NSG 3100, Exam 2
Question 1.
Vital signs
ANSWER
-Vital signs are key in obtaining physiologic data on patients. -They are used to monitor physiological functioning of body systems. -Useful in assessing for
condition changes in patients as well as determining the effectiveness of interventions.
Question 2.
6 vital signs
ANSWER
-Temperature -Pulse -Respirations -Blood pressure -Pulse oximetry -Pain
Question 3.
Temperature
ANSWER
-Measurable heat of the body. -97.6-99.5 F -Can be measured in multiple waysmeasurement type (oral, rectal, axillary, and temporal) will be based on
patient status. -Rectal temperature is rarely used in adultsnever if rectal/anal surgery, diarrhea, or tissue trauma is present. -***Increased temperature when
infections are present (fever) is associated with a mild increase in heart rate and blood pressure r/t increased metabolic demand in the body***
Question 4.
Things that affect temperature readings:
ANSWER
-Anything that increased metabolic activity (running, fever, physical activity, smoking ) -Age: Older adults typically have a lower temperature than younger
adults. Older adults are less likely to have a high fever due to decreased immune response. Older adults are more susceptible/sensitive to environmental
temperature changes. -Can be the first signs of infection: this is a concerning and priority finding within the first 48 hours after a surgical or other invasive
procedure!
Question 5.
Pulse
ANSWER
-Palpable rhythmic expansion of the artery as a result of the heart pumping number of heartbeats per minute. -60-100 BPM -Assessment includes rate,
rhythm, and force (strength) -If any regulatory is noted on the palpation, check apical pulse/radial pulse at the same time for one full minute. -Always assess
symmetry; both sides at the same time EXCEPT carotid pulse (this will decrease the blood flow to the brain!) -If an area has a pulse (for example the
dorsalis pedis) that means there is blood flow to that area!
Question 6.
Factors that affect pulse rate:
ANSWER
-Age decreases with age. -Increased with fever, activity, smoking. -Medications can decrease or increase HR. -HR decreases with hypovolemia/dehydration
(low volume in the vascular system) -HR increases with standing briefly to meet blood flow demand of the brain (needs to increase because of gravity)
, Question 7.
Where can you find/palpate a pulse?
ANSWER
-Temporal: head -Carotid: neck (check first if pt is found unresponsive) -Apical: chest -Brachial: arm -Radial: wrist -Femoral: thigh/groin -Popliteal: knee
-Posterior tibial: ankle -Dorsalis pedis: foot (lateral to the extensor tendon on the great toe).
Question 8.
Respirations
ANSWER
-The act of breathing. -Normal range: 12-20 -Below 12 is not compatible with life! This requires immediate intervention! -Monitor for depth, rate, and rhythm.
-Activity, fever, infections and medications especially narcotics) can affect respiratory assessment findings. -One of the first signs of low oxygen levels is
anxiety then confusion.
Question 9.
Blood pressure
ANSWER
-Measure of pressure within the systemic arteries. -Normal range: 120/80 -There is a slight elevation expected with age! Typically 130/80s for the older adult.
-Systolic pressure: Peak pressure in the systemic arteries (resistance against the artery). The first sound you hear when taking blood pressure. -Diastolic:
Lowest pressure in the systemic arteries after relaxation of the vessel (the last sound you hear when taking blood pressure). -Know how to take a 2-step
blood pressure!
Question 10.
Factors that affect blood pressure:
ANSWER
-Medications, dehydration, fluid overload (too much volume in the vascular system ), activity, smoking, etc.
Question 11.
What happens if a blood pressure cuff is too small or narrow?
ANSWER
Your reading will be falsely high.
Question 12.
What happens if your blood pressure cuff is too big?
ANSWER
Your reading will be falsely low.
Question 13.
What happens if you do not place the arm at the level of the heart when taking a blood pressure?
ANSWER
Falsely low reading
Question 1.
Vital signs
ANSWER
-Vital signs are key in obtaining physiologic data on patients. -They are used to monitor physiological functioning of body systems. -Useful in assessing for
condition changes in patients as well as determining the effectiveness of interventions.
Question 2.
6 vital signs
ANSWER
-Temperature -Pulse -Respirations -Blood pressure -Pulse oximetry -Pain
Question 3.
Temperature
ANSWER
-Measurable heat of the body. -97.6-99.5 F -Can be measured in multiple waysmeasurement type (oral, rectal, axillary, and temporal) will be based on
patient status. -Rectal temperature is rarely used in adultsnever if rectal/anal surgery, diarrhea, or tissue trauma is present. -***Increased temperature when
infections are present (fever) is associated with a mild increase in heart rate and blood pressure r/t increased metabolic demand in the body***
Question 4.
Things that affect temperature readings:
ANSWER
-Anything that increased metabolic activity (running, fever, physical activity, smoking ) -Age: Older adults typically have a lower temperature than younger
adults. Older adults are less likely to have a high fever due to decreased immune response. Older adults are more susceptible/sensitive to environmental
temperature changes. -Can be the first signs of infection: this is a concerning and priority finding within the first 48 hours after a surgical or other invasive
procedure!
Question 5.
Pulse
ANSWER
-Palpable rhythmic expansion of the artery as a result of the heart pumping number of heartbeats per minute. -60-100 BPM -Assessment includes rate,
rhythm, and force (strength) -If any regulatory is noted on the palpation, check apical pulse/radial pulse at the same time for one full minute. -Always assess
symmetry; both sides at the same time EXCEPT carotid pulse (this will decrease the blood flow to the brain!) -If an area has a pulse (for example the
dorsalis pedis) that means there is blood flow to that area!
Question 6.
Factors that affect pulse rate:
ANSWER
-Age decreases with age. -Increased with fever, activity, smoking. -Medications can decrease or increase HR. -HR decreases with hypovolemia/dehydration
(low volume in the vascular system) -HR increases with standing briefly to meet blood flow demand of the brain (needs to increase because of gravity)
, Question 7.
Where can you find/palpate a pulse?
ANSWER
-Temporal: head -Carotid: neck (check first if pt is found unresponsive) -Apical: chest -Brachial: arm -Radial: wrist -Femoral: thigh/groin -Popliteal: knee
-Posterior tibial: ankle -Dorsalis pedis: foot (lateral to the extensor tendon on the great toe).
Question 8.
Respirations
ANSWER
-The act of breathing. -Normal range: 12-20 -Below 12 is not compatible with life! This requires immediate intervention! -Monitor for depth, rate, and rhythm.
-Activity, fever, infections and medications especially narcotics) can affect respiratory assessment findings. -One of the first signs of low oxygen levels is
anxiety then confusion.
Question 9.
Blood pressure
ANSWER
-Measure of pressure within the systemic arteries. -Normal range: 120/80 -There is a slight elevation expected with age! Typically 130/80s for the older adult.
-Systolic pressure: Peak pressure in the systemic arteries (resistance against the artery). The first sound you hear when taking blood pressure. -Diastolic:
Lowest pressure in the systemic arteries after relaxation of the vessel (the last sound you hear when taking blood pressure). -Know how to take a 2-step
blood pressure!
Question 10.
Factors that affect blood pressure:
ANSWER
-Medications, dehydration, fluid overload (too much volume in the vascular system ), activity, smoking, etc.
Question 11.
What happens if a blood pressure cuff is too small or narrow?
ANSWER
Your reading will be falsely high.
Question 12.
What happens if your blood pressure cuff is too big?
ANSWER
Your reading will be falsely low.
Question 13.
What happens if you do not place the arm at the level of the heart when taking a blood pressure?
ANSWER
Falsely low reading
