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BSN 206 - Hallmark Study Stack
Which of following patients would reguire following 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- 20
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- 25
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
for which patient would a tympanic thermometer be the preferred thermometer to use?
A tachypneic patient who is receiving oxygen by nasal cannula.
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
temps fluctuate 0.9-1.8 throughout day
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
Assessing pulse rythym
should be regular and steady
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
hypertension classifications
prehypertension 120-139 / 80- 89
stage 1 - 140 - 159/90- 99
stage 2 160+/100+
repirations 12 + kids
12 - 20
respirations kids 5- 12
20 - 25
respirations kids 2- 5
25 - 30
respirations 1- 2
25 - 35
respirations less than 1 yer
normal bp kids chart
infant 72-104/27/
toddler 85-106/42- 58
preschool 90-110/48- 70
school age 93-120/60- 78
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
use the bell side
keep the stethoscope tubing still to avoid extraneous sound
ensure the bladder of the cuff is centered 1 in above the brachial artery
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
65 year old with bp of 140/
88 year old with temp of 96.
75 year old with pulse ox of 88 %
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.
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
