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temperature, pulse, respiration, blood pressure, pain Normal temperature 98.6 Factors that influence temperature age, circadian rhythm, exercise, hormone level, stress, environment temperature hyperpyrexia extremely high body temperature or fever 105+ heat exhaustion excessive heat and dehydration. S/S pale, n/v, syncope, collapse, increased temp 101 to 102 pyrexia fever remittent fever Fluctuating, remains elevated and does not return to baseline within 24 hours period relapse fever short febrile periods interspersed with periods of 1-2 days of normal temp. heat stroke person has generally been working in hot Normal Pulse 60-100 Factors affective pulse Age Normal Respiration 12-20 Factors affecting respiration Increases RR Normal Blood Pressure 120/80 Factors impacting blood pressure Age vasoconstriction Variations in blood pressure because of age Rises with age Korotkoff sounds series of sounds that correspond to changes in blood flow through an artery as pressure is released Phase 1 of Korotkoff sounds Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; the first tapping sound is the systolic pressure Phase 5 of Korotkoff sounds The last sound heard before a period of continuous silence; the pressure at which the last sound is the second diastolic pressure Steps in assessing vital signs TPR Pulse oximetry (not vital sign) affected by hemoglobin, circulation, activity. Factors affecting pain - Ethnic and cultural beliefs Characteristics of pulse rate, rhythm, volume, arterial wall elasticity, bilateral equality Strength of pulse 0 = absent Mechanics of Temperature Neural and Vascular Control Pulse A wave of blood created by contraction of the left ventricle of the heart. Generally the pulse wave represents the stroke volume (SV) output or amount of blood that enters the arteries with each ventricular contraction. Aldo Causes tubules of the kidneys to increase the reabsorption of Na+ and H2O into the blood which increases the volume of fluid in the body, and increases B/P Baroreceptor Reflex response to stimulation of baroreceptors of the carotid sinus and aortic arch, regulating Pallor (Paleness, lack of color, anemia, Cyanosis (bluish, unoxygenated hemoglobin) Male RBC count 4.5-5.3 million Male Hgb (hemoglobin) 13-18 g/dL Male Hct 37-49% Normal WBC 4500-11000 circadian rhythm affect body temp. colder in the am and highest between 4 and 6 PM An older client has an oral temperature reading of 97.2 degrees F. The nurse realizes that this clients low temperature could be due to which observation? 1. The anxiety level of the client has increased. 2. Hormones have fluctuated in this client. 3. Muscle activity has increased during the clients therapy session. 4. Loss of subcutaneous fat is noted. Correct Answer: 4 The nurse is preparing to measure a clients temperature. What is the first thing that the nurse should do to ensure an accurate temperature reading? 1. Assess that the equipment used is working properly. 2. Place the client in a position that is most comfortable for the health care provider. 3. Take the temperature with a chemical disposable thermometer when the client is perspiring. 4. Wait at least 10 minutes before taking the temperature after a client has been smoking. Correct Answer: 1 The nurse needs to measure the temperature of a client who has a history of heart disease and has eaten a bowl of vegetable soup 45 minutes ago. Which site should the nurse use? 1. Axilla 2. Oral 3. Popliteal 4. Rectal Correct Answer: 2 While waiting for the physician to respond regarding a clients elevated temperature, what can the nurse do to assist the client? 1. Bathe the client with ice water. 2. Give the client an antipyretic. 3. Increase fluid intake. 4. Lower the room temperature. Correct Answer: 3 While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds of capillary refilling time. How would the nurse explain these findings? 1. A change in the clients health status has occurred. 2. The client has thrown a blood clot in that extremity. 3. The RNs watch has stopped working. 4. Too much pressure was applied over the pulse site. Correct Answer: 4 The RN assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing intervention would be most appropriate for the nurse to use? 1. Ask another nurse to assess the pulses. 2. Document the findings. 3. Obtain a Doppler ultrasound stethoscope. 4. Wait and try again later. Correct Answer: 3 When assessing a clients peripheral pulse, the health care provider is also assessing which of the following? 1. Depth 2. Rhythm 3. Sound 4. Stress Correct Answer: 2 The nurse is going to assess the apical-radial pulse of a client with a cardiovascular disorder. Which rationale did the RN use to make this decision? 1. A forceful radial pulse is much too difficult to count correctly. 2. Both arteriole and venous sounds were heard simultaneously. 3. The pulse was bounding and easily obliterated. 4. The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site. Correct Answer: 4 A client is unconscious and in respiratory distress after being in a motor vehicle crash. Which should the nurse realize as being a factor that caused a change in this clients respiratory rate? 1. Exercise 2. Increased intracranial pressure 3. Increased environmental temperature 4. Stress Correct Answer: 2 The nurse needs to assess a clients respiratory status. Which client position would be the best for this assessment? 1. Prone 2. Semi-Fowlers 3. Side-lying 4. Supine Correct Answer: 2 A client is being treated for congestive heart failure. Which physical finding would lead the RN to believe the clients condition has not improved? 1. Temperature of 98.6F (37C) 2. Moderate amount of clear thin mucus 3. Pulse oximetry reading of 96% 4. Wheezing of breath sounds in all lobes Correct Answer: 4 Which determinant of blood pressure would explain a clients blood pressure reading of 120/100? 1. Blood viscosity 2. Blood volume 3. Pumping action of the heart 4. Peripheral vascular resistance Correct Answer: 4 The nurse is assessing a clients blood pressure. What should the nurse hear during phase 2 of Korotkoffs sounds? 1. A muffled, whooshing, or swishing sound 2. Disappearance of sound 3. Faint, clear tapping sound 4. Increased intensity of sound Correct Answer: 1 The nurse is preparing to assess a clients blood pressure. Which artery will the nurse use for this assessment? 1. Brachial 2. Femoral 3. Radial 4. Ulnar Correct Answer: 1 In the palpatory method of blood pressure determination, instead of listening for the blood flow sounds, light to moderate pressure is used over the artery as the pressure in the cuff is released. When will the nurse read the pressure from the sphygmomanometer? 1. When the cuff is applied 2. When the cuff is being deflated 3. When the first pulsation is felt 4. When the second pulsation is felt Correct Answer: 3 Which condition would lead the RN to choose the dorsalis pedis pulse as the site for further assessing the clients status? 1. Altered level of consciousness 2. Decreased urine output 3. Irregular radial pulse 4. Toes cool to touch Correct Answer: 4
When assessing a clients oxygen saturation reading, the nurse realizes that what will affect this reading? 1. Activity 2. Environmental conditions 3. Nutrition 4. Skin color Correct Answer: 1 As the RN is suctioning a client, the pulse oximetry reading drops to 83%. What should the nurse do? 1. Allow the client to take some extra deep breaths. 2. Continue to suction but only intermittently. 3. Keep the catheter in place and wait a few minutes. 4. Stop suctioning and give supplemental oxygen. Correct Answer: 4 The RN needs vital signs assessed for four clients. Which client should the nurse address and not assign to the UAP? 1. Cardiac catheterization client returning to the nursing unit 2. COPD client on 2 Lpm oxygen via nasal cannula 3. Pneumonia client nearing discharge 4. Post-op client of 2 days from gallbladder surgery Correct Answer: 1 Prior to assessing a clients blood pressure, the nurse reviews factors that could affect the reading. Which factors could impact blood pressure? Standard Text: Select all that apply. 1. Stress 2. Race 3. Obesity 4. Medications 5. Employment Correct Answer: 1, 2, 3, 4 The nurse is planning to assess a clients pulse. What characteristics should the nurse include in this assessment? Standard Text: Select all that apply. 1. Rate 2. Rhythm 3. Volume 4. Tone 5. Viscosity Correct Answer: 1, 2, 3 When assessing a clients respirations, the nurse realizes that the respiratory centers and chemoreceptors respond to changes in which factors? Standard Text: Select all that apply. 1. Oxygen concentration 2. Carbon dioxide concentration 3. Hydrogen ions 4. Potassium level 5. Serum calcium level Correct Answer: 1, 2, 3 Even though a UAP is available to assist with vital sign assessment, the nurse is going to conduct these assessments independently in which situations? Standard Text: Select all that apply. 1. Client who complains of chest pain 2. Client returning from surgery 3. Prior to administering a medication that affects blood pressure 4. Client who complains of dizziness after ambulating. 5. Client being admitted to the care area Correct Answer: 1, 2, 3, 4 When documenting a clients axillary temperature on the graphic sheet, how should the nurse identify the method of assessing the temperature? 1. AX 2. O 3. R 4. SL Correct Answer: 1 The nurse assesses phase 1 Korotkoffs sound occurring at 136 and phase 5 Korotkoffs sound occurring at 72. How should the nurse document this clients blood pressure reading? 1. 136/72 2. 72/136 3. 136 72 4. 72 136 Correct Answer: 1 A client comes to the emergency department with a temperature of 104F. Which assessment findings should the nurse use to determine if this client is experiencing heat stroke? Standard Text: Select all that apply. 1. Delirious 2. Pale and dizzy 3. Skin warm and flushed 4. No evidence of sweating 5. Had been playing tennis in the sun Correct Answer: 1, 3, 4, 5 The nurse determines that unlicensed assistive personnel (UAP) are not to be delegated client blood pressure measurements. What did the nurse observe to make this clinical decision? Standard Text: Select all that apply. 1. The valve on the bulb was closed. 2. The client was sitting with the legs crossed. 3. The arm was below the level of the heart. 4. The UAP waited 2 minutes before re-measuring. 5. The cuff bladder was placed over the brachial artery. Correct Answer: 2, 3 The nurse is teaching a client with heart failure about diagnostic tests. Which test should the nurse emphasize in this teaching? 1. BNP 2. CBC 3. LDH 4. PKU Correct Answer: 1 Stridor a shrill, harsh sound, especially the respiratory sound heard during inspiration in a person with a laryngeal obstruction stertor snoring or sonorous respiration, usually due to a partial obstruction of the upper airway wheeze Continuous high-pitched whistling sound heard when air is forced through a narrow space during inspiration or expiration. hemoptysis coughing up blood intermittent fever Fluctuating fever that returns to or below baseline then rises again. relapsing fever Short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature. factors affecting pulse age, sex, exercise, fever, medications, hypovolemia/dehydration, stress, position, pathology hypovolemia/dehydration and pulse loss of blood from the vascular system increases the pulse rate Phase 2 of Korotkoff sounds a soft tapping or murmur sound that has a swishing quality Phase 3 of Korotkoff sounds Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery Phase 4 of Korotkoff sounds Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; first diastolic blood pressure What is the first thing that the nurse should do to ensure an accurate temperature reading for a client?Place the patient's arm securely against their body. Turn thermometer on. For a more accurate reading, wait >3 minutes with thermometer in situ before obtaining a measurement.
What should the nurse hear during Phase 2 of korotkoff's sounds?Phase 2: A swishing/whooshing sound. Swishing sounds as the blood flows through blood vessels as the cuff is deflated. Phase 3: A thump (softer than phase 1).
Which of the following characteristics is assessed when taking a client's peripheral pulse?The pulse rhythm, rate, force, and equality are assessed when palpating pulses.
How long should the nurse wait before taking again the client's blood pressure for accurate reading?If the BP needs to be repeated, wait for at least one minute before each reading.
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Which determinant of blood pressure would explain a clients blood pressure reading of 120/100?
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