Nurs 226 Quiz 1 Questions and Correct
Answers
Normal ranges for vitals ✅temperature 96.8-100.4F or 36-38C
blood pressure <120/<80
respirations 12-20 breaths/min
oxygen saturation 95-100%
pulse 60-100 bpm
What is critical thinking ✅open-mindedness, continual inquiry, and perseverance
combined with a willingness to look at each unique patient situation and determine
which identified assumptions are true and relevant
Critical thinking skills ✅1. Determining that a vital sign is normal or abnormal based
upon further assessment of the patient
2. being able to determine how often a patient should be reassessed
3. knowing when a situation requires immediate action or when it can wait
How to develop your critical thinking ✅1. journaling
2. discussing with colleagues
3. reflecting
Modes of taking temp ✅Oral: easy, cheap, but mouth movement required
Axillary: easy noninvasive, inaccurate, takes long
Skin
Tympanic: rapid, accurate, but wax and aids
Rectal: reliable rapid, pushback and stool
Temporal: noninvasive, no probe, rapid, sweat
Heat exhaustion ✅fluid deficit, still sweating!
low electrolytes
faint/dizzy
cool, pale, clammy
rapid weak pulse
heat stroke ✅medical emergency
temp over 104 (40)
hot, dry skin
confusion, LOC, HA
rapid strong pulse
no heat loss mechanism,s
, Pulse deficit ✅difference between the apical and radial pulse rates
Modes of taking pulse ✅Apical
Radial
Ulnar
Femoral
Popliteal
Pedalis
Brachial
Carotid
When do you need to check the apical pulse? ✅1. weak or irregular radial
2. Tachy or Brady
3. Patient on cardiac meds
4. Infants 3-4
5. Dyspnea, Pallor, Cyanosis, Syncope, Palpations
Classifications of pulse ✅Rate: Tachy over 100
Brady under 60
Strength: 0: none
1: weak
2: regular
3: strong
4: bulging
Rhythm: regular or irregular
Ventilation ✅movement of air (gas) in and out of the lungs
assess w/ RR and depth
Diffusion ✅O2 and CO2 exchange between alveoli and RBCs
Perfusion ✅distribution of RBCs to and from pulmonary capillaries
Assessing resp rate ✅Eupnea: normal
Apnea: absence
Tachypnea: over 20
Bradypnea: lower than 12
Assessing resp rhythm ✅Regular: Diaphragmatic/Thoracic
Irregular: Cheyne: apnea then hyperventialtion
Biot's: similar to apnea slight rise and fall of chest
Kussmaul's: deep/fast, seen in DKA, build up CO2
Factors that may effect pulse ox reading ✅nail polish, temperature, skin pigment,
tobacco use, skin thickness
Answers
Normal ranges for vitals ✅temperature 96.8-100.4F or 36-38C
blood pressure <120/<80
respirations 12-20 breaths/min
oxygen saturation 95-100%
pulse 60-100 bpm
What is critical thinking ✅open-mindedness, continual inquiry, and perseverance
combined with a willingness to look at each unique patient situation and determine
which identified assumptions are true and relevant
Critical thinking skills ✅1. Determining that a vital sign is normal or abnormal based
upon further assessment of the patient
2. being able to determine how often a patient should be reassessed
3. knowing when a situation requires immediate action or when it can wait
How to develop your critical thinking ✅1. journaling
2. discussing with colleagues
3. reflecting
Modes of taking temp ✅Oral: easy, cheap, but mouth movement required
Axillary: easy noninvasive, inaccurate, takes long
Skin
Tympanic: rapid, accurate, but wax and aids
Rectal: reliable rapid, pushback and stool
Temporal: noninvasive, no probe, rapid, sweat
Heat exhaustion ✅fluid deficit, still sweating!
low electrolytes
faint/dizzy
cool, pale, clammy
rapid weak pulse
heat stroke ✅medical emergency
temp over 104 (40)
hot, dry skin
confusion, LOC, HA
rapid strong pulse
no heat loss mechanism,s
, Pulse deficit ✅difference between the apical and radial pulse rates
Modes of taking pulse ✅Apical
Radial
Ulnar
Femoral
Popliteal
Pedalis
Brachial
Carotid
When do you need to check the apical pulse? ✅1. weak or irregular radial
2. Tachy or Brady
3. Patient on cardiac meds
4. Infants 3-4
5. Dyspnea, Pallor, Cyanosis, Syncope, Palpations
Classifications of pulse ✅Rate: Tachy over 100
Brady under 60
Strength: 0: none
1: weak
2: regular
3: strong
4: bulging
Rhythm: regular or irregular
Ventilation ✅movement of air (gas) in and out of the lungs
assess w/ RR and depth
Diffusion ✅O2 and CO2 exchange between alveoli and RBCs
Perfusion ✅distribution of RBCs to and from pulmonary capillaries
Assessing resp rate ✅Eupnea: normal
Apnea: absence
Tachypnea: over 20
Bradypnea: lower than 12
Assessing resp rhythm ✅Regular: Diaphragmatic/Thoracic
Irregular: Cheyne: apnea then hyperventialtion
Biot's: similar to apnea slight rise and fall of chest
Kussmaul's: deep/fast, seen in DKA, build up CO2
Factors that may effect pulse ox reading ✅nail polish, temperature, skin pigment,
tobacco use, skin thickness
