Nursing Vital Signs and Procedures Quiz

Podcast

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What can produce an inaccurate blood test result when drawing specimens from an extremity?

Using an outdated needle.

Not using a tourniquet.

Infusing an IV solution. (correct)

Using a larger syringe.

Which of the following is a major intracellular cation that regulates various bodily functions?

Potassium (correct)

Sodium

Calcium

Chloride

What is a potential outcome of prolonged use of a tourniquet before venous sampling?

Lower glucose concentrations.

Decreased blood viscosity.

Elevated potassium levels. (correct)

Increased blood volume.

Why is frequent collaboration between the nurse and provider important for patients on controlled substances?

To ensure multiple prescriptions are monitored. Signup and view all the answers

Which method is used for continuous or dose-demand IV infusion of opioid analgesics?

Electronic infusion device. Signup and view all the answers

What do vital signs include?

Temperature, pulse, and respiration Signup and view all the answers

When should vital signs be reassessed?

Whenever a client’s condition changes Signup and view all the answers

What is the nurse's role in relation to delegated vital sign measurements?

To interpret the findings from the measurements Signup and view all the answers

What is the normal range for body temperature as noted in literature?

97.0° F to 99.0° F Signup and view all the answers

In what scenario might a nurse decide to more frequently check vital signs?

The client is experiencing a known infection Signup and view all the answers

Which vital sign assessment may NOT be delegated to assistive personnel?

Interpreting results of vital signs Signup and view all the answers

What is the purpose of a pulse oximeter?

To assess the oxygen saturation of hemoglobin Signup and view all the answers

What is the significance of initial measurements of vital signs?

Provides a baseline for comparing client history Signup and view all the answers

When should vital signs be assessed following an intervention like ambulation?

Immediately after the intervention Signup and view all the answers

What is the normal range for oxygen saturation as measured by pulse oximetry?

95% to 100% Signup and view all the answers

Which of the following indicates that a client's pulse oximetry might warrant further investigation?

A reading below normal values Signup and view all the answers

What does Sao2 represent in relation to oxygen levels?

Oxygen attached to hemoglobin Signup and view all the answers

What might a significant change in a client's vital signs post-surgery indicate?

Postoperative bleeding Signup and view all the answers

What nursing consideration is essential for accurate pulse oximetry readings?

Assessing a vascular, pulsatile area Signup and view all the answers

Which type of pain is characterized by lasting hours to a few days?

Acute/transient pain Signup and view all the answers

What is a characteristic of chronic/persistent noncancer pain?

Linked to long-term illnesses Signup and view all the answers

What is one primary function of transcutaneous electrical nerve stimulation (TENS)?

To deliver low electrical currents to block pain Signup and view all the answers

Which supportive device can help reduce swelling in an affected body part?

Pillow to elevate the limb Signup and view all the answers

What important consideration must be taken when applying heat to a patient's skin?

The temperature of the application must be monitored carefully Signup and view all the answers

What is required for some TENS devices regarding their use?

They require a prescription from a PHCP Signup and view all the answers

What can the alternating application of heat and cold effectively treat?

Muscle strains and sprains Signup and view all the answers

Which of the following is NOT a consideration when using heat therapy?

Checking the patient's blood pressure Signup and view all the answers

Which of these is a potential method used for heat application?

Warm-water compresses Signup and view all the answers

How can cold application assist in treatment?

By reducing swelling Signup and view all the answers

What is the initial step when starting an intravenous procedure?

Apply a tourniquet 10 to 15 cm above the site. Signup and view all the answers

What should be done with the tubing insertion port before withdrawing a blood sample?

Scrub the port with antiseptic swab. Signup and view all the answers

What quantity of blood should be discarded before collecting a sample?

5-10 mL. Signup and view all the answers

After flushing the line with normal saline, what is the next step in the procedure?

Remove the flush syringe and endcap the IV line. Signup and view all the answers

What should be done to ensure the line is unobstructed before sample collection?

Flush the line with the appropriate amount of saline. Signup and view all the answers

What should replace the flush syringe after completing the saline flush?

A vacuum transfer device. Signup and view all the answers

Why is it necessary to clamp the IV line after flushing?

To prevent blood flow back to the site. Signup and view all the answers

What is the appropriate action if masks are being used during the procedure?

Remove them if it is appropriate and acceptable to do so. Signup and view all the answers

What should be monitored to prevent hypotension before administering pain medications?

Blood pressure Signup and view all the answers

Which of the following is advised to help reduce gastric irritation when taking oral doses of medication?

Consuming with milk or a snack Signup and view all the answers

What is the normal reference interval for serum sodium levels?

135 to 145 mEq/L Signup and view all the answers

Which of the following could indicate elevated serum sodium levels?

Dehydration Signup and view all the answers

What activity is recommended to prevent atelectasis and pneumonia in a client?

Encouraging incentive spirometry Signup and view all the answers

In which situation should a physician's preference be considered regarding pain management?

If bradycardia develops Signup and view all the answers

What is a common side effect of opioid use that should be monitored?

Urine retention Signup and view all the answers

What equipment should be available in case of an opioid overdose?

Oxygen and resuscitation equipment Signup and view all the answers

Study Notes

Vital Signs and Laboratory Reference Intervals

Vital signs include temperature, pulse, respirations, blood pressure (BP), oxygen saturation (pulse oximetry), and pain assessment.
Initial vital sign measurements provide baseline data and help identify changes in a client's health status.
Some vital sign measurements (temperature, pulse, respirations, BP, pulse oximetry) may be delegated to assistive personnel (AP), but the nurse is responsible for interpreting the findings.
The nurse collaborates with the primary health care provider (PHCP) to determine the frequency of vital sign assessment and makes independent decisions based on the client's status.
The nurse documents vital signs and reports abnormal or unexpected findings to the PHCP.
Vital signs are measured on initial contact with a client, during physical assessments, before and after invasive or surgical procedures, during medication administration if it affects cardiac, respiratory, or temperature control, and before, during, and after blood transfusions.
Vital signs are checked whenever a client's condition changes or reports unusual feelings.
Vital signs are checked with fever or known infection, every 2-4 hours.

Temperature

Normal body temperature can range from 97.0° F (36.1° C) to 99.0° F (37.2° C) (according to WebMD, 2020).
A fever is present when temperature is elevated, feels warm to touch, or report feeling feverish.
A client might have a flushed face, glassy eyes, or chills with a fever.
Some health care providers consider a fever when the temperature is 100.4° F (38° C) or higher.
Common measurement sites are the mouth, rectum (unless contraindicated), axilla, ear, and forehead (temporal artery).
Rectal temperatures are usually 1° F (0.5° C) higher and tympanic and axillary temperatures about 1° F (0.5° C) lower than oral temperature.

Pulse

Average adult heart rate is 60 to 100 beats per minute.
Pulse measurements can evaluate a client's tolerance to interventions like ambulation, bathing, and exercise.
A Doppler ultrasound stethoscope is used to amplify pulse sounds when difficult to locate manually.

Respirations

Respiration is the exchange of gases (atmosphere to blood and blood to cells).
Normal adult respiratory rate is 12-20 breaths per minute.
Respirations are affected by factors like exercise, pain, anxiety, smoking, and body position.

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

Test your knowledge on vital signs, their importance, and nursing procedures related to blood sampling and medication administration. This quiz covers key concepts in patient monitoring, including proper techniques and the role of nurses in managing vital signs and controlled substances. Ideal for nursing students and professionals to assess their understanding.