NRSG 2220 NEW FINAL EXAM 100% VERIFIED
Taking Blood Pressure - Answer Locate Brachial artery,
Line artery marking on cuff with brachial artery
Palpate artery while inflating
When you feel no pulse deflate
After 15 seconds reinflate cuff to 30 above palpated pressure.
Deflate cuff at 2-3 mm per second
If retake wait 2 min.
Blood pressure definition - Answer the force of the moving blood against arterial walls
Blood pressure numbers-Adults - Answer Normal- less than 120 over less the 80
Prehypertension- 120-139 over 80-89
High blood pressure Stage 1- 140-159 over 90-99
High blood pressure Stage 2-greater than 160 over greater 100
Factors causing blood pressure variations in healthy people - Answer Age- older adult
has decreased elasticity of the arteries, which increases peripheral resistance.
Circadium rhythm- Normal fluctuations occur during the day. Usually lowest when first
getting up.
Gender- women usually have lower BP than men until menopause
Food Intake- Blood pressure increases after eating.
Exercise- systolic pressure rises during exercise
Weight- Higher in obese people
Emotional state- Anger, fear, excitement, pain can cause BP to rise, but goes back to
normal afterward
,Body position- Lower when prone or supine, than when sitting or standing
Race- More prevalent in African american men and women
Drugs-Oral contraceptives cause a mild increase
BP false low readings- Response Hearing deficit, Noise in environment, Viewing
meniscus above eye level, applying a too wide cuff, using stethoscope incorrectly,
cracked or kinked tubing, Releasing valve to quickly, Misplacing the bell, Failing to
pump cuff 20 to 30 above pulse disappearance.
BP false high readings Using manometer not calibrated at zero, taking right after
exercise,Viewing meniscus below eye level, cuff to narrow, releasing valve too slowly,
Reinflating bladder during auscultation
Kortokoff sounds series of sounds that correspond to changes in blood flow through an
artery as pressure is released.
Normal Body temperature 35.9 to 38C, 96.7 to 100.5F depending on route
Primary source of heat - Answer Metabolism
Primary source of Heat loss - Answer Skin
Factors affecting Body temperature - Answer Circadium rhythms, Age and gender,
Physical activity, State of health, Environmental temp.
Normal temperatures at different sites - Answer Oral: 37.0C-98.6F Rectal: 37.5C-99.5F
Axillary: 36.5C- 97.7F Tympanic: 37.5C-99.5F Temporal Artery: 37C- 98.6F
Fever - A nswer Elevation in normal body temperature. Occurs as a result of an upward
displacement of the thermoregulatory set point in the hypothalamus. Caused by
bacteria, microorganisms, viruses or by chemicals produced to respond to tissue injury.
, Hyperthermia - A nswer hypothalamus set point not changed, Caused by extreme heat
exposure or production (strenous exercise)
Hypothermia - Answer temp below lower limit of normal, caused by unprotected
exposure to cold environments. Alcoholism, malnutrition, and hypothyroidism increase
the risk of hypothermia.
Pulse - Answer Normal pulse rates adults are 60 to 100 beats/min
Factors that influence the Pulse - Answer Age, Gender, physical activity, fever, stress,
med use, presence of disease
Tachycardia - Answer Increased pulse rate 100 to 180 beats/min Can be caused by
decrease in BP, elevated temp, anemia, exercise, pain, strong emotions, she meds.
Bradycardia - Answer Pulse rate below 60 beats/min. report immediately if assoc.
difficulty breathing, angina, Decreased BP.
Sites of Pulses - Answer Radial, Brachial, carotid, Temporal, femoral, Popliteal,
posterior tibial, Dorsalis pedis
Respirations - Answer Normal for healthy adults 12 to 20 times a minute
Factors that affect respiratory rate - Answer Age- decreses with age 30-55 in newborn
to 12 to 20 in adult.
Exercise- Increases respiratory rate.
Acid-Base balance- alterations in acid base balance(acidosis) result in increased rate.
Brain lesions- Cheyne Stokes respirations
Increased altitude-Cheyne Stokes respirations
Taking Blood Pressure - Answer Locate Brachial artery,
Line artery marking on cuff with brachial artery
Palpate artery while inflating
When you feel no pulse deflate
After 15 seconds reinflate cuff to 30 above palpated pressure.
Deflate cuff at 2-3 mm per second
If retake wait 2 min.
Blood pressure definition - Answer the force of the moving blood against arterial walls
Blood pressure numbers-Adults - Answer Normal- less than 120 over less the 80
Prehypertension- 120-139 over 80-89
High blood pressure Stage 1- 140-159 over 90-99
High blood pressure Stage 2-greater than 160 over greater 100
Factors causing blood pressure variations in healthy people - Answer Age- older adult
has decreased elasticity of the arteries, which increases peripheral resistance.
Circadium rhythm- Normal fluctuations occur during the day. Usually lowest when first
getting up.
Gender- women usually have lower BP than men until menopause
Food Intake- Blood pressure increases after eating.
Exercise- systolic pressure rises during exercise
Weight- Higher in obese people
Emotional state- Anger, fear, excitement, pain can cause BP to rise, but goes back to
normal afterward
,Body position- Lower when prone or supine, than when sitting or standing
Race- More prevalent in African american men and women
Drugs-Oral contraceptives cause a mild increase
BP false low readings- Response Hearing deficit, Noise in environment, Viewing
meniscus above eye level, applying a too wide cuff, using stethoscope incorrectly,
cracked or kinked tubing, Releasing valve to quickly, Misplacing the bell, Failing to
pump cuff 20 to 30 above pulse disappearance.
BP false high readings Using manometer not calibrated at zero, taking right after
exercise,Viewing meniscus below eye level, cuff to narrow, releasing valve too slowly,
Reinflating bladder during auscultation
Kortokoff sounds series of sounds that correspond to changes in blood flow through an
artery as pressure is released.
Normal Body temperature 35.9 to 38C, 96.7 to 100.5F depending on route
Primary source of heat - Answer Metabolism
Primary source of Heat loss - Answer Skin
Factors affecting Body temperature - Answer Circadium rhythms, Age and gender,
Physical activity, State of health, Environmental temp.
Normal temperatures at different sites - Answer Oral: 37.0C-98.6F Rectal: 37.5C-99.5F
Axillary: 36.5C- 97.7F Tympanic: 37.5C-99.5F Temporal Artery: 37C- 98.6F
Fever - A nswer Elevation in normal body temperature. Occurs as a result of an upward
displacement of the thermoregulatory set point in the hypothalamus. Caused by
bacteria, microorganisms, viruses or by chemicals produced to respond to tissue injury.
, Hyperthermia - A nswer hypothalamus set point not changed, Caused by extreme heat
exposure or production (strenous exercise)
Hypothermia - Answer temp below lower limit of normal, caused by unprotected
exposure to cold environments. Alcoholism, malnutrition, and hypothyroidism increase
the risk of hypothermia.
Pulse - Answer Normal pulse rates adults are 60 to 100 beats/min
Factors that influence the Pulse - Answer Age, Gender, physical activity, fever, stress,
med use, presence of disease
Tachycardia - Answer Increased pulse rate 100 to 180 beats/min Can be caused by
decrease in BP, elevated temp, anemia, exercise, pain, strong emotions, she meds.
Bradycardia - Answer Pulse rate below 60 beats/min. report immediately if assoc.
difficulty breathing, angina, Decreased BP.
Sites of Pulses - Answer Radial, Brachial, carotid, Temporal, femoral, Popliteal,
posterior tibial, Dorsalis pedis
Respirations - Answer Normal for healthy adults 12 to 20 times a minute
Factors that affect respiratory rate - Answer Age- decreses with age 30-55 in newborn
to 12 to 20 in adult.
Exercise- Increases respiratory rate.
Acid-Base balance- alterations in acid base balance(acidosis) result in increased rate.
Brain lesions- Cheyne Stokes respirations
Increased altitude-Cheyne Stokes respirations
