Nursing Vital Signs and Procedures Quiz
45 Questions
0 Views

Choose a study mode

Play Quiz
Study Flashcards
Spaced Repetition
Chat to Lesson

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  • Using an outdated needle.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?

<p>To ensure multiple prescriptions are monitored. (D)</p> Signup and view all the answers

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

<p>Electronic infusion device. (D)</p> Signup and view all the answers

What do vital signs include?

<p>Temperature, pulse, and respiration (B)</p> Signup and view all the answers

When should vital signs be reassessed?

<p>Whenever a client’s condition changes (B)</p> Signup and view all the answers

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

<p>To interpret the findings from the measurements (C)</p> Signup and view all the answers

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

<p>97.0° F to 99.0° F (A)</p> Signup and view all the answers

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

<p>The client is experiencing a known infection (A)</p> Signup and view all the answers

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

<p>Interpreting results of vital signs (C)</p> Signup and view all the answers

What is the purpose of a pulse oximeter?

<p>To assess the oxygen saturation of hemoglobin (A)</p> Signup and view all the answers

What is the significance of initial measurements of vital signs?

<p>Provides a baseline for comparing client history (B)</p> Signup and view all the answers

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

<p>Immediately after the intervention (D)</p> Signup and view all the answers

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

<p>95% to 100% (C)</p> Signup and view all the answers

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

<p>A reading below normal values (A)</p> Signup and view all the answers

What does Sao2 represent in relation to oxygen levels?

<p>Oxygen attached to hemoglobin (A)</p> Signup and view all the answers

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

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

What nursing consideration is essential for accurate pulse oximetry readings?

<p>Assessing a vascular, pulsatile area (A)</p> Signup and view all the answers

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

<p>Acute/transient pain (B)</p> Signup and view all the answers

What is a characteristic of chronic/persistent noncancer pain?

<p>Linked to long-term illnesses (B)</p> Signup and view all the answers

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

<p>To deliver low electrical currents to block pain (A)</p> Signup and view all the answers

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

<p>Pillow to elevate the limb (A)</p> Signup and view all the answers

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

<p>The temperature of the application must be monitored carefully (A)</p> Signup and view all the answers

What is required for some TENS devices regarding their use?

<p>They require a prescription from a PHCP (D)</p> Signup and view all the answers

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

<p>Muscle strains and sprains (D)</p> Signup and view all the answers

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

<p>Checking the patient's blood pressure (A)</p> Signup and view all the answers

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

<p>Warm-water compresses (D)</p> Signup and view all the answers

How can cold application assist in treatment?

<p>By reducing swelling (A)</p> Signup and view all the answers

What is the initial step when starting an intravenous procedure?

<p>Apply a tourniquet 10 to 15 cm above the site. (D)</p> Signup and view all the answers

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

<p>Scrub the port with antiseptic swab. (A)</p> Signup and view all the answers

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

<p>5-10 mL. (D)</p> Signup and view all the answers

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

<p>Remove the flush syringe and endcap the IV line. (D)</p> Signup and view all the answers

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

<p>Flush the line with the appropriate amount of saline. (B)</p> Signup and view all the answers

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

<p>A vacuum transfer device. (C)</p> Signup and view all the answers

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

<p>To prevent blood flow back to the site. (A)</p> Signup and view all the answers

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

<p>Remove them if it is appropriate and acceptable to do so. (D)</p> Signup and view all the answers

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

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

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

<p>Consuming with milk or a snack (C)</p> Signup and view all the answers

What is the normal reference interval for serum sodium levels?

<p>135 to 145 mEq/L (A)</p> Signup and view all the answers

Which of the following could indicate elevated serum sodium levels?

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

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

<p>Encouraging incentive spirometry (D)</p> Signup and view all the answers

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

<p>If bradycardia develops (D)</p> Signup and view all the answers

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

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

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

<p>Oxygen and resuscitation equipment (B)</p> Signup and view all the answers

Flashcards

Vital signs

Measurements of temperature, pulse, respirations, blood pressure (BP), oxygen saturation, and pain assessment.

Frequency of vital signs

Depends on client's health status and is determined collaboratively with the healthcare provider; nurse decides independently based on the situation.

Initial vital signs

Baseline measurements used to track health changes in a patient.

Assisting personnel

Can measure some vital signs, but a nurse is ultimately responsible for interpreting results.

Signup and view all the flashcards

Normal body temperature range

97.0°F (36.1°C) to 99.0°F (37.2°C)

Signup and view all the flashcards

Client condition change

Situations in which frequent vital sign checks are needed because of changes in health status.

Signup and view all the flashcards

Unusual symptoms

Signs of potential problems in a client's health.

Signup and view all the flashcards

Vital sign monitoring frequency

Vital signs should be checked with a defined frequency and the frequency is based on medical needs.

Signup and view all the flashcards

Diabetic Ketoacidosis

A serious complication of diabetes, characterized by high blood sugar, and the production of ketones.

Signup and view all the flashcards

Serum Potassium

Potassium level in the blood.

Signup and view all the flashcards

Opioid Analgesics Use

Use of opioid pain relievers needs close monitoring with risk assessments, consent forms, and prescription checks.

Signup and view all the flashcards

IV Infusion Device

Necessary for continuous or dose-dependent intravenous opioid delivery.

Signup and view all the flashcards

Inaccurate Blood Testing

Infusion solutions or prolonged tourniquets can compromise test accuracy, especially for potassium.

Signup and view all the flashcards

Pulse Oximetry

A noninvasive test measuring the oxygen saturation of hemoglobin in the blood.

Signup and view all the flashcards

Sao2

Capillary oxygen saturation, expressed as a percentage.

Signup and view all the flashcards

Normal Sao2

95% to 100%.

Signup and view all the flashcards

Hypoxemia

Low blood oxygen levels.

Signup and view all the flashcards

Pulse Oximeter Use

Detects hypoxemia before symptoms appear.

Signup and view all the flashcards

Low Pulse Oximetry Reading

Indicates a need for oxygen therapy and/or deep breathing exercises.

Signup and view all the flashcards

Acute Pain

Pain that comes quickly and disappears (from hours to a few days) and is usually connected to an event.

Signup and view all the flashcards

Chronic Pain

Pain that lasts long-term (months or even years) that commonly results from long-term diseases or disorders.

Signup and view all the flashcards

Bradycardia and Pain Medication

If bradycardia (slow heartbeat) develops while giving pain medication, stop the medication and tell the doctor.

Signup and view all the flashcards

Hypotension and Pain Medications

Check blood pressure (BP) before and after giving pain medication to prevent low blood pressure.

Signup and view all the flashcards

Respiratory Monitoring

Listen to the lungs for normal breathing sounds and encourage deep breathing to help prevent lung problems.

Signup and view all the flashcards

Opioid Analgesics Limitations

Opioid pain medications are only used in specific situations.

Signup and view all the flashcards

Serum Sodium

Serum sodium is a major part of body fluids, maintaining balance and nerve function.

Signup and view all the flashcards

Sodium Levels - High

High sodium levels can result from dehydration, kidney issues, or high sodium intake.

Signup and view all the flashcards

Transcutaneous electrical nerve stimulation (TENS)

A technique using a battery-operated device to deliver a low electrical current to the skin, potentially blocking pain.

Signup and view all the flashcards

TENS device prescription

Usage of some TENS devices may require a prescription from a qualified healthcare professional.

Signup and view all the flashcards

Sodium Levels - Low

Low sodium levels can be caused by conditions like Addison's disease and low sodium intake.

Signup and view all the flashcards

Patient Safety Precautions

Put safety measures in place to protect the client, such as having oxygen, resuscitation equipment, and an opioid antagonist available.

Signup and view all the flashcards

Supports (binders, slings)

Wrappings or devices used to support a limb or body part, easing pain from injuries or incisions

Signup and view all the flashcards

Heat/Cold Applications

Treating pain with heat or cold, heat for muscle relief, and cold for reducing swelling

Signup and view all the flashcards

Heat Application Safety

Carefully monitor heat application temperature to avoid burns; skin of young/old clients is more prone to heat sensitivity.

Signup and view all the flashcards

Pain Relief Methods

Using various techniques such as TENS, supports, heat or cold for pain relief.

Signup and view all the flashcards

Percutaneous electrical nerve stimulation (PENS)

Another name for transcutaneous electrical nerve stimulation (TENS).

Signup and view all the flashcards

Elevating affected areas

Raising the injured body part to reduce swelling from an injury or surgery.

Signup and view all the flashcards

Apply tourniquet

Place a tourniquet 10-15 cm above the intravenous site.

Signup and view all the flashcards

Clean port

Use an antiseptic swab to scrub the port.

Signup and view all the flashcards

Flush line

Use saline to clean the IV line, disposing of a specific amount of blood.

Signup and view all the flashcards

Detach/re-attach

Disconnect and re-connect equipment, using syringes, collection devices, or specimen containers to withdraw samples.

Signup and view all the flashcards

Withdraw Blood/Sample

Collect blood or other samples using appropriate collection devices.

Signup and view all the flashcards

Clamp line

Close the IV line using a clamp.

Signup and view all the flashcards

Remove tourniquet

Take off the tourniquet once procedure completed.

Signup and view all the flashcards

Transfer Specimen

Move the specimen to the intended collection device per agency policy.

Signup and view all the flashcards

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.

Quiz Team

Related Documents

Vital Signs and Laboratory Reference Intervals PDF

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.

More Like This

Use Quizgecko on...
Browser
Open
Browser
Browser