GNRS 555 Midterm Study Guide with
Questions and Correct Answers
· What are the general guidelines for measuring and documenting vital signs?
✅Measuring vitals is my responsibility
Select right equipment
Know the baseline
Use an organized systemic approach
Control environmental factors
Analyze results based on medical history and current illness
Always double-check abnormal vitals
Take appropriate nursing actions
Notify MD of abnormal findings
Document findings accurately
Take vital before med administration
Do not delegate unstable pts to CNAs
When to take vitals ✅At change of shift
Before med administration
Per hospital policy
· Acceptable ranges of vital signs (baseline) for adults ✅Temp: 36-38
Pulse: 60-100 BPM
Respiration: 12-20 breaths/min
O2 sat (greater than or equal to 95)
BP 120/80
Pain
Advantages of oral temperature ✅Easily accessible
Comfortable for pt
Provides accurate surface temp reading
Reflects rapid change in core temp
Reliable route to measure temp in pts who are intubated
Disadvantages of oral temperature ✅Causes delay in measurement if pt recently
ingested hot/cold fluids, smoked, receiving O2 by mask/nasal cannula
Not for pts who have oral surgery, trauma, hx of epilepsy, or shaking chills
Not for infants, small children, or confused pts
Risk of body fluid exposure
Tympanic membrane advantages ✅Easily accessible site
Found to be most accurate method in critically ill pts
Minimal pt repositioning required
,Obtained w/o disturbing, waking, or repositioning pts
Used for pts with tachypnea w/o affecting breathing
Sensitive to core temp changes
Very rapid measurement
Unaffected by oral intake of fluids or smoking
Not influenced by environmental temps
TM disadvantages ✅More variability of measurement than w/ other core temp devices
Requires removal of hearing aids before measurement
Requires disposable sensor cover with only one size available
Otitis media and cerumen impaction distorts readings
Not used in patients who have had surgery of the ear or tympanic membrane
Does not accurately measure core temperature changes during and after exercise
Does not obtain continuous measurement
Affected by ambient temperature devices such as incubators, radiant warmers, and
facial fans
Use in infants older than 6 months (Seattle Children's Hospital, 2019) and children
under 3 years of age; use care to position device correctly because anatomy of ear
canal makes it difficult to position.
Inaccuracies reported caused by incorrect positioning of handheld unit
Rectal temp advantages ✅Argued to be more reliable when oral temperature is difficult
or impossible to obtain
Rectal Temp Disadvantages ✅Lags behind core temperature during rapid temperature
changes
Not for patients with diarrhea, rectal disorders, or bleeding tendencies or those who had
rectal surgery
Requires positioning and is often source of patient embarrassment and anxiety
Risk of body fluid exposure and injury to rectal lining
Requires lubrication
Not for routine vital signs in newborns
Readings influenced by impacted stool
Skin temperature advantages ✅Inexpensive
Provides continuous reading
Safe and noninvasive
Used for neonates
Skin temperature disadvantages ✅Measurement lags behind other sites during
temperature changes, especially during hyperthermia
Adhesion impaired by diaphoresis or sweat
Reading affected by environmental temperature
Cannot be used for patients with allergy to adhesives
Temporal artery advantages ✅Easy to access without position change
, Very rapid measurement
Comfortable with no risk of injury to patient or nurse
Eliminates need to disrobe or be unbundled
Comfortable for patient
Used in premature infants, newborns, and children (Reynolds et al., 2014)
Reflects rapid change in core temperature
Sensor cover not required
Temporal artery disadvantages ✅Inaccurate with head covering or hair on forehead
Affected by skin moisture such as diaphoresis or sweating
Axillary advantages ✅Safe and inexpensive
Reliable in stable term and preterm infants
Axillary disadvantages ✅Long measurement time
Requires continuous positioning
Measurement lags behind core temperature during rapid temperature changes
Not recommended for detecting fever
Requires exposure of thorax that can result in temperature loss, especially in newborns
Affected by exposure to environment, including time to place the thermometer
Underestimates core temperature
Factors affecting body temperature ✅Age, decreases
Exercise, increases
Hormone levels, increases
Cardiac rhythm
Stress
Environment, depends
Temperature alterations
Factors affecting pulse ✅Exercise, increase
Fever, increase
Stress, increase
Medications
Hypovolemia, increases initially
BP changes
Postural changes
Pulmonary conditions
Pain, increases
Electrolyte balance
Factors affecting respiration ✅Exercise
Acute pain
Anxiety
Smoking
Body position
Questions and Correct Answers
· What are the general guidelines for measuring and documenting vital signs?
✅Measuring vitals is my responsibility
Select right equipment
Know the baseline
Use an organized systemic approach
Control environmental factors
Analyze results based on medical history and current illness
Always double-check abnormal vitals
Take appropriate nursing actions
Notify MD of abnormal findings
Document findings accurately
Take vital before med administration
Do not delegate unstable pts to CNAs
When to take vitals ✅At change of shift
Before med administration
Per hospital policy
· Acceptable ranges of vital signs (baseline) for adults ✅Temp: 36-38
Pulse: 60-100 BPM
Respiration: 12-20 breaths/min
O2 sat (greater than or equal to 95)
BP 120/80
Pain
Advantages of oral temperature ✅Easily accessible
Comfortable for pt
Provides accurate surface temp reading
Reflects rapid change in core temp
Reliable route to measure temp in pts who are intubated
Disadvantages of oral temperature ✅Causes delay in measurement if pt recently
ingested hot/cold fluids, smoked, receiving O2 by mask/nasal cannula
Not for pts who have oral surgery, trauma, hx of epilepsy, or shaking chills
Not for infants, small children, or confused pts
Risk of body fluid exposure
Tympanic membrane advantages ✅Easily accessible site
Found to be most accurate method in critically ill pts
Minimal pt repositioning required
,Obtained w/o disturbing, waking, or repositioning pts
Used for pts with tachypnea w/o affecting breathing
Sensitive to core temp changes
Very rapid measurement
Unaffected by oral intake of fluids or smoking
Not influenced by environmental temps
TM disadvantages ✅More variability of measurement than w/ other core temp devices
Requires removal of hearing aids before measurement
Requires disposable sensor cover with only one size available
Otitis media and cerumen impaction distorts readings
Not used in patients who have had surgery of the ear or tympanic membrane
Does not accurately measure core temperature changes during and after exercise
Does not obtain continuous measurement
Affected by ambient temperature devices such as incubators, radiant warmers, and
facial fans
Use in infants older than 6 months (Seattle Children's Hospital, 2019) and children
under 3 years of age; use care to position device correctly because anatomy of ear
canal makes it difficult to position.
Inaccuracies reported caused by incorrect positioning of handheld unit
Rectal temp advantages ✅Argued to be more reliable when oral temperature is difficult
or impossible to obtain
Rectal Temp Disadvantages ✅Lags behind core temperature during rapid temperature
changes
Not for patients with diarrhea, rectal disorders, or bleeding tendencies or those who had
rectal surgery
Requires positioning and is often source of patient embarrassment and anxiety
Risk of body fluid exposure and injury to rectal lining
Requires lubrication
Not for routine vital signs in newborns
Readings influenced by impacted stool
Skin temperature advantages ✅Inexpensive
Provides continuous reading
Safe and noninvasive
Used for neonates
Skin temperature disadvantages ✅Measurement lags behind other sites during
temperature changes, especially during hyperthermia
Adhesion impaired by diaphoresis or sweat
Reading affected by environmental temperature
Cannot be used for patients with allergy to adhesives
Temporal artery advantages ✅Easy to access without position change
, Very rapid measurement
Comfortable with no risk of injury to patient or nurse
Eliminates need to disrobe or be unbundled
Comfortable for patient
Used in premature infants, newborns, and children (Reynolds et al., 2014)
Reflects rapid change in core temperature
Sensor cover not required
Temporal artery disadvantages ✅Inaccurate with head covering or hair on forehead
Affected by skin moisture such as diaphoresis or sweating
Axillary advantages ✅Safe and inexpensive
Reliable in stable term and preterm infants
Axillary disadvantages ✅Long measurement time
Requires continuous positioning
Measurement lags behind core temperature during rapid temperature changes
Not recommended for detecting fever
Requires exposure of thorax that can result in temperature loss, especially in newborns
Affected by exposure to environment, including time to place the thermometer
Underestimates core temperature
Factors affecting body temperature ✅Age, decreases
Exercise, increases
Hormone levels, increases
Cardiac rhythm
Stress
Environment, depends
Temperature alterations
Factors affecting pulse ✅Exercise, increase
Fever, increase
Stress, increase
Medications
Hypovolemia, increases initially
BP changes
Postural changes
Pulmonary conditions
Pain, increases
Electrolyte balance
Factors affecting respiration ✅Exercise
Acute pain
Anxiety
Smoking
Body position
