Vital Signs & Patient Assessment

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Questions and Answers

What is a common symptom when a patient has a temperature of 102°F?

  • Elevated heart rate (correct)
  • Normal body temperature
  • Decreased heart rate
  • Low fever

When obtaining oxygen saturation, which finger should be chosen?

  • Any finger can be chosen.
  • The finger without capillary refill.
  • The finger with capillary refill quicker than 2 seconds. (correct)
  • The finger with capillary refill more than 5 seconds.

What is an appropriate intervention for a patient with hypothermia (35°C)?

  • Increase the room temperature (correct)
  • Remove excess clothing
  • Apply a cold compress
  • Give the patient ice water

What indicates orthostatic hypotension when checking a patient's blood pressure supine?

<p>A decrease of 20 mmHg systolic pressure (A)</p> Signup and view all the answers

What is an appropriate first intervention if a patient's oxygen saturation is 88%?

<p>Encourage a deep breath (C)</p> Signup and view all the answers

What should the nurse do when a patient's heart rate is irregular?

<p>Auscultate the apical pulse. (D)</p> Signup and view all the answers

What is an expected symptom to observe when a patient's heart rate is 56 bpm?

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

What action should the nurse take for a patient experiencing dehydration and hypotension?

<p>Increase fluid intake. (A)</p> Signup and view all the answers

What intervention is appropriate for a patient with postural hypotension?

<p>Assist from lying to standing. (B)</p> Signup and view all the answers

When obtaining an electronic blood pressure reading, where should the arm be?

<p>Above the level of the heart (C)</p> Signup and view all the answers

What is the appropriate action when a patient's temperature is 35°C?

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

What should be done when a patient's oxygen saturation is 88%?

<p>Encourage a deep breath. (C)</p> Signup and view all the answers

What assessment finding is associated with a heart rate of 56 bpm?

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

What is the first action to take for a patient experiencing dehydration and hypotension?

<p>Increase fluid intake. (C)</p> Signup and view all the answers

What change in systolic blood pressure indicates orthostatic hypotension when obtained with the patient supine?

<p>A decrease of 20 mmHg (B)</p> Signup and view all the answers

Flashcards

Symptoms of 102°F Temperature

High fever, elevated heart rate

Oxygen saturation

Choose the finger with capillary refill less than 2 seconds.

Intervention for 35°C (hypothermia)

Remove excess clothing, apply a cold compress.

Orthostatic hypotension

A decrease of 20 mmHg systolic indicates orthostatic hypotension.

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Intervention for Oâ‚‚ Saturation of 88%

Encourage a deep breath.

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Palpating radial pulses

Report as 4+80

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Constipation symptom

Decreased heart rate

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Irregular heart rate intervention

Auscultate the apical pulse

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56 bpm heart rate symptom

Dizziness (bradycardia)

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Dehydration and hypotension intervention

Increase fluid intake

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High temperature effect

Elevated temp increases heart rate.

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Electronic BP arm position

Brachial artery must be below the heart level.

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Postural hypotension assistance

Assist from lying to standing and systolic pressure may be higher.

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Hypothermia intervention

Apply cold compress and remove blankets.

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Oxygen saturation location

Assess capillary refill under two seconds.

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Study Notes

  • If a patient's temperature is 102°F, symptoms include high fever and an elevated heart rate.
  • When obtaining oxygen saturation, choose a finger with capillary refill less than 2 seconds.
  • If a patient's temperature is 35°C (hypothermia), interventions include removing excess clothing, applying a cold compress, and removing excess blankets.
  • If a patient shows orthostatic hypotension, check blood pressure while they are supine; a decrease of 20 mmHg systolic indicates orthostatic hypotension
  • If a patient has an oxygen saturation of 88% (O2 %), encourage a deep breath.
  • When palpating radial pulses (right: 80 bpm, left: 48 bpm), report as 4+80.
  • A patient with constipation and recent bowel movement may experience a decreased heart rate.
  • If a patient has an irregular heart rate, auscultate the apical pulse.
  • If a patient's heart rate is 56 bpm, expect dizziness (bradycardia).
  • For a patient with dehydration and hypotension, increase fluid intake.
  • For a patient with postural hypotension, assist them from lying down to a standing position; systolic pressure may be higher when standing.
  • If a patient has an elevated temperature of 108°F, this causes an increased heart rate.
  • When obtaining electronic blood pressure, elevate the client's arm above the level of the heart (brachial artery).

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