Download Vital Signs Assessment: A Comprehensive Study Guide and more Exams Nursing in PDF only on Docsity!
BSN !! 206 !! - !! Hallmark !! Study !! Stack !!
Exam !! with !! accurate !! detailed !!
solutions
Which !! of !! the !! following !! patients !! would !! require !! follow !! up? An !! adult !! with !! a !! respiratory !! rate !! of !! 10 !! breaths !! per !! minute. !! The !! normal !! respiratory !! rate !! for !! a !! newborn !! is !! 30 !! to !! 60 !! breaths !! per !! minute. !! The !! normal! ! respiratory !! rate !! of !! a !! child !! is !! 20 !! breaths !! per !! minute. !! The !! normal !! respiratory !! rate !! for !! a !! teenager !! is !! 16-20 !! breaths !! per !! minute !!. !! Respirations !! for !! adult !! is !! 12- therefore !! a !! 10 !! breaths !! per !! minute !! for !! a !! follow !! up Which !! of !! the !! following !! vital !! signs !! recorded !! for !! an !! older !! adult !! would !! be !! considered !! acceptable !! (within !! normal !! Limits)? Temp !! 97.0 !! F !! (36.1C), !! P-60, !! R-16, !! BP !! 116/78, !! O2 !! sat !! 95% Normal !! Older !! Adult !! Body !! temp- !! 36c(96.8F) Normal !! HR !! 60-100 !! BPM Normal !! Resp. !! rate !_! 16-
Average !! BP !! 120/80 !! (BP !! over !! 140/90 !! is !! HTN) Pulse !! Ox !! - !! 95-100% The !! nurse !! has !! delegated !! the !! task !! of !! temperature !! assessment !! to !! the !! NAP. !! Which !! information !! should !! be !! provided !! to !! the !! NAP? !! Select !! all !! the !! apply The !! frequency !! for !! taking !! or !! monitoring !! the !! temperature What !! changes !! to !! report !! immediately !! to !! the !! nurse The !! type !! of !! temperature !! required Which !! of !! the !! following !! situations !! may !! affect !! a !! patient's !! vital !! signs? (Select !! all !! that !! apply) Time !! of !! day Moving !! from !! lying !! to !! standing !! position !! Pain !! rated !! as !! a !! 7 !! to !! 0-10 !! pain !! scale
Ask !! the !! patient !! not !! to !! eat, !! drink, !! or !! smoke !! for !! 20 !! minutes !! and !! then !! assess !! the !! patient's !! oral !! temperature. for !! which !! patient !! would !! a !! tympanic !! thermometer !! be !! the !! preferred !! thermometer !! to !! use? A !! tachypneic !! patient !! who !! is !! receiving !! oxygen !! by !! nasal !! cannula. We !! have !! an !! expert-written !! solution !! to !! this !! problem! Adult !! Normal !! body !! temp 36c !! - !! 38c !! (96.8-100.4) Temperature !! Measurement !! sites rectum tympanic !! membrane oral temporal !! artery types !! of !! thermometers electronic tympanic/ear !! theremometer temporal !! artery !! theremometer chemical !! dot !_! disposable axillary
electronic !! thermometer oral !! - !! blue rectal !! - !! red Axillary !! - !! blue tympanic !! theremometer does !! not !! accurately !! measure !! core !! temp. !! changes !! during !! and !! after !! exercise Do !! not !! use !! with !! those !! who !! have !! had !! ear !! surgery signs !! of !! hyperthermia decreased !! skin !! turgor dry !! mucous !! membranes tachycardia hypotension !! (low !! bp) decreased !! venous !! filling concentrated !! urine signs !! of !! heatstroke body !! temp !! - !! 40 !! c !! (104 !! f) !! or !! more hot !! dry !! skin tachycardia
how !! to !! take !! rectal !! temp red !! prob sims !! position lubricate !! water !! soluble !! 1 !! -1.5 !! in insert !! prob !! 1.5 !! in !! anus !! (adult) insert !! probe !! .5-1 !! inch !! for !! child insert !! toward !! umbilcus how !! to !! take !! axillary !! temp use !! blue !! tip cover !! probe raise !! arm place !! probe rest !! arm !! across !! chest How !! to !! take !! temp !! with !! tympanic !! thermometer !! adult hold !! thermometer !! with !! your !! dominant !! hand use !! ear !! on !! your !! dominant !! side Ie !! youre !! left !! handed !! take !! temp !! in !! pts !! left !! ear pull !! pinna !! back, !! up !! and !! out !! fit !! tip !! in !! the !! ear !! canal !! and !! aim !! toward !! pts !_! nose.
How !! to !! take !! temp !! with !! tympanic !! thermometer !! child !! under !! 3 pull !! pinna !! down !! and !! back !! and !! aim !! speculum !! toward !! midpoint !! between !! eyebrow !! and !! sideburns How !! to !! take !! temp !! with !! tympanic !! thermometer !! older !! than !! 3 pull !! pinna !! up !! and !! back Pulse !! sites temporal carotid Brachial Apical radial femoral popliteal posterial !! tibial dorsal !! pedis ulnar where !! to !! locate !! apical !! pulse between !! 4th !! and !! 5th !! intercostal !! space !! at !! left !! midclavicular !_! line
irregular !! may !! have !! pause assessing !! amplitude 3+ !! full !! - !! bounding 2+ !! normal 1+ !! weak 0 !! absent how !! long !! should !! a !! weak !! pulse !! be !! counted !! for? one !! minute when !! should !! a !! pulse !! be !! measured !! for !! 1 !! minute abnormality !! of !! rate, !! rhythm !! or !! amplitude anatomy !! of !! stethoscope earpiece binaural tubing bell !! - !! low !! pitched !! sounds diaphragm !! - !! used !! for !! high !! pitched !! sounds
Heart !! ascultation see !! chart !! for !! where !! each !! area !! is !! located apical !! aka PMI normal !! adult !! respirations 12-20/minute cheyne-stokes abnormal !! breathing !! pattern; !! periods !! of !! dyspnea !! and !! apnea kussmaul rapid !! breathing !! - !! deep !! labored systolic !! pressure top !! number !! - !! normal !! up !! to !! 120 the !! force !! exerted !! agains !! the !! wall !! of !! the !! artery !! when !! the !! ventricles !! contract. the !! exerted !! systolic !! pressure !! of !! the !! pulse !! is !! due !! to !! cardiac !! output !! and !! blood !_! volume.
repirations !! 12 !! + !_! kids
- 12-
- respirations !! kids !! 5-
- 20-
- respirations !! kids !! 2-
- 25-
- respirations !_! 1-
- 25-
- 30- respirations !! less !! than !! 1 !! yer
- infant !! 72-104/27/ normal !! bp !! kids !! chart
- toddler !_! 85-106/42-
- preschool !_! 90-110/48-
school !! age !! 93-120/60- which !! of !! the !! following !! vitale !! signs !! are !! expected !! for !! the !! adult !! patient !! who !! has !! problems !! with !! oxygenation? temp !! 98.6f, !! p-102, !! R-28, !! BP !! 98/50, !! O2 !! sat !! 85% 3 !! multiple !! choice !! options a !! healthy !! 30 !! year !! old !! male !! arrives !! at !! the !! clinic !! for !! a !! physical. !! the !! nurse !! is !! responsible !! for !! collecting !! his !! vital !! signes. which !! of !! these !! can !! be !! delegated !! to !! the !! NAP? bp, !! temp, !! pulse !! ox, !! resp, !! pulse !! - !! because !! the !! patient !! has !! not !! indicated !! any !! physical !! complaints !! that !! would !! affect. the !! nurse !! decides !! to !! collect !! the !! patient's !! temp !! orally !! using !! an !! electronic !! thermometer. !! choose !! equipment !! to !! be !! used !! from !! the !! list: lubricant, !! tympanic !! thermometer, !! chemical !! oral !! thermometer, !! tissue, !! chemical !! external !! thermometer !! red !! probed !! thermometer, !! blue !! probe !! electronic !! thermometer, !! watch !! with !! second !! hand, !! patient !! data !! recording !! sheet !! and !! pen, !! thermometer !! cover blue !! probe !! thermometer patient !! data !! recording !! sheet thermometer !! cover the !! patient's !! bp !! reading !! is !! 150/80 !! mmHg. !! for !! this !! patient, !! 80 !! is !! representative !! of: !! (select !! all !! that !_! apply)
ensure !! the !! chest !! piece !! is !! rotated !! to !! the !! diaphragm !! side reduce !! environment !! noise !! by !! turning !! off !! the !! TV !! or !! closing !! the !! door make !! sure !! the !! stethoscope !! does !! not !! touch !! the !! patient's !! clothing !! or !! BP !! cuff keep !! the !! stethoscope !! tubing !! still !! to !! avoid !! extraneous !! sound ensure !! the !! bladder !! of !! the !! cuff !! is !! centered !! 1 !! in !! above !! the !! brachial !! artery the !! NAP !! reports !! to !! the !! nurse !! that !! the !! patient's !! pulse !! oximetry !! is !! 88% !! what !! actions !! should !! the !! nurse !! take !! (select !! all !! that !! apply) be !! prepared !! to !! admin. !! o verify !! the !! reading !! by !! taking !! the !! patient's !! spo perform !! a !! cardiopulmonary !! assessment assist !! the !! patient !! to !! a !! high-fowlers !! position notify !! the !! health !! care !! provider a !! 15 !! year !! old !! male !! patient !! is !! hypothermic. !! which !! temperature !! reflects !! hypothermia? 95 !! f 3 !! multiple !! choice !! options
Identify !! why !! a !! child's !! respirations !! might !! be !! shallow. the !! child !! is !! in !! acute !! pain 3 !! multiple !! choice !! options you !! are !! taking !! a !! patient's !! bp !! by !! using !! the !! one-step !! method. !! which !! of !! the !! following !! is !! the !! incorrect !! step !! in !! the !! sequence? pup !! the !! cuff !! to !! 20 !! mm !! hg !! above !! the !! patient's !! normal !! diastolic !! pressure. !! release !! the !! valve !! quickly !! observe !! the !! needle !! fall. !! identify !! the !! onset !! of !! the !! first !! korokoff !! sound !! in !! mmh. the !! cuff !! should !! be !! pumped !! 30 !! over !! normal !! systolic !! and !! valve !! release !! slowly a !! patient !! has !! been !! given !! an !! opioid !! (e.g !! Morphine) !! for !! pain !! relief. !! why !! does !! the !! nurse !! assess !! the !! patients !! respiratory !! rate !! before !! administering !! the !! next !! dose. opioid !! analgesics !! may !! depress !! rate !! and !! depth !! of !! respirations 3 !! multiple !! choice !! options A !! teen !! has !! come !! to !! the !! health !! care !! provider's !! office !! because !! he !! does !! not !! feel !! well !! after! ! football !! practice. !! His !! temperature !! is !! 102F. !! The !! nurse !! may !! conclude !! which !! of !! the !! following !! regarding !! temperature !! reading? this !! is !! a !! high !! temp !! for !! a !! person !! his !! age 3 !! multiple !! choice !_! options
8 !! year !! old !! with !! resp. !! rate !! of !! 24 !! bpm 65 !! year !! old !! with !! bp !! of !! 140/ 75 !! year !! old !! with !! pulse !! ox !! of !! 88 !! % The !! nurse !! reads !! the !! following !! nurse's !! note !! in !! the !! patient's !! health !! record. !! What !! is !! the !! priority !! nursing !! intervention !! based !! on !! this !! information? 9/21/17 !! 1800 !! patient !! complains !! of !! headaches !! almost !! daily !! occurring !! more !! frequently !! in !! the !! evening. !! bp !! 164/98 !! p !! johnson !! NAP obtain !! a !! complete !! set !! of !! vitals !! and !! gather !! further !! assessment !! data 3 !! multiple !! choice !! options a !! nursing !! student !! is !! assigned !! to !! take !! the !! vital !! sings !! on !! a !! patient !! and !! finds !! the !! radial !! pulse !! to !! be !! irregular !! what !! action !! should !! the !! nursing !! student !! take auscultate !! the !! patient's !! apical !! pulse. We !! have !! an !! expert-written !! solution !! to !! this !! problem! name !! 5 !! safety !! considerations call !! bell !! within !! reach non-exit !! side !! rails !! up !! for !_! support
bed !! alarm bedside !! commode !! placed !! alongside !! bed !! if !! needed nonskid !! footwear !! available S.P.L.A.T.T symptoms !! at !! time !! of !! fall previous !! fall location !! of !! fall activity !! at !! time !! of !! fall time !! of !! fall trauma !! after !! fall timed !! get !! up !! and !! go !! (TUG) longer !! than !! 12 !! seconds !! to !! complete !! - !! high !! risk an !! elderly !! patient !! was !! recently !! admitted !! to !! a !! medical !! unit !! with !! severe !! fluid !! and !! electrolyte !! imbalance. !! his !! family !! states !! that !! he !! has !! periods !! of !! confusion. !! what !! are !! some !! practical !! precautions !! the !! nurse !! can !! take !! to !! ensure !! the !! patient's !! safety !! w/out !! having !! to !! use !! restraints make !! staff !! assignments !! for !! pts !! in !! adjacent !! rooms activate !! the !! bed !! alarm !! when !! the !! pateitn !! is !! in !! bed
