DSCC Fundamentals of Nursing Exam 1 - Vital Signs & Health
Assessment Questions with Complete Solutions
What are some factors that influence pulse rate? Correct Answ_-Developmental level
-Gender
-Exercise
-Food intake
-Stress
-Fever
-Disease
-Blood loss
-Position change
-Medication
Guidelines for obtaining a pulse rate? Correct Answ_-apical pulse is most accurate (left side, midclavicular, 5ICS)
-use stethoscope to auscultate number of heart beats
-a watch or clock with a second hand or digital display is required (listen for 60 seconds)
-a heartbeat is one series of LUB DUB sounds
,Common pulse points? Correct Answ_-Radial: Laterally on the anterior wrist
-Brachial: Medially in the antecubital space
-Carotid: Between midline and side of neck. Only for CPR-trained professional; and assessing circulation to the head.
-Temporal: Located on the side of the forehead
-Dorsalis pedis: Top of the foot
-Femoral: In the groin fold
-Popliteal: Behind the knee
-Apical: At the apex of the heart (60 seconds)
When should you measure the apical pulse? Correct Answ_-pulse is weak or irregular
-rate less than 60 beat/min or greater than 100 beats/min
-cardiac medication
-infants or child under 3 years old
Variances in pulse rates? Correct Answ_-pulse deficit: hear a heart beat but do not feel a beat at a pulse point
-bradycardia: rate less than 60 bpm
-tachycardia: rate greater than 100 beats/min
,Inadequate circulation? Correct Answ_-Pallor: paleness of skin when compared with another part of the body
-Cyanosis: a bluish or grayish discoloration of the skin due to excessive carbon dioxide and deficient oxygen in the blood
What is respiration? Correct Answ_-exchange of oxygen and carbon dioxide in the body
-two separate processes (mechanical and chemical)
What is mechanical ventilation? Correct Answ_active movement of air in and out of the respiratory system
What is chemical ventilation? Correct Answ_chemical aspects; gas transport, internal and external respiration
What is inspiration? Correct Answ_-drawing air into the lungs
-involves the ribs and diaphragm, creating negative pressure and allowing air to flow into the lungs
What is expiration? Correct Answ_-relaxation of thoracic muscles and diaphragm, causing air to expel from the lungs
-is passive and normally takes 2-3 seconds
What are factors that influence respirations? Correct Answ_-developmental level
, -exercise
-pain
-stress
-smoking
-fear
-hemoglobin
-disease
-meds
-position
How to count respiratory rate? Correct Answ_-count after taking radial pulse (makes patient unaware)
-patient can alter rate and pattern of respiration
-RR must be accurate, especially in older adults
Kinds of respiratory rates? Correct Answ_-apnea: cessation of breathing
-bradypnea: abnormally slow
-tachypnea: abnormally fast
Assessment Questions with Complete Solutions
What are some factors that influence pulse rate? Correct Answ_-Developmental level
-Gender
-Exercise
-Food intake
-Stress
-Fever
-Disease
-Blood loss
-Position change
-Medication
Guidelines for obtaining a pulse rate? Correct Answ_-apical pulse is most accurate (left side, midclavicular, 5ICS)
-use stethoscope to auscultate number of heart beats
-a watch or clock with a second hand or digital display is required (listen for 60 seconds)
-a heartbeat is one series of LUB DUB sounds
,Common pulse points? Correct Answ_-Radial: Laterally on the anterior wrist
-Brachial: Medially in the antecubital space
-Carotid: Between midline and side of neck. Only for CPR-trained professional; and assessing circulation to the head.
-Temporal: Located on the side of the forehead
-Dorsalis pedis: Top of the foot
-Femoral: In the groin fold
-Popliteal: Behind the knee
-Apical: At the apex of the heart (60 seconds)
When should you measure the apical pulse? Correct Answ_-pulse is weak or irregular
-rate less than 60 beat/min or greater than 100 beats/min
-cardiac medication
-infants or child under 3 years old
Variances in pulse rates? Correct Answ_-pulse deficit: hear a heart beat but do not feel a beat at a pulse point
-bradycardia: rate less than 60 bpm
-tachycardia: rate greater than 100 beats/min
,Inadequate circulation? Correct Answ_-Pallor: paleness of skin when compared with another part of the body
-Cyanosis: a bluish or grayish discoloration of the skin due to excessive carbon dioxide and deficient oxygen in the blood
What is respiration? Correct Answ_-exchange of oxygen and carbon dioxide in the body
-two separate processes (mechanical and chemical)
What is mechanical ventilation? Correct Answ_active movement of air in and out of the respiratory system
What is chemical ventilation? Correct Answ_chemical aspects; gas transport, internal and external respiration
What is inspiration? Correct Answ_-drawing air into the lungs
-involves the ribs and diaphragm, creating negative pressure and allowing air to flow into the lungs
What is expiration? Correct Answ_-relaxation of thoracic muscles and diaphragm, causing air to expel from the lungs
-is passive and normally takes 2-3 seconds
What are factors that influence respirations? Correct Answ_-developmental level
, -exercise
-pain
-stress
-smoking
-fear
-hemoglobin
-disease
-meds
-position
How to count respiratory rate? Correct Answ_-count after taking radial pulse (makes patient unaware)
-patient can alter rate and pattern of respiration
-RR must be accurate, especially in older adults
Kinds of respiratory rates? Correct Answ_-apnea: cessation of breathing
-bradypnea: abnormally slow
-tachypnea: abnormally fast
