Nursing Vitals Delegation and Assessment Quiz
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Questions and Answers

Which factor affects blood pressure by increasing it after eating?

  • Exercise
  • Food intake (correct)
  • Emotional state
  • Circadian rhythm

    • What should be avoided before taking an oral temperature?

  • Having facial surgery
  • Doing physical activity
  • Chewing gum (correct)
  • Drinking water

    • Which method of taking temperature may be affected by ear infections or earwax?

  • Tympanic (correct)
  • Axillary
  • Rectal
  • Oral

    • What is afebrile?

    <p>Without fever</p> Signup and view all the answers

    Which system in the body increases blood pressure?

    <p>Renin-angiotensin-aldosterone system</p> Signup and view all the answers

    When using a sphygmomanometer, which sound indicates systolic blood pressure?

    <p>First sound heard</p> Signup and view all the answers

    When should a nurse take her own vitals instead of delegating?

    <p>If there is a change in the patient's condition</p> Signup and view all the answers

    What are the six vital signs?

    <p>Temperature, Pulse, Respiration, Blood Pressure, Pulse Oximeter, Pain</p> Signup and view all the answers

    How often should a patient's vitals be taken at a minimum?

    <p>Every 4 hours unless there is a change</p> Signup and view all the answers

    Which of the following is NOT a reason to assess vitals?

    <p>Before or after consuming a meal</p> Signup and view all the answers

    What are the four ways heat can be transferred to external environments?

    <p>Radiation, Conduction, Convection, Evaporation</p> Signup and view all the answers

    Which of the following is an example of convection?

    <p>Blowing cool air across a warm body with a fan</p> Signup and view all the answers

    What is the recommended frequency for removing contacts?

    <p>At least twice per day</p> Signup and view all the answers

    When storing a hearing aid, what is the correct procedure?

    <p>Wipe them with a dry towel and store in a dry container</p> Signup and view all the answers

    What is the most crucial aspect to inquire about when assessing a patient's skin?

    <p>How they care for it</p> Signup and view all the answers

    For hygiene assessment of nails and feet, what should be done after cleaning dentures?

    <p>Put in a container with water to keep them hydrated</p> Signup and view all the answers

    During skin assessment, what should be compared for symmetry?

    <p>Bilateral parts</p> Signup and view all the answers

    When assessing the skin, what should be used to report and record findings?

    <p>Standard terminology</p> Signup and view all the answers

    What are the purposes of bathing for a patient?

    <p>Stimulates respiration rate and depth, and promotes comfort</p> Signup and view all the answers

    During perineal and vaginal care, what should be done?

    <p>Perform care in a dignified manner according to procedure</p> Signup and view all the answers

    Which of the following is part of proper eye care?

    <p>Cleaning eyeglasses with alcohol-based solutions</p> Signup and view all the answers

    What should be avoided for patients on anticoagulant therapy during hair care?

    <p>Using regular razors</p> Signup and view all the answers

    How should external ear care be performed?

    <p>Washing the external ear with a washcloth-covered finger</p> Signup and view all the answers

    When teaching skin care to patients, what points should be addressed?

    <p>Soaps/cleansers, deodorants, cosmetics, sunscreen</p> Signup and view all the answers

    What should be inquired about during a skin assessment to understand the patient's symptoms better?

    <p>If they have found anything helpful in relieving symptoms</p> Signup and view all the answers

    When assessing dentures, what is the correct storage recommendation to keep them clean and hydrated?

    <p>Put in a container with water</p> Signup and view all the answers

    What is the recommended frequency for turning a patient to prevent bedsores?

    <p>Every 2 hours</p> Signup and view all the answers

    During a skin assessment, why is it essential to compare bilateral parts for symmetry?

    <p>To recognize normal variations</p> Signup and view all the answers

    What should be considered the primary focus when storing a hearing aid?

    <p>Dry them and store in a container</p> Signup and view all the answers

    Which aspect is crucial for assessing the skin during examinations of other body systems?

    <p>Incorporating skin assessment into general examination</p> Signup and view all the answers

    What should be assessed during hygiene assessment for perineal and vaginal areas?

    <p>Odor</p> Signup and view all the answers

    What is the purpose of bathing for a patient?

    <p>Improves self-image/self-esteem</p> Signup and view all the answers

    Which step is part of proper eye care for patients?

    <p>Using a wet, warm cloth to clean from outer to inner</p> Signup and view all the answers

    What is recommended when caring for a patient's hair who is on anticoagulant therapy?

    <p>Using regular razors for shaving</p> Signup and view all the answers

    What should be done during oral hygiene care for a patient?

    <p>Moisten the mouth before cleaning</p> Signup and view all the answers

    Why is capillary refill and contour of the nail bed important in hygiene assessment?

    <p>To evaluate peripheral circulation and tissue oxygenation</p> Signup and view all the answers

    Which type of exercise is defined as muscle contraction without shortening?

    <p>Isometric</p> Signup and view all the answers

    What is a key factor that can lead to back injuries in healthcare workers?

    <p>Lifting patients when fatigued</p> Signup and view all the answers

    Which equipment is used for stand-assist and repositioning in patient handling?

    <p>Gait belts</p> Signup and view all the answers

    What is the correct way to lift objects to prevent back injuries?

    <p>Lift with your legs, not your back</p> Signup and view all the answers

    Which type of exercise involves muscle shortening and active movement?

    <p>Isotonic</p> Signup and view all the answers

    What should be avoided to prevent patient handling injuries?

    <p>Standing for long periods</p> Signup and view all the answers

    What is the purpose of positioning patients every 4 hours?

    <p>To prevent bed sores</p> Signup and view all the answers

    In which position is the patient sitting with legs straight in front of them?

    <p>Fowler’s position</p> Signup and view all the answers

    What is the correct definition of the Sim's position?

    <p>Laying on the side with opposite leg up and bent in front</p> Signup and view all the answers

    Which temperature range is considered normal for adults?

    <p>$35.8-37.5$ C</p> Signup and view all the answers

    What can walking aids like crutches help prevent when used properly?

    <p>Axillary nerve damage</p> Signup and view all the answers

    Which fever type involves the temperature remaining above normal with minimal variations per day?

    <p>Sustained or continuous fever</p> Signup and view all the answers

    What is a common symptom associated with Tachypnea?

    <p>Increased respiratory rate</p> Signup and view all the answers

    Which condition is characterized by a pulse rate below 60 BPM?

    <p>'Bradycardia'</p> Signup and view all the answers

    What is the primary purpose of using compression stockings?

    <p>Prevent blood clots</p> Signup and view all the answers

    When is it appropriate for a nurse to take her own vitals instead of delegating the task?

    <p>If narcotic medication has been administered</p> Signup and view all the answers

    Which is an example of evaporation as a way to transfer heat to the external environment?

    <p>Sweating and vaporizing moisture from the skin</p> Signup and view all the answers

    What is the primary source of heat loss from the body?

    <p>Skin</p> Signup and view all the answers

    How often should a patient's vitals be taken at a minimum?

    <p>Every 4 hours unless there is a change</p> Signup and view all the answers

    Which of the following is NOT considered a vital sign?

    <p>Blood Glucose Level</p> Signup and view all the answers

    In which situation should a nurse be the one to assess the vital signs?

    <p>If there is a change in condition</p> Signup and view all the answers

    What physical, mental, and behavioral change follows a 24-hour cycle and happens naturally?

    <p>Circadian Rhythms</p> Signup and view all the answers

    If a patient has Thrombocytopenia (low platelets), why is it advised not to take a rectal temperature?

    <p>May cause bleeding</p> Signup and view all the answers

    What is the primary factor that affects blood pressure according to the text?

    <p>Age</p> Signup and view all the answers

    Which body system increases blood pressure through the Renin-angiotensin-aldosterone system according to the text?

    <p>Renal system</p> Signup and view all the answers

    What is the correct sequence of sounds when taking blood pressure with a stethoscope and sphygmomanometer?

    <p>Systolic, diastolic</p> Signup and view all the answers

    Which statement is true about axillary temperature measurements?

    <p>It can be affected by external factors like environmental temperature</p> Signup and view all the answers

    What is an example of a subjective assessment?

    <p>Assessing based on feelings</p> Signup and view all the answers

    When should a nurse be the one to take her own vitals?

    <p>If administering medications affecting cardio and respiratory systems</p> Signup and view all the answers

    In which situation should a nurse NOT delegate the task of taking vitals?

    <p>After a change in condition</p> Signup and view all the answers

    What is the primary mode of heat loss from the body?

    <p>Radiation</p> Signup and view all the answers

    How many vital signs are typically assessed?

    <p>6</p> Signup and view all the answers

    Which is an example of heat transfer by conduction?

    <p>Transferring heat to ice causing it to melt</p> Signup and view all the answers

    Which method is least suitable for taking temperature if the patient is unable to open and close their mouth?

    <p>Rectal</p> Signup and view all the answers

    What system in the body is responsible for increasing blood pressure, according to the information provided?

    <p>Renin-angiotensin-aldosterone system</p> Signup and view all the answers

    Which physical position is expected to have lower blood pressure based on the information given?

    <p>Prone position</p> Signup and view all the answers

    What body factor influences blood pressure by decreasing it during exercise?

    <p>Cardiac output</p> Signup and view all the answers

    What is the first sound heard in a blood pressure measurement known as?

    <p>Systolic sound</p> Signup and view all the answers

    If a patient has an ear infection, which temperature measurement should be avoided?

    <p>Axillary</p> Signup and view all the answers

    What should a nurse do if there is a change in a patient's condition regarding taking vitals?

    <p>Take the vitals herself/himself</p> Signup and view all the answers

    Which situation warrants a nurse to personally take her own vitals?

    <p>If blood is being administered</p> Signup and view all the answers

    What can be considered as an example of heat transfer by conduction?

    <p>Body transferring heat to an ice pack causing it to melt</p> Signup and view all the answers

    When should a nurse take her own vitals based on the text?

    <p>If there is a change in condition</p> Signup and view all the answers

    Which of the following is a primary source of heat loss according to the text?

    <p>Skin</p> Signup and view all the answers

    What are the four ways heat can be transferred to external environments?

    <p>Radiation, Convection, Evaporation, Conduction</p> Signup and view all the answers

    What is the most important factor to consider when deciding whether to take an oral temperature?

    <p>Facial surgery history</p> Signup and view all the answers

    If a patient has Thrombocytopenia (low platelets), which temperature measurement method should be avoided?

    <p>Rectal</p> Signup and view all the answers

    What is the primary cause of increased blood pressure in some races like African Americans?

    <p>Race</p> Signup and view all the answers

    Which system in the body plays a crucial role in regulating blood pressure by increasing it?

    <p>Renin-angiotensin-aldosterone system</p> Signup and view all the answers

    What is the primary reason for avoiding taking a forehead temperature?

    <p>Scarring</p> Signup and view all the answers

    During skin assessment, what is crucial to ensure when comparing bilateral parts?

    <p>Ensuring symmetry</p> Signup and view all the answers

    Which step is part of proper denture care to keep them clean and hydrated?

    <p>Cleaning them and storing in a water-filled container</p> Signup and view all the answers

    What is the purpose of using compression stockings in patient care?

    <p>To prevent blood clots</p> Signup and view all the answers

    Which position involves the patient lying flat on their back with legs slightly bent or straight?

    <p>Supine position</p> Signup and view all the answers

    Which fever type involves the temperature returning to normal between exacerbations?

    <p>Intermittent fever</p> Signup and view all the answers

    What is the primary source of heat loss from the body through electromagnetic waves?

    <p>Radiation</p> Signup and view all the answers

    Which method is used for transferring heat through direct contact?

    <p>Conduction</p> Signup and view all the answers

    What is the suggested pulse rate range for an adult in a normal state?

    <p>$80-120$ BPM</p> Signup and view all the answers

    Which type of respiratory rate is characterized by over 20 breaths per minute?

    <p>$Tachypnea$</p> Signup and view all the answers

    $Grade 0$ pulse strength indicates:

    <p>$Absent, unable to palpate$ pulse amplitude</p> Signup and view all the answers

    $Orthostatic hypotension$ results from position changes to:

    <p>Standing position</p> Signup and view all the answers

    What is the primary function of bathing according to the text?

    <p>Promotes circulation by stimulating the skin’s peripheral nerve endings and underlying tissues</p> Signup and view all the answers

    Which of the following is NOT part of the hygiene assessment for perineal and vaginal areas as described in the text?

    <p>Checking for ticks</p> Signup and view all the answers

    What is the correct order of steps for oral hygiene care based on the information provided?

    <p>Moisten the mouth, clean the mouth, care for dentures, brush and floss teeth, use mouthwash</p> Signup and view all the answers

    Why do patients on anticoagulant therapy require electric razors instead of regular razors according to the text?

    <p>Electric razors prevent skin irritation and bleeding due to thinner skin</p> Signup and view all the answers

    What is an important aspect to consider during proper eye care based on the information given?

    <p>Using artificial tear solution every 4 hours if blink reflex is absent</p> Signup and view all the answers

    Which type of exercise is characterized by muscle contraction without shortening?

    <p>Isometric exercise</p> Signup and view all the answers

    What should be avoided during proper lifting techniques according to the text?

    <p>Lifting with your back instead of your legs</p> Signup and view all the answers

    What is a common variable leading to back injuries in healthcare workers based on the information provided?

    <p>Lifting after recent back injury recovery</p> Signup and view all the answers

    What is the primary effect of isotonic exercise on muscles according to the text?

    <p>Muscle shortening and active movement</p> Signup and view all the answers

    Why is squatting down to pick up objects recommended over bending over?

    <p>To prevent back injuries</p> Signup and view all the answers

    Study Notes

    Circadian Rhythms and Body Temperature

    • Circadian rhythms are physical, mental, and behavioral changes that follow a 24-hour cycle and happen naturally
    • Examples of circadian rhythms include:
      • Lower body temperature and blood pressure in the morning
      • Higher body temperature and blood pressure in the evening
    • Factors that affect body temperature:
      • Circadian rhythms
      • Age or gender (peds and elderly are more sensitive and need more coverings)
      • Physical activity (e.g., running a mile)
      • State of health (e.g., severe infection)
      • Environmental temperature (e.g., walking in 102°F heat)

    Vital Signs

    • The six vital signs are:
      • Temperature
      • Pulse
      • Respiration
      • Blood pressure
      • Pulse oximetry
      • Pain
    • The frequency of vital sign assessment:
      • Every 4 hours, unless there is a change in condition
    • Seven times to assess vitals:
      • On admission
      • Based on policy and procedures
      • Change in condition
      • Change in or loss of consciousness
      • Before or after surgery or other invasive diagnostic procedure
      • Before or after activity that may increase risk
      • Before or after administering meds that affect cardio and respiratory

    Blood Pressure

    • Regulation of blood pressure:
      • Nerve regulation
      • Cardiac output
      • Stimulation of the vagus nerve
      • Sympathetic stimulation
      • Baroreceptors in the heart
      • Renin-angiotensin-aldosterone system
    • Factors that affect blood pressure:
      • Age
      • Circadian rhythm
      • Sex
      • Food intake
      • Exercise
      • Weight
      • Emotional state
      • Body position
      • Race
      • Drugs and medications

    Temperature Assessment

    • The five ways to take a temperature:
      • Oral
      • Rectal
      • Axillary
      • Tympanic
      • Forehead
    • Contraindications for taking a temperature:
      • Oral: eating, chewing gum, facial surgery, trauma, pediatrics, or inability to open and close mouth
      • Rectal: thrombocytopenia (low platelets)
      • Axillary: environmental factors
      • Tympanic: ear infections, earwax, or discharge
      • Forehead: scar tissue or wearing a hat

    Hygiene and Skin Care

    • Hygiene assessment for skin:
      • Cleanliness and intactness
      • Capillary refill and contour of the nail bed
      • Swelling, inflammation, lesions
    • Hygiene assessment for perineal and vaginal areas:
      • Color lesions, swelling, inflammation, excoriation, tenderness, discharge
      • Anal cracks, nodules, distended veins, masses, or polyps
      • Odor
    • Steps to oral hygiene:
      • Moisten the mouth
      • Clean the mouth
      • Care for dentures
      • Brush and floss teeth
      • Use mouthwash
    • Proper eye care:
      • Cleaning from inner to outer with wet, warm cloth
      • Use artificial tear solution every 4 hours if blink reflex is absent
      • Care for eyeglasses, contacts, or artificial eyes
    • Ear and nose care:
      • Wash external ear with washcloth-covered finger
      • Perform hearing aid teaching and care
      • Clean nose by having patient blow it if both nares are patent
      • Remove crusted secretions around nose by applying warm, moist compress### Hygiene Assessment
    • Hygiene assessment for nails and feet: cleanliness and intactness, capillary refill and contour of the nail bed, swelling, inflammation, lesions of the feet
    • Hygiene assessment for perineal and vaginal areas: color, lesions, swelling, inflammation, excoriation, tenderness, discharge, anal cracks, nodules, distended veins, masses, or polyps, odor

    Oral Hygiene

    • Steps to oral hygiene: moisten the mouth, clean the mouth, care for dentures, brush and floss teeth, use mouthwash
    • Potential oral problems: dental caries, plaque, or periodontal disease, loose teeth

    Eye Care

    • Proper eye care: cleaning from inner to outer with wet, warm cloth, use artificial tear solution every 4 hours if blink reflex is absent, care for eyeglasses, contacts, or artificial eyes

    Ear and Nose Care

    • Ear and nose care: wash external ear with washcloth-covered finger, not Qtips, perform hearing aid teaching and care, clean nose by having patient blow it if both nares are patent, remove crusted secretions around nose by applying warm, moist compress

    Hair Care

    • Hair care for patients on anticoagulant therapy: use electric razors, not regular razors, assist with caring for beards and mustaches, as well as assisting with unwanted hair removal

    Skin Care

    • Purposes of bathing: cleanses the skin, acts as a skin conditioner, helps to relax a person, promotes circulation, increases sensation, serves as musculoskeletal exercise, stimulates rate and depth of respirations, promotes comfort, provides person with sensory input, helps improve self-image/self-esteem, strengthens nurse-patient relationship
    • What to do during perineal and vaginal care: assess for problems and related treatments, perform a physical assessment of genitalia, perform care in a matter-of-fact and dignified manner according to procedure, cleanse vaginal area with plain soap and water

    Safe Patient Handling and Mobility (SPHM)

    • Variables leading to patient handling injuries: uncoordinated lifts, high exertion, awkward or static postures, manual lifting and transferring, repetitive movements or tasks, standing for long periods of time
    • The 8 main variables leading to back injury in health care workers: uncoordinated lifts, manual lifting and transferring of patients without assistive devices, lifting when fatigued or after recent back injury recovery, repetitive movements, standing for long periods of time, transferring patients, repetitive tasks, transferring/repositioning uncooperative or confused patients
    • Proper way to lift: use your legs, not your back, squat down to pick up objects, not bend over

    Vital Signs

    • The six vital signs: temperature, pulse, respiration, blood pressure, pulse ox, pain
    • How often should patients' vitals be taken at minimum: every 4 hours, unless there is a change
    • Four ways to transfer heat to external environments: radiation, convection, evaporation, conduction

    Body Temperature

    • Factors affecting body temperature: circadian rhythms, age or gender, physical activity, state of health, environmental temperature
    • Afebrile: without fever
    • Pyrexia: with fever (febrile)

    Pulse

    • Tachycardic: pulse rate above 100
    • Bradycardic: pulse rate below 60
    • Normal pulse rate: 60-100 BPM

    Blood Pressure

    • Regulation of blood pressure: nerve regulation, cardiac output, stimulation of the vagus nerve, sympathetic stimulation, baroreceptors in the heart, renin-angiotensin-aldosterone system

    • How to take a blood pressure: using a stethoscope and sphygmomanometer, or using an electronic or automated device

    • Factors affecting blood pressure: age, circadian rhythm, sex, food intake, exercise, weight, emotional state, body position, race, drugs and medications### Mechanical Lateral-Assist Devices

    • Types of mechanical lateral-assist devices include transfer chairs, powered stand-assist and repositioning lifts, and powered full-body lifts.

    Patient Positioning

    • Patients must be positioned every 4 hours to prevent bed sores.
    • Fowler's position: sitting with legs straight in front of them.
    • Supine or dorsal recumbent position: laying flat on their back with legs straight or slightly bent.
    • Side lying or lateral position: laying on their side with legs straight.
    • Sim's position: laying on their side with the opposite leg up and bent in front of them.
    • Prone position: lying face down.

    Transfer and Ambulation

    • To help transfer a patient, have them cross their arms and feet.
    • Mechanical aids for walking include walkers, canes, braces, and crutches.
    • Proper positioning of crutches prevents axillary nerve damage.

    Vital Sign Norms in Adults

    • Pulse rate: 60-100 (average: 80)
    • Respirations: 12-20 breaths per minute
    • Blood pressure: less than 120/80
    • Oral temperature: 35.8-37.5°C (96.4-99.5°F)
    • Pulse strength:
      • Grade 0: absent, unable to palpate
      • Grade +1: diminished, weaker than expected
      • Grade +2: normal, brisk, expected
      • Grade 3+: bounding

    Heat Transfer

    • Radiation: dissemination of heat by electromagnetic waves (e.g., body gives off heat waves from uncovered surfaces)
    • Convection: dissemination of heat by motion between areas of unequal density (e.g., oscillating fan blowing cool air)
    • Evaporation: conversion of a liquid to a vapor (e.g., body fluid in the form of sweat vaporizing from skin)
    • Conduction: transfer of heat to another object during direct contact (e.g., body heat transferred to an ice pack, causing it to melt)

    Fevers

    • Intermittent fever: temperature returns to normal between exacerbations, at least once every 24 hours
    • Remittent fever: temperature does not return to normal and fluctuates a few degrees
    • Sustained or continuous fever: temperature remains above normal with minimal variations
    • Relapsing or recurrent fever: temperature returns to normal for one or more days with one or more episodes of fever

    Pulse and Respiratory

    • Pulse:
      • Tachycardic: pulse rate above 100
      • Bradycardic: pulse rate below 60
      • Normal pulse rate: 60-100 BPM
      • Amplitude and quality: strong or weak pulse
    • Respiratory:
      • Normal rate: 12-20 breaths per minute
      • Eupnea: normal, unlabored respiration
      • Tachypnea: increased respiratory rate
      • Bradypnea: decreased respiratory rate
      • Apnea: periods of no breathing
      • Dyspnea: difficult or labored breathing
      • Orthopnea: changes in breathing when sitting or standing

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    Test your knowledge on delegating vitals and assessing vital signs in nursing. Topics include when nurses should take their own vitals, the six vital signs, and the frequency of vital sign assessments for patients.

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