NUR 152 Vital Signs and Head to Toe
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Assessment exam with correct answers
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Frequency |of |Vital |Signs |- |✔✔💯Determined |by:
- |Physician |order
- |Nursing |judgement
- |Patient |condition
- |Facility |standards |(specific |unit |or |situation)
General |Guidelines:
General |hospital: |Q4H-Q8H
| Critical |care: |Q1H-Q4H
| Post |Procedure: |Q15 |MIN-Q1H
Clinic: |Each |visit
Skilled |nursing |facility |[SNF]: |Weekly |to |monthly
Measuring |Body |Temperature |- |✔✔💯Surface |temperature: |Axillary |(least |accurate), |oral, |temporal.
Core |temperature: |Rectal |(most |accurate), |tympanic. |
*TIP* |Use |the |same |modality |to |maintain |accuracy |and |monitor |trends.
Variations |of |Temperature |- |✔✔💯Normal |- |Based |on |modality |- |*See |handout*
Hyperthermia: |Greater |than |100°F |or |37.8°C
, Is |a |"fever" |bad? |No, |immune |system |could |be |fighting |that |fever. |
Hypothermia: |Lower |than |95°F |or |35°C
When |do |we |treat |a |fever? |- |✔✔💯When |the |temperature |is |getting |too |high.
The |nurse |would |monitor |the |body |temperature |most |closely/frequently |in |the |care |of |which |client?
A) |With |an |infection
B) |Who |is |an |infant
C) |Who |has |experienced |heat |stroke
D) |With |a |head |injury |- |✔✔💯D
Temperature |is |controlled |in |the |hypothalamus.
HR |x |SV |= |CO |- |✔✔💯Heart |Rate |x |Stroke |Volume |= |Cardiac |Output
Pulse |Points |- |✔✔💯Temporal |
Facial
Carotid
Brachial
Radial
Femoral
Popliteal
Posterior |Tibial |
Dorsalis |Pedal |(pedal)
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Assessment exam with correct answers
| | | |
Frequency |of |Vital |Signs |- |✔✔💯Determined |by:
- |Physician |order
- |Nursing |judgement
- |Patient |condition
- |Facility |standards |(specific |unit |or |situation)
General |Guidelines:
General |hospital: |Q4H-Q8H
| Critical |care: |Q1H-Q4H
| Post |Procedure: |Q15 |MIN-Q1H
Clinic: |Each |visit
Skilled |nursing |facility |[SNF]: |Weekly |to |monthly
Measuring |Body |Temperature |- |✔✔💯Surface |temperature: |Axillary |(least |accurate), |oral, |temporal.
Core |temperature: |Rectal |(most |accurate), |tympanic. |
*TIP* |Use |the |same |modality |to |maintain |accuracy |and |monitor |trends.
Variations |of |Temperature |- |✔✔💯Normal |- |Based |on |modality |- |*See |handout*
Hyperthermia: |Greater |than |100°F |or |37.8°C
, Is |a |"fever" |bad? |No, |immune |system |could |be |fighting |that |fever. |
Hypothermia: |Lower |than |95°F |or |35°C
When |do |we |treat |a |fever? |- |✔✔💯When |the |temperature |is |getting |too |high.
The |nurse |would |monitor |the |body |temperature |most |closely/frequently |in |the |care |of |which |client?
A) |With |an |infection
B) |Who |is |an |infant
C) |Who |has |experienced |heat |stroke
D) |With |a |head |injury |- |✔✔💯D
Temperature |is |controlled |in |the |hypothalamus.
HR |x |SV |= |CO |- |✔✔💯Heart |Rate |x |Stroke |Volume |= |Cardiac |Output
Pulse |Points |- |✔✔💯Temporal |
Facial
Carotid
Brachial
Radial
Femoral
Popliteal
Posterior |Tibial |
Dorsalis |Pedal |(pedal)
