nurse is reviewing lifestyle modifications with a client diagnosed with stage II hypertension. Which of the following recommendations is most appropriate?
A nurse is reviewing lifestyle modifications with a client diagnosed with stage II hypertension. Which of the following recommendations is most appropriate?
A diagnosis of hypertension is typically based on:
A diagnosis of hypertension is typically based on:
What is the primary reason that thickening of arterial vessel walls and decreased elasticity contribute to hypertension?
What is the primary reason that thickening of arterial vessel walls and decreased elasticity contribute to hypertension?
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?
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?
When measuring blood pressure, at which point on the manometer does the nurse identify the diastolic pressure?
When measuring blood pressure, at which point on the manometer does the nurse identify the diastolic pressure?
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?
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?
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?
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?
A nurse palpates the popliteal artery when measuring blood pressure on the client's thigh. Where is the popliteal artery located?
A nurse palpates the popliteal artery when measuring blood pressure on the client's thigh. Where is the popliteal artery located?
What is the recommended rate at which the air pressure should be released from the blood pressure cuff during measurement?
What is the recommended rate at which the air pressure should be released from the blood pressure cuff during measurement?
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?
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?
Which action by the nurse might cause a falsely elevated blood pressure reading?
Which action by the nurse might cause a falsely elevated blood pressure reading?
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?
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?
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?
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?
What does the artery indicator label on a blood pressure cuff need to be aligned with?
What does the artery indicator label on a blood pressure cuff need to be aligned with?
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?
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?
What is the correct placement of the blood pressure cuff on the upper arm in relation to the antecubital fossa?
What is the correct placement of the blood pressure cuff on the upper arm in relation to the antecubital fossa?
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?
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?
What is the primary reason for advising a client to avoid crossing their legs during blood pressure measurement?
What is the primary reason for advising a client to avoid crossing their legs during blood pressure measurement?
A nurse is caring for a client experiencing shock. Which intervention is the priority?
A nurse is caring for a client experiencing shock. Which intervention is the priority?
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?
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?
A nurse is teaching a client about managing orthostatic hypotension. Which of the following instructions should the nurse include?
A nurse is teaching a client about managing orthostatic hypotension. Which of the following instructions should the nurse include?
A client with a history of falls is being assessed for orthostatic hypotension. Which of the following assessment techniques is most appropriate?
A client with a history of falls is being assessed for orthostatic hypotension. Which of the following assessment techniques is most appropriate?
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?
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?
A client reports chest pain and activity intolerance. The nurse recognizes that these symptoms can be associated with which blood pressure alteration?
A client reports chest pain and activity intolerance. The nurse recognizes that these symptoms can be associated with which blood pressure alteration?
After teaching a client about preventing falls related to orthostatic hypotension, which statement by the client indicates a need for further teaching?
After teaching a client about preventing falls related to orthostatic hypotension, which statement by the client indicates a need for further teaching?
A nurse is evaluating a client's blood pressure readings and notices a consistent downward trend. What is the most appropriate nursing action?
A nurse is evaluating a client's blood pressure readings and notices a consistent downward trend. What is the most appropriate nursing action?
A nurse documents a client's blood pressure as 110/70 mmHg, right arm, sitting. What additional documentation is essential for a comprehensive record?
A nurse documents a client's blood pressure as 110/70 mmHg, right arm, sitting. What additional documentation is essential for a comprehensive record?
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?
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?
A client with hypotension is being discharged. Which discharge instruction is most important for the nurse to emphasize to ensure client safety at home?
A client with hypotension is being discharged. Which discharge instruction is most important for the nurse to emphasize to ensure client safety at home?
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?
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?
A nurse provides care for several clients. Which client is at greatest risk for development of orthostatic hypotension?
A nurse provides care for several clients. Which client is at greatest risk for development of orthostatic hypotension?
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?
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?
Which blood pressure readings, taken sequentially, would indicate possible orthostatic hypotension?
Which blood pressure readings, taken sequentially, would indicate possible orthostatic hypotension?
A nurse is caring for a client with hypotension. Which intervention should be implemented first?
A nurse is caring for a client with hypotension. Which intervention should be implemented first?
Using a blood pressure cuff that is too small for the client's arm would result in what type of blood pressure measurement?
Using a blood pressure cuff that is too small for the client's arm would result in what type of blood pressure measurement?
After gathering supplies, what is the next step a nurse should take when manually measuring a client's blood pressure?
After gathering supplies, what is the next step a nurse should take when manually measuring a client's blood pressure?
Which of the following is considered an intrinsic (nonmodifiable) risk factor for hypertension?
Which of the following is considered an intrinsic (nonmodifiable) risk factor for hypertension?
What part of the heart is known as the intrinsic pacemaker?
What part of the heart is known as the intrinsic pacemaker?
Which of the following pulse rates would be considered within the expected reference range for a 15-year-old adolescent?
Which of the following pulse rates would be considered within the expected reference range for a 15-year-old adolescent?
A client's pulse rate increases after walking up stairs. Which factor is most directly influencing this change in pulse rate?
A client's pulse rate increases after walking up stairs. Which factor is most directly influencing this change in pulse rate?
Which of the following physiological responses would be expected in a client experiencing tachycardia?
Which of the following physiological responses would be expected in a client experiencing tachycardia?
A nurse is caring for a client experiencing tachycardia. Which intervention should the nurse implement first?
A nurse is caring for a client experiencing tachycardia. Which intervention should the nurse implement first?
The nurse instructs a client with tachycardia to perform the Valsalva maneuver. What is the primary physiological effect the nurse anticipates from this action?
The nurse instructs a client with tachycardia to perform the Valsalva maneuver. What is the primary physiological effect the nurse anticipates from this action?
What is the expected outcome of stimulating the parasympathetic nervous system?
What is the expected outcome of stimulating the parasympathetic nervous system?
Which condition can cause bradycardia?
Which condition can cause bradycardia?
A physically fit client has a resting pulse rate of 55/min. What is the most likely explanation for this finding?
A physically fit client has a resting pulse rate of 55/min. What is the most likely explanation for this finding?
A client with bradycardia reports experiencing dizziness and fatigue. What is the priority nursing intervention?
A client with bradycardia reports experiencing dizziness and fatigue. What is the priority nursing intervention?
A nurse assesses a client's pulse and notes an irregular rhythm. What term is used to describe this finding?
A nurse assesses a client's pulse and notes an irregular rhythm. What term is used to describe this finding?
When auscultating the apical pulse of an adult, where should the nurse place the stethoscope?
When auscultating the apical pulse of an adult, where should the nurse place the stethoscope?
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?
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?
During an assessment, a nurse identifies an irregular radial pulse. What is the MOST appropriate next step?
During an assessment, a nurse identifies an irregular radial pulse. What is the MOST appropriate next step?
A nurse palpates a client's radial pulse and documents it as 'bounding'. What numerical value corresponds with this finding?
A nurse palpates a client's radial pulse and documents it as 'bounding'. What numerical value corresponds with this finding?
To accurately assess for a pulse deficit, what is required?
To accurately assess for a pulse deficit, what is required?
A nurse is unable to palpate the dorsalis pedis pulse on a client. What is the most appropriate INITIAL action?
A nurse is unable to palpate the dorsalis pedis pulse on a client. What is the most appropriate INITIAL action?
What is the correct technique for auscultating the apical pulse?
What is the correct technique for auscultating the apical pulse?
When auscultating heart sounds, which characteristic differentiates S1 from S2?
When auscultating heart sounds, which characteristic differentiates S1 from S2?
To palpate a peripheral pulse accurately, what technique should the nurse employ?
To palpate a peripheral pulse accurately, what technique should the nurse employ?
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?
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?
Which anatomical location is used to auscultate the pulmonic valve?
Which anatomical location is used to auscultate the pulmonic valve?
Before assessing a client’s pulse rate, what should the nurse ensure?
Before assessing a client’s pulse rate, what should the nurse ensure?
Which of the following pulses is NOT routinely assessed during vital sign measurement?
Which of the following pulses is NOT routinely assessed during vital sign measurement?
A nurse is assessing a 5-year-old child. Where would the nurse expect to find the apical pulse?
A nurse is assessing a 5-year-old child. Where would the nurse expect to find the apical pulse?
When documenting pulse strength, what does a '0' indicate?
When documenting pulse strength, what does a '0' indicate?
Which of the following physiological mechanisms is the primary way the body loses heat through convection?
Which of the following physiological mechanisms is the primary way the body loses heat through convection?
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?
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?
A nurse is caring for a client experiencing hyperthermia. Which intervention is most important for the nurse to implement?
A nurse is caring for a client experiencing hyperthermia. Which intervention is most important for the nurse to implement?
Which statement best differentiates fever from hyperthermia?
Which statement best differentiates fever from hyperthermia?
A nurse notes that a client who is afebrile begins to shiver. Which physiological process is most likely occurring?
A nurse notes that a client who is afebrile begins to shiver. Which physiological process is most likely occurring?
Which of the following clients is at highest risk for developing hyperthermia?
Which of the following clients is at highest risk for developing hyperthermia?
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?
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?
A nurse plans to use cold packs to reduce a client's fever. Which location is most appropriate for applying the cold packs?
A nurse plans to use cold packs to reduce a client's fever. Which location is most appropriate for applying the cold packs?
When evaluating the effectiveness of interventions for hyperthermia, which assessment finding indicates improvement?
When evaluating the effectiveness of interventions for hyperthermia, which assessment finding indicates improvement?
A nurse is teaching a client about preventing hyperthermia during exercise. Which instruction is most important?
A nurse is teaching a client about preventing hyperthermia during exercise. Which instruction is most important?
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?
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?
An adolescent patient's pulse rate is 40 bpm. Which medication is most likely responsible for this finding, assuming no underlying cardiac conditions?
An adolescent patient's pulse rate is 40 bpm. Which medication is most likely responsible for this finding, assuming no underlying cardiac conditions?
A newborn has a pulse rate of 158/min. Is this an expected or unexpected assesment finding?
A newborn has a pulse rate of 158/min. Is this an expected or unexpected assesment finding?
A nurse is assessing an adult client who has bradycardia, Which of the following physical manifestations of bradycardia should the nurse expect?
A nurse is assessing an adult client who has bradycardia, Which of the following physical manifestations of bradycardia should the nurse expect?
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?
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?
After scanning a temporal artery temperature, what is the next step a nurse should take to ensure an accurate reading?
After scanning a temporal artery temperature, what is the next step a nurse should take to ensure an accurate reading?
For which temperature measurement route is a disposable cover required for a chemical dot thermometer?
For which temperature measurement route is a disposable cover required for a chemical dot thermometer?
When using a temperature-sensitive patch, what is critical for the nurse to assess prior to application?
When using a temperature-sensitive patch, what is critical for the nurse to assess prior to application?
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?
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?
Mr. Ricci's temperature is 39°C (102.2°F), and he is shivering. Beyond antipyretics, which nursing intervention is most appropriate?
Mr. Ricci's temperature is 39°C (102.2°F), and he is shivering. Beyond antipyretics, which nursing intervention is most appropriate?
During inspiration, what physiological action directly causes air to enter the lungs?
During inspiration, what physiological action directly causes air to enter the lungs?
Which nursing action is most important when administering warmed IV fluids to a client with significant hypothermia?
Which nursing action is most important when administering warmed IV fluids to a client with significant hypothermia?
Why should a nurse avoid informing a client that their respirations are being assessed?
Why should a nurse avoid informing a client that their respirations are being assessed?
A nurse is caring for a newborn at risk for hypothermia. Which intervention is most appropriate to prevent heat loss through radiation?
A nurse is caring for a newborn at risk for hypothermia. Which intervention is most appropriate to prevent heat loss through radiation?
A newborn has a respiratory rate of 45 breaths per minute. How should the nurse interpret this finding?
A newborn has a respiratory rate of 45 breaths per minute. How should the nurse interpret this finding?
A client with mild hypothermia is shivering uncontrollably. What is the physiological rationale for this manifestation?
A client with mild hypothermia is shivering uncontrollably. What is the physiological rationale for this manifestation?
When assessing a client with hypothermia, which neurological change requires the most immediate intervention?
When assessing a client with hypothermia, which neurological change requires the most immediate intervention?
An adult patient is breathing at a rate of 24 breaths per minute. What term should the nurse use to document this?
An adult patient is breathing at a rate of 24 breaths per minute. What term should the nurse use to document this?
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?
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?
A nurse is taking the temperature of a 4-year-old child. Which temperature-taking method would be least appropriate?
A nurse is taking the temperature of a 4-year-old child. Which temperature-taking method would be least appropriate?
For a client experiencing tachypnea due to anxiety, which intervention is most appropriate?
For a client experiencing tachypnea due to anxiety, which intervention is most appropriate?
Which factor should a nurse consider when selecting the most appropriate method for measuring a client's body temperature?
Which factor should a nurse consider when selecting the most appropriate method for measuring a client's body temperature?
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?
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?
When assessing a client's respiratory rate, what is the recommended duration for counting respirations in a stable adult?
When assessing a client's respiratory rate, what is the recommended duration for counting respirations in a stable adult?
Which of the following clients would be most suitable for assessing temperature using the temporal artery method?
Which of the following clients would be most suitable for assessing temperature using the temporal artery method?
A nurse observes a client's chest movement while assessing respiration. What is the purpose of this action?
A nurse observes a client's chest movement while assessing respiration. What is the purpose of this action?
Why is a rectal temperature contraindicated for a client with a coagulation disorder?
Why is a rectal temperature contraindicated for a client with a coagulation disorder?
What is the correct term for respirations that fall within the expected reference range?
What is the correct term for respirations that fall within the expected reference range?
What underlying mechanism allows for the exchange of gases in the alveoli?
What underlying mechanism allows for the exchange of gases in the alveoli?
What is the benefit of using a temporal artery thermometer compared to an axillary thermometer?
What is the benefit of using a temporal artery thermometer compared to an axillary thermometer?
Which of the following is a limitation of using a tympanic thermometer for temperature measurement?
Which of the following is a limitation of using a tympanic thermometer for temperature measurement?
Which of the following conditions may lead to tachypnea?
Which of the following conditions may lead to tachypnea?
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?
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?
A client is prescribed a rectal temperature, but has a history of hemorrhoids. What should the nurse do?
A client is prescribed a rectal temperature, but has a history of hemorrhoids. What should the nurse do?
Which statement accurately describes the advantage of using an axillary temperature measurement?
Which statement accurately describes the advantage of using an axillary temperature measurement?
When using a temporal artery thermometer, what is the most important initial step to ensure accurate temperature measurement?
When using a temporal artery thermometer, what is the most important initial step to ensure accurate temperature measurement?
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?
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?
What is the primary reason for applying a disposable cover to a thermometer probe before measuring a patient's temperature?
What is the primary reason for applying a disposable cover to a thermometer probe before measuring a patient's temperature?
A client with chronic lung disease has an oxygen saturation of 85%. Besides administering oxygen, which intervention is MOST appropriate initially?
A client with chronic lung disease has an oxygen saturation of 85%. Besides administering oxygen, which intervention is MOST appropriate initially?
A newborn has a pulse oximeter probe on their foot. What is the MOST important nursing consideration regarding the probe application?
A newborn has a pulse oximeter probe on their foot. What is the MOST important nursing consideration regarding the probe application?
When taking a rectal temperature on an adult, how far should the nurse insert the thermometer probe?
When taking a rectal temperature on an adult, how far should the nurse insert the thermometer probe?
When performing oral temperature measurement, what is the primary reason for instructing the client to close their lips around the thermometer probe?
When performing oral temperature measurement, what is the primary reason for instructing the client to close their lips around the thermometer probe?
Which type of thermometer relies on liquid crystals that change color based on temperature and is affected by environmental temperature?
Which type of thermometer relies on liquid crystals that change color based on temperature and is affected by environmental temperature?
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?
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?
A patient with diarrhea needs a temperature taken, what is the best route?
A patient with diarrhea needs a temperature taken, what is the best route?
Why is it important to support the arm when taking an axillary temperature of an infant or young child?
Why is it important to support the arm when taking an axillary temperature of an infant or young child?
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?
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?
Which finding would be MOST concerning in a client with a decreased oxygen saturation level?
Which finding would be MOST concerning in a client with a decreased oxygen saturation level?
During rectal temperature measurement on an adult client, at what angle and depth should the nurse insert the probe?
During rectal temperature measurement on an adult client, at what angle and depth should the nurse insert the probe?
What is the recommended waiting period before taking an oral temperature on a patient who has just consumed a cup of hot coffee?
What is the recommended waiting period before taking an oral temperature on a patient who has just consumed a cup of hot coffee?
Why is it important to apply lubricant to the temperature probe before inserting it into the rectum?
Why is it important to apply lubricant to the temperature probe before inserting it into the rectum?
When measuring an axillary temperature, where should the nurse place the thermometer probe for accurate measurement?
When measuring an axillary temperature, where should the nurse place the thermometer probe for accurate measurement?
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?
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?
To ensure an accurate oxygen saturation reading using a finger probe, what should the nurse assess PRIOR to applying the probe?
To ensure an accurate oxygen saturation reading using a finger probe, what should the nurse assess PRIOR to applying the probe?
A client is experiencing dyspnea. Which question is MOST important for the nurse to ask when assessing the client's dyspnea?
A client is experiencing dyspnea. Which question is MOST important for the nurse to ask when assessing the client's dyspnea?
Following the measurement of a rectal temperature, what is the correct procedure for cleaning the thermometer probe?
Following the measurement of a rectal temperature, what is the correct procedure for cleaning the thermometer probe?
When measuring a tympanic temperature on a client older than 3 years, in which direction should the nurse pull the pinna?
When measuring a tympanic temperature on a client older than 3 years, in which direction should the nurse pull the pinna?
A client is exhibiting Cheyne-Stokes respirations. Which combination of underlying conditions is MOST likely contributing to this breathing pattern?
A client is exhibiting Cheyne-Stokes respirations. Which combination of underlying conditions is MOST likely contributing to this breathing pattern?
A postoperative client has a respiratory rate of 10 breaths per minute. Which term BEST describes this respiratory rate?
A postoperative client has a respiratory rate of 10 breaths per minute. Which term BEST describes this respiratory rate?
For a child younger than 3 years old, what is the correct technique for positioning the pinna when using a tympanic thermometer?
For a child younger than 3 years old, what is the correct technique for positioning the pinna when using a tympanic thermometer?
A nurse is using a chemical dot thermometer. What is a key consideration when using this type of thermometer compared to a digital thermometer?
A nurse is using a chemical dot thermometer. What is a key consideration when using this type of thermometer compared to a digital thermometer?
A client with diabetic ketoacidosis (DKA) is exhibiting Kussmaul respirations. Which physiological mechanism is the primary driver of this respiratory pattern?
A client with diabetic ketoacidosis (DKA) is exhibiting Kussmaul respirations. Which physiological mechanism is the primary driver of this respiratory pattern?
Which of the following clients is least suitable for oral temperature measurement?
Which of the following clients is least suitable for oral temperature measurement?
An assistive personnel (AP) reports a client's apical pulse is 130 bpm. What action should the nurse take FIRST?
An assistive personnel (AP) reports a client's apical pulse is 130 bpm. What action should the nurse take FIRST?
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?
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?
After inserting the tympanic thermometer probe into the ear canal, why should the probe be gently rotated?
After inserting the tympanic thermometer probe into the ear canal, why should the probe be gently rotated?
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?
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?
Following the procedure, why is it important for the nurse to assist the client in cleaning the perianal area after taking a rectal temperature?
Following the procedure, why is it important for the nurse to assist the client in cleaning the perianal area after taking a rectal temperature?
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?
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?
What should the nurse do when the reading displayed on the pulse oximeter does not correlate with the client's clinical presentation?
What should the nurse do when the reading displayed on the pulse oximeter does not correlate with the client's clinical presentation?
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)?
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)?
A nurse is preparing to measure a child's oxygen saturation. Which site is MOST appropriate for accurate measurement in this population?
A nurse is preparing to measure a child's oxygen saturation. Which site is MOST appropriate for accurate measurement in this population?
Why should the nurse use their non-dominant hand to separate the client's buttocks when preparing to insert a rectal thermometer?
Why should the nurse use their non-dominant hand to separate the client's buttocks when preparing to insert a rectal thermometer?
What is the most important consideration when selecting a temperature measurement site for a patient?
What is the most important consideration when selecting a temperature measurement site for a patient?
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?
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?
A nurse assesses a client and obtains a respiratory rate of 30 breaths per minute. What condition is the client MOST likely experiencing?
A nurse assesses a client and obtains a respiratory rate of 30 breaths per minute. What condition is the client MOST likely experiencing?
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?
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?
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?
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?
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?
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?
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?
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?
A client presents with frequent cough, tachycardia, and confusion. Which condition is MOST likely indicated by this combination of manifestations?
A client presents with frequent cough, tachycardia, and confusion. Which condition is MOST likely indicated by this combination of manifestations?
For which of the following patients would the nurse consider the rectal route to obtain the core temperature?
For which of the following patients would the nurse consider the rectal route to obtain the core temperature?
What is the most important action for a nurse to take immediately after removing a rectal temperature probe from a patient?
What is the most important action for a nurse to take immediately after removing a rectal temperature probe from a patient?
The physician orders albuterol for a client experiencing tachypnea due to asthma exacerbation. What is the PRIMARY expected outcome?
The physician orders albuterol for a client experiencing tachypnea due to asthma exacerbation. What is the PRIMARY expected outcome?
A geriatric client has significant hypoxia. What findings should a nurse monitor for?
A geriatric client has significant hypoxia. What findings should a nurse monitor for?
A client presents with a respiratory rate of 10 breaths per minute. Which assessment finding would warrant immediate notification of the health care provider?
A client presents with a respiratory rate of 10 breaths per minute. Which assessment finding would warrant immediate notification of the health care provider?
Why is a disposable probe cover used for most temperature measurement methods?
Why is a disposable probe cover used for most temperature measurement methods?
A client reports feeling short of breath or having difficulty breathing. Which condition is the client MOST likely experiencing?
A client reports feeling short of breath or having difficulty breathing. Which condition is the client MOST likely experiencing?
What should the nurse do immediately after removing the temperature probe from a patient's axilla?
What should the nurse do immediately after removing the temperature probe from a patient's axilla?
An unresponsive client is found to have no respirations. What is the priority intervention?
An unresponsive client is found to have no respirations. What is the priority intervention?
A client with severe kidney disease is exhibiting Kussmaul respirations. What acid-base imbalance is most likely present in this client?
A client with severe kidney disease is exhibiting Kussmaul respirations. What acid-base imbalance is most likely present in this client?
During tympanic temperature measurement, why is it important to gently insert the probe at a slightly anterior angle?
During tympanic temperature measurement, why is it important to gently insert the probe at a slightly anterior angle?
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?
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?
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?
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?
A client has a respiratory rate of 30 breaths per minute. Which of the following conditions is the client most likely experiencing?
A client has a respiratory rate of 30 breaths per minute. Which of the following conditions is the client most likely experiencing?
What is the rationale behind discarding the probe cover of a thermometer after use?
What is the rationale behind discarding the probe cover of a thermometer after use?
Why is it important to ensure a client's forehead is dry before using a temporal artery thermometer?
Why is it important to ensure a client's forehead is dry before using a temporal artery thermometer?
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?
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?
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?
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?
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?
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?
Which temperature measurement site is generally avoided in young children due to the risk of injury?
Which temperature measurement site is generally avoided in young children due to the risk of injury?
After obtaining a client's temperature, what is the next best step for the nurse to take?
After obtaining a client's temperature, what is the next best step for the nurse to take?
What is the normal expected range in Celcius for an adult?
What is the normal expected range in Celcius for an adult?
Which action is most important for the nurse include before going to the next patient?
Which action is most important for the nurse include before going to the next patient?
Which of these is not an expected client safety measures.
Which of these is not an expected client safety measures.
For a newborn baby, which is the most common site to monitor body temperature?
For a newborn baby, which is the most common site to monitor body temperature?
If a client has eaten in the previous 30 minutes, which method should be avoided.
If a client has eaten in the previous 30 minutes, which method should be avoided.
If the temperature is above the expected range what are the next steps.
If the temperature is above the expected range what are the next steps.
A nurse is teaching a new graduate nurse on using the tympanic method. What is an important teaching point?
A nurse is teaching a new graduate nurse on using the tympanic method. What is an important teaching point?
A client’s temperature has been consistently increasing over the past 24 hours. What might the nurse infer from this observation?
A client’s temperature has been consistently increasing over the past 24 hours. What might the nurse infer from this observation?
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?
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?
A client has a history of a coagulation disorder and reports discomfort and visible hemorrhoids. Which temperature route should the nurse avoid, and why?
A client has a history of a coagulation disorder and reports discomfort and visible hemorrhoids. Which temperature route should the nurse avoid, and why?
The nurse is preparing to use a tympanic thermometer on a client. What action is MOST important to ensure an accurate reading?
The nurse is preparing to use a tympanic thermometer on a client. What action is MOST important to ensure an accurate reading?
When using a temporal artery thermometer, what should the nurse do to ensure an accurate temperature reading?
When using a temporal artery thermometer, what should the nurse do to ensure an accurate temperature reading?
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?
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?
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?
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?
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?
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?
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?
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?
The nurse closes the door and pulls the curtain before taking the client's temperature. What is the primary rationale for these actions?
The nurse closes the door and pulls the curtain before taking the client's temperature. What is the primary rationale for these actions?
What is the primary purpose of using a disposable probe cover when measuring a client's temperature, regardless of the route (oral, rectal, tympanic)?
What is the primary purpose of using a disposable probe cover when measuring a client's temperature, regardless of the route (oral, rectal, tympanic)?
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?
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?
A nurse identifies that a client has a elevated temperature. What would be the most appropriate next step?
A nurse identifies that a client has a elevated temperature. What would be the most appropriate next step?
A patient has a history of seizures, which temperature taking method should be avoided?
A patient has a history of seizures, which temperature taking method should be avoided?
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?
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?
A client reports breathing through their mouth, which method of assessing temperature should be avoided?
A client reports breathing through their mouth, which method of assessing temperature should be avoided?
Flashcards
Vital Signs
Vital Signs
Clinical measurements of body functions: blood pressure, pulse, temperature, respirations, and oxygen saturation.
Purpose of Monitoring Vital Signs
Purpose of Monitoring Vital Signs
To provide a baseline for future comparisons, identify trends and inform treatment decisions.
Significance of Vital Signs
Significance of Vital Signs
Objective data reflecting the body’s essential functions, crucial for client care across health settings.
Trends in Vital Signs
Trends in Vital Signs
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Analyzing Vital Signs
Analyzing Vital Signs
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Components of Vital Signs
Components of Vital Signs
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Impact of Vital Signs on Care
Impact of Vital Signs on Care
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Vital signs within the nursing process
Vital signs within the nursing process
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Critical Thinking in Nursing
Critical Thinking in Nursing
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Institutional Policy
Institutional Policy
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Intuitive Sense
Intuitive Sense
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Infection Control
Infection Control
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Delegation
Delegation
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Blood Pressure
Blood Pressure
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Systolic Pressure
Systolic Pressure
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Diastolic Pressure
Diastolic Pressure
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Cardiac Output (CO)
Cardiac Output (CO)
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Stroke Volume (SV)
Stroke Volume (SV)
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Cardiac Output Formula
Cardiac Output Formula
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Increase in Cardiac Output
Increase in Cardiac Output
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Blood Volume
Blood Volume
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Blood Viscosity
Blood Viscosity
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Decreased Blood Volume
Decreased Blood Volume
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Cuff too narrow
Cuff too narrow
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Cuff too wide
Cuff too wide
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Cuff placement
Cuff placement
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Artery indicator
Artery indicator
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Cuff inflation
Cuff inflation
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Korotkoff sounds
Korotkoff sounds
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Arm contraindications
Arm contraindications
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Thigh as alternative site
Thigh as alternative site
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Thigh blood pressure
Thigh blood pressure
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Thigh pressure vs. arm
Thigh pressure vs. arm
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Alternative methods for inaccurate readings
Alternative methods for inaccurate readings
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Cuff too small/tight
Cuff too small/tight
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"White coat syndrome"
"White coat syndrome"
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Viscosity
Viscosity
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Elasticity
Elasticity
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Peripheral Vascular Resistance
Peripheral Vascular Resistance
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Contractility
Contractility
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Preload
Preload
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Afterload
Afterload
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Heart Blood Flow
Heart Blood Flow
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Sphygmomanometer
Sphygmomanometer
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Stethoscope
Stethoscope
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Palpating Blood Pressure
Palpating Blood Pressure
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Electronic Blood Pressure Machine
Electronic Blood Pressure Machine
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Appropriate Cuff Size
Appropriate Cuff Size
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Preload
Preload
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Vessel Elasticity
Vessel Elasticity
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Popliteal Artery Auscultation
Popliteal Artery Auscultation
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Blood Pressure Factors
Blood Pressure Factors
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Hypertension
Hypertension
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Cause of Hypertension
Cause of Hypertension
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Diagnosing Hypertension
Diagnosing Hypertension
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Elevated Blood Pressure
Elevated Blood Pressure
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Stage I Hypertension
Stage I Hypertension
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Stage II Hypertension
Stage II Hypertension
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Hypertensive Crisis
Hypertensive Crisis
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Pediatric Hypertension
Pediatric Hypertension
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Hypertension Interventions
Hypertension Interventions
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Hypotension
Hypotension
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Causes of Hypotension
Causes of Hypotension
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Hypotension Symptoms
Hypotension Symptoms
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Shock Symptoms
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Arrhythmias
Arrhythmias
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Auscultating Apical Pulse
Auscultating Apical Pulse
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Apical Pulse Location (Adults)
Apical Pulse Location (Adults)
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S1 Heart Sound
S1 Heart Sound
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S2 Heart Sound
S2 Heart Sound
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Aortic Valve Auscultation Location
Aortic Valve Auscultation Location
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Determining Apical Pulse Rate
Determining Apical Pulse Rate
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Peripheral Pulses
Peripheral Pulses
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Radial Pulse
Radial Pulse
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Pulse Deficit
Pulse Deficit
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Palpating a Pulse
Palpating a Pulse
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Pulse Rating Scale
Pulse Rating Scale
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Bilateral Pulse Equality
Bilateral Pulse Equality
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Doppler Ultrasound Stethoscope (DUS)
Doppler Ultrasound Stethoscope (DUS)
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Manifestations of Impaired Circulation
Manifestations of Impaired Circulation
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Shock Interventions
Shock Interventions
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Orthostatic Hypotension
Orthostatic Hypotension
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Assess for Orthostatic Hypotension
Assess for Orthostatic Hypotension
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Orthostatic Hypotension - 3 Minute Recheck
Orthostatic Hypotension - 3 Minute Recheck
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Interventions for Hypotension
Interventions for Hypotension
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Prevent Orthostatic Hypotension
Prevent Orthostatic Hypotension
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Medication Review for Hypotension
Medication Review for Hypotension
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Hypotension Risks
Hypotension Risks
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Evaluate Hypotension Treatment
Evaluate Hypotension Treatment
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Anxiety-Induced Hypertension
Anxiety-Induced Hypertension
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Data drives action.
Data drives action.
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Persistent Increased BP
Persistent Increased BP
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Document BP Measurement
Document BP Measurement
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Next step to evaluate effectiveness
Next step to evaluate effectiveness
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Factors Increasing BP
Factors Increasing BP
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Pulse
Pulse
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SA Node
SA Node
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Tachycardia
Tachycardia
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Tachycardia Management
Tachycardia Management
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Bradycardia
Bradycardia
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Bradycardia Management
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Normal Newborn Pulse
Normal Newborn Pulse
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Normal Infant Pulse
Normal Infant Pulse
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Normal Toddler Pulse
Normal Toddler Pulse
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Normal Preschooler Pulse
Normal Preschooler Pulse
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Normal School-age Pulse
Normal School-age Pulse
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Normal Adolescent Pulse
Normal Adolescent Pulse
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Normal Adult Pulse
Normal Adult Pulse
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Tachycardia Risk
Tachycardia Risk
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Bradycardia Manifestation
Bradycardia Manifestation
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Core Temperature
Core Temperature
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Surface Temperature
Surface Temperature
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Expected Body Temperature Range
Expected Body Temperature Range
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Fever
Fever
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Febrile
Febrile
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Afebrile
Afebrile
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Hyperthermia
Hyperthermia
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Hyperthermia Symptoms
Hyperthermia Symptoms
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Hyperthermia Interventions
Hyperthermia Interventions
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Conduction
Conduction
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Convection
Convection
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Thermometer Disinfection
Thermometer Disinfection
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Rectal Thermometer Cover
Rectal Thermometer Cover
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Temperature Patch Prep
Temperature Patch Prep
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Inspiration
Inspiration
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Expiration
Expiration
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Gas Exchange
Gas Exchange
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Healthy Breathing
Healthy Breathing
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Respiratory Rate
Respiratory Rate
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Eupnea
Eupnea
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Newborn Respiratory Rate
Newborn Respiratory Rate
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Infant Respiratory Rate
Infant Respiratory Rate
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Toddler Respiratory Rate
Toddler Respiratory Rate
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Preschooler Respiratory Rate
Preschooler Respiratory Rate
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School age Respiratory Rate
School age Respiratory Rate
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Adolescent Respiratory Rate
Adolescent Respiratory Rate
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Adult Respiratory Rate
Adult Respiratory Rate
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Tachypnea
Tachypnea
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Temporal Artery Thermometer
Temporal Artery Thermometer
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Chemical Dot Thermometer
Chemical Dot Thermometer
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Adhesive Patch/Tape Thermometer
Adhesive Patch/Tape Thermometer
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Oral Temperature
Oral Temperature
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Sublingual Area
Sublingual Area
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Oral Temperature Delay
Oral Temperature Delay
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Axillary Temperature
Axillary Temperature
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Rectal Temperature
Rectal Temperature
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Tympanic Temperature
Tympanic Temperature
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Tympanic Thermometer Use
Tympanic Thermometer Use
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Temporal Temperature
Temporal Temperature
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Temporal Temperature Prep
Temporal Temperature Prep
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Temporal Thermometer Placement
Temporal Thermometer Placement
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Probe Cover Use
Probe Cover Use
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Oral Temperature Smoking Wait
Oral Temperature Smoking Wait
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Early Hypothermia Symptoms
Early Hypothermia Symptoms
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Advanced Hypothermia Symptoms
Advanced Hypothermia Symptoms
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Severe Hypothermia Risks
Severe Hypothermia Risks
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Severe Hypothermia Treatment
Severe Hypothermia Treatment
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Monitoring During Hypothermia Treatment
Monitoring During Hypothermia Treatment
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Initial Response to Hypothermia (PACU)
Initial Response to Hypothermia (PACU)
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Core Temperature Sites
Core Temperature Sites
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Oral Temperature Advantages
Oral Temperature Advantages
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Oral Temperature Limitations
Oral Temperature Limitations
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Tympanic Temperature Advantages
Tympanic Temperature Advantages
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Tympanic Temperature Limitations
Tympanic Temperature Limitations
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Temporal Artery Temperature Advantages
Temporal Artery Temperature Advantages
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Temporal Artery Temperature Limitations
Temporal Artery Temperature Limitations
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Lips around oral probe
Lips around oral probe
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Hold oral probe still
Hold oral probe still
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Gentle probe removal
Gentle probe removal
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Discard probe cover
Discard probe cover
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Clean thermometer
Clean thermometer
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Hand hygiene
Hand hygiene
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Probe in axilla center
Probe in axilla center
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Support arm in axilla
Support arm in axilla
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Hand hygiene
Hand hygiene
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Side-lying position
Side-lying position
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Lubricate rectal probe
Lubricate rectal probe
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Separate buttocks
Separate buttocks
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Probe towards umbilicus
Probe towards umbilicus
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Hold rectal probe still
Hold rectal probe still
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Scan tympanic membrane
Scan tympanic membrane
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Pulse Oximetry
Pulse Oximetry
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Earlobe Pulse Oximetry Steps
Earlobe Pulse Oximetry Steps
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Skin Prep for Oximetry
Skin Prep for Oximetry
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Probe Application
Probe Application
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Causes of Decreased SpO2
Causes of Decreased SpO2
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Dyspnea
Dyspnea
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Hypoxia
Hypoxia
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Hypoxemia
Hypoxemia
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Manifestations of Low SpO2
Manifestations of Low SpO2
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Interventions for Low SpO2
Interventions for Low SpO2
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Monitoring Low SpO2
Monitoring Low SpO2
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Assessing Respiratory Status
Assessing Respiratory Status
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Preparing for Respiratory Distress
Preparing for Respiratory Distress
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Verify Client Identity
Verify Client Identity
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Tachypnea Treatment (Asthma)
Tachypnea Treatment (Asthma)
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Evaluating Tachypnea Interventions
Evaluating Tachypnea Interventions
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Bradypnea
Bradypnea
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Bradypnea Symptoms
Bradypnea Symptoms
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Causes of Bradypnea
Causes of Bradypnea
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Bradypnea Treatment
Bradypnea Treatment
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Evaluating Bradypnea Interventions
Evaluating Bradypnea Interventions
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Apnea Consequences
Apnea Consequences
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Cheyne-Stokes Respirations
Cheyne-Stokes Respirations
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Causes of Cheyne-Stokes
Causes of Cheyne-Stokes
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Kussmaul Respirations
Kussmaul Respirations
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Retractions
Retractions
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Oxygen Saturation (SpO2)
Oxygen Saturation (SpO2)
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Holding Thermometer Still
Holding Thermometer Still
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Discarding Probe Cover
Discarding Probe Cover
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Cleaning Thermometer
Cleaning Thermometer
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Forehead Preparation
Forehead Preparation
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Disposable Probe Cover
Disposable Probe Cover
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Probe Placement (Forehead)
Probe Placement (Forehead)
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Sliding the Probe
Sliding the Probe
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Probe Behind the Ear
Probe Behind the Ear
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Releasing the Button
Releasing the Button
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Expected Temperature Range
Expected Temperature Range
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Previous Vital Signs Data
Previous Vital Signs Data
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Infant Temperature Site
Infant Temperature Site
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Older Adult Temperature
Older Adult Temperature
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Standard Precautions
Standard Precautions
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Additional Infection Control Measures
Additional Infection Control Measures
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PPE (Personal Protective Equipment)
PPE (Personal Protective Equipment)
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Disposable Thermometer Probe Cover
Disposable Thermometer Probe Cover
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Review Client Medical Record
Review Client Medical Record
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Provide Privacy
Provide Privacy
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Identify the Client
Identify the Client
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Hypothermia Manifestations
Hypothermia Manifestations
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Fever Manifestations
Fever Manifestations
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Rectal Route Contraindications
Rectal Route Contraindications
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Oral Route Contraindication
Oral Route Contraindication
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Tympanic Membrane Considerations
Tympanic Membrane Considerations
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Oral Temperature Interference
Oral Temperature Interference
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Oral Thermometer Placement
Oral Thermometer Placement
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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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Description
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.