Nursing 220-Exam # 1 Questions And Answers Already Graded A+

A patient is placed in contact precautions due to an infection caused by methicillinresistant Staphylococcus aureus. The nurse prepares to provide colostomy care. Which PPE are needed? A. Gown and gloves. B. Gloves and goggles C. Gloves, gown, and mask D. Gloves, gown, goggles and/or face shield - ️️D The nurse is caring for a client who has an oral temperature of 99.6 °F at 0800. The client's orders indicate that vital signs should be taken once a shift. In planning care for the client, which action is most appropriate? A. Ensure that the temperature is taken promptly at 1600. B. Call the physician for a more frequent order. C. Take the temperature as necessary. D. Begin cooling measures - ️️C Four Vital Signs - ️️-temperature -pulse -respiratory rate -blood pressure 5th vital sign - ️️pain normal temperature ranges for adults - ️️36-38 celcius ot 96.8 to 100.4 F influencing factors of temperature - ️️-age -exercise -hormones -environment -stress where to measure temperature - ️️-oral -rectal -tymphanic membrane (ear) when to measure vitals - ️️-on admission -during assessments -doctors orders -before/after surgery-before, during, after blood transfusions -before, during, after medications -patient change -patient feels funny -routinely in hospital -before, during, after nursing interventions what would happen if blood pressure cuff too big.... - ️️false low reading what would happen if blood pressure cuff to small... - ️️false high reading positions for respirations - ️️-body straight promotes good respirations -body slumped impaired respirations -body laying down prevents full chest expansion position for pulse - ️️-supine/sitting position for blood pressure - ️️-sitting with arm at heart level normal pulse for adult - ️️60-100 beats/min normal pulse of adolescent - ️️60-90 beats/min normal pulse for toddler - ️️90-140 beats/min normal pulse for infant - ️️120-160 beats/min normal pulse oximetry - ️️>= 90% normal respiration rate for adults - ️️12-20 breaths/min normal respiration rate for adolescent - ️️16-20 breaths/min normal respiration rate for toddler - ️️25-32 breaths/min normal respiration rate for infant - ️️30-50 normal respiration rate for newborn - ️️30-60 breaths/min normal blood pressure for adults - ️️Systolic <120 mm Hg Diastolic <80 mm Hg Pulse pressure: 30 to 50 mm HgBlood pressure - ️️-"force exerted on the walls f=of artery by pulsing blood under pressure from the heart" -DONT take BP on side of mastectomy or side of dialysis or shunt (can cause lymphoma) -BP highest between 10 am and 6 pm -BP lowest between sleep and 3 am