Patient Centered Care Exam 1 questions
and answers graded A+
Vital signs - correct answer ✔✔HR
RR
BP
O2 Sat
Temp
Standards for monitoring vital signs - correct answer ✔✔Hospital: every 4-8 hours (more
frequently post-op, neuro checks, specific problems)
Home Health Setting: each visit
Outpatient Clinic: each visit
Skilled Nursing Facility (SNF): weekly to monthly
VS delegation - correct answer ✔✔-CAN delegate routine VS and documentation
-CANNOT delegate interpretation to LNA/CAN
-RN should get VS on acutely ill/complex pt
-RN responsible for follow up on abnormal VS
Temperature - correct answer ✔✔-heat produced minus heat lost
-degree of heat maintained in body
-controlled by hypothalamus
-produced by metabolism, skeletal muscle movement, shivering as a means of raising temp
-lowered by peripheral vasodilation and sweating
,Which is lower surface or core temperature? - correct answer ✔✔surface= LOWER
core=HIGHER
Measuring surface vs core - correct answer ✔✔surface: oral and axillary
core: rectal and tympanic
Core temperature - correct answer ✔✔-Normal range: 97 F to 100.8 F (36.1 C to 38.2 C) with
some variation
-Typically 1 F to 2 F (0.6 C to 1.2 C) higher than skin temp
conduction - correct answer ✔✔transfer of heat from a warm to cool surface by direct contact
convection - correct answer ✔✔transfer of heat through currents of air or water
radiation - correct answer ✔✔loss of heat through electromagnetic waves emitting from
surfaces that are warmer than the surrounding air
evaporation - correct answer ✔✔water converted to vapor and lost from the skin (perspiration)
or the mucous membranes (breath)
Fever (pyrexia) - correct answer ✔✔-abnormally high body temp (>100 F or 37.8 C)
-occurs in response to pyrogen (ex: bacteria)
-pyrogens induce secretion or substances (prostaglandins) that reset the hypothalamic
thermostat at a higher temp
hyperpyrexia - correct answer ✔✔-fever >105.8 F (41 C)
,-dangerous and requires intervention
hypothermia - correct answer ✔✔-core temp below normal (<95 F or 35 C)
-extended exposure to cold water, air, lack of shelter
-death occurs when temp below 70-75 F
Febrile Stages of fever - correct answer ✔✔initial: febrile onset, body temp rising. May be
sudden or gradual. person feels chilly/uncomfortable/may shiver
second: temp reaches max and remains constant for days or weeks. person is flushed, warm or
dry
third: temp returns to norm. person feels warm and appears flushed. diaphoresis to lower temp
through evaporation.
benefits of fever - correct answer ✔✔-kills/inhibits growth of microorganisms
-enhance phagocytosis
-cause destruction of virally infected cells
-cause release of interferon, which protects cells from viral infections
Pulse (HR) - correct answer ✔✔-"wave" that begins when LV contracts and ends when ventricle
relaxes
-cardiac contraction forces blood into full aorta -> increase pressure in arterial system
-measured in BPM
HR range - correct answer ✔✔norm for healthy adult= 60-100
average= 70-80
systole - correct answer ✔✔peak of HR wave or heart contraction
, diastole - correct answer ✔✔trough or resting phase of contraction
measuring pulse rate - correct answer ✔✔-use stethescope to auscultate number of heart beats
-each beat= one lub dub series
common pulse points - correct answer ✔✔apical: at apex of heart, most accurate, count for a
full min
carotid: between midline and side of neck
brachial: medial antecubital space
radial: lateral anterior wrist
femoral: in groin fold
popliteal: behind the knee
pedal: top of feet and posterior tibial
always take apical pulse when... - correct answer ✔✔-abnormal findings
-pts take cardiac meds
bradycardia - correct answer ✔✔rate <60 bpm
tachycardia - correct answer ✔✔rate> 100 bpm
quality of pulse - correct answer ✔✔bounding: pulse felt easily w little pressure
thready: barely felt and easily lost w pressure
stroke volume - correct answer ✔✔quantity of blood pumped out by each contraction of the
left ventricle
and answers graded A+
Vital signs - correct answer ✔✔HR
RR
BP
O2 Sat
Temp
Standards for monitoring vital signs - correct answer ✔✔Hospital: every 4-8 hours (more
frequently post-op, neuro checks, specific problems)
Home Health Setting: each visit
Outpatient Clinic: each visit
Skilled Nursing Facility (SNF): weekly to monthly
VS delegation - correct answer ✔✔-CAN delegate routine VS and documentation
-CANNOT delegate interpretation to LNA/CAN
-RN should get VS on acutely ill/complex pt
-RN responsible for follow up on abnormal VS
Temperature - correct answer ✔✔-heat produced minus heat lost
-degree of heat maintained in body
-controlled by hypothalamus
-produced by metabolism, skeletal muscle movement, shivering as a means of raising temp
-lowered by peripheral vasodilation and sweating
,Which is lower surface or core temperature? - correct answer ✔✔surface= LOWER
core=HIGHER
Measuring surface vs core - correct answer ✔✔surface: oral and axillary
core: rectal and tympanic
Core temperature - correct answer ✔✔-Normal range: 97 F to 100.8 F (36.1 C to 38.2 C) with
some variation
-Typically 1 F to 2 F (0.6 C to 1.2 C) higher than skin temp
conduction - correct answer ✔✔transfer of heat from a warm to cool surface by direct contact
convection - correct answer ✔✔transfer of heat through currents of air or water
radiation - correct answer ✔✔loss of heat through electromagnetic waves emitting from
surfaces that are warmer than the surrounding air
evaporation - correct answer ✔✔water converted to vapor and lost from the skin (perspiration)
or the mucous membranes (breath)
Fever (pyrexia) - correct answer ✔✔-abnormally high body temp (>100 F or 37.8 C)
-occurs in response to pyrogen (ex: bacteria)
-pyrogens induce secretion or substances (prostaglandins) that reset the hypothalamic
thermostat at a higher temp
hyperpyrexia - correct answer ✔✔-fever >105.8 F (41 C)
,-dangerous and requires intervention
hypothermia - correct answer ✔✔-core temp below normal (<95 F or 35 C)
-extended exposure to cold water, air, lack of shelter
-death occurs when temp below 70-75 F
Febrile Stages of fever - correct answer ✔✔initial: febrile onset, body temp rising. May be
sudden or gradual. person feels chilly/uncomfortable/may shiver
second: temp reaches max and remains constant for days or weeks. person is flushed, warm or
dry
third: temp returns to norm. person feels warm and appears flushed. diaphoresis to lower temp
through evaporation.
benefits of fever - correct answer ✔✔-kills/inhibits growth of microorganisms
-enhance phagocytosis
-cause destruction of virally infected cells
-cause release of interferon, which protects cells from viral infections
Pulse (HR) - correct answer ✔✔-"wave" that begins when LV contracts and ends when ventricle
relaxes
-cardiac contraction forces blood into full aorta -> increase pressure in arterial system
-measured in BPM
HR range - correct answer ✔✔norm for healthy adult= 60-100
average= 70-80
systole - correct answer ✔✔peak of HR wave or heart contraction
, diastole - correct answer ✔✔trough or resting phase of contraction
measuring pulse rate - correct answer ✔✔-use stethescope to auscultate number of heart beats
-each beat= one lub dub series
common pulse points - correct answer ✔✔apical: at apex of heart, most accurate, count for a
full min
carotid: between midline and side of neck
brachial: medial antecubital space
radial: lateral anterior wrist
femoral: in groin fold
popliteal: behind the knee
pedal: top of feet and posterior tibial
always take apical pulse when... - correct answer ✔✔-abnormal findings
-pts take cardiac meds
bradycardia - correct answer ✔✔rate <60 bpm
tachycardia - correct answer ✔✔rate> 100 bpm
quality of pulse - correct answer ✔✔bounding: pulse felt easily w little pressure
thready: barely felt and easily lost w pressure
stroke volume - correct answer ✔✔quantity of blood pumped out by each contraction of the
left ventricle
