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CNA 2016 C. 26*
Measuring vital signs
| Question | Answer |
|---|---|
| The nurse asks you to take an apical-radial pulse. The apical and radial pulses are taken | at the same time |
| The amount of force exerted against the walls of an artery by the blood is the | blood pressure |
| The amount of heat in the body that is a balance between the amount of heat produced and the amount lost by the body is | body temperature |
| A heart rate less than 60 beats per minute is | bradycardia |
| The heart muscle relaxes during | diastole |
| The pressure in the arteries when the heart is at rest is | diastolic pressure |
| A systolic blood pressure that remains above 140 mm Hg and a diastolic pressure that remains above 90 mm Hg is | hypertenstion |
| A systolic blood pressure below 90 mm Hg or a diastolic pressure below 60 mm Hg is | hypotension |
| The beat of the heart felt at an artery as a wave of blood passes through the artery is the | pulse |
| The difference between the apical and radial pulses is the | pulse deficit |
| The number of pulses felt in 1 minute is the | pulse rate |
| The act of inhalation and exhalation is | respiration |
| What is used to measure blood pressure? | sphygmomanometer |
| __________________is used to listen to sounds produced by the body. | stethoscope |
| The period of heart muscle contraction is | systole |
| The pressure in the arteries when the heart contracts is known as | systolic pressure |
| A heart rate over 100 beats per minute is | tachycardia |
| Temperature, pulse, respirations, and blood pressure are | vital signs |
| Vital signs detect | changes in body function |
| A resident is 83 years old. You measure the person’s vital signs | according to the person's care plan |
| Vital signs are normally taken with the person | is sitting or lying down |
| Vital signs are immediately reported to the nurse if | there is a change from the previous measurement |
| Body temperature is usually the lowest | in the morning |
| A female resident is 83 years old. What will affect her body temperature? | weather and exercise |
| Body temperature is measured at what sites? | rectum, mouth, forehead, ear, axilla |
| A resident is 55 years old. The person needs rehabilitation after hip replacement surgery. You take the person’s temperature orally. 99.8 measurement is _____________. | abnormal |
| A resident is 55 years old. The person needs rehabilitation after hip replacement surgery. You take the person’s tympanic membrane temperature. 98.6 measurement is | normal |
| Taking temperatures is delegated to you. The nurse and care plan tell you | what site to use |
| A glass thermometer is appropriate to use to obtain an oral temperature. | false |
| A rectal thermometer is color-coded in | red |
| You are taking an oral temperature.. How long do you request the person have nothing to eat or drink prior to you taking his or her temperature? | 15-20 minutes |
| You are taking a temperature with a tympanic thermometer. How long do you leave the thermometer in place? | 1 to 3 seconds |
| You are taking temperature using a temporal artery thermometer. How long would you anticipate this thermometer taking to obtain a temperature? | 3-4 seconds |
| A person has a naso-gastric tube. When measuring temperature, you cannot use the _______ site. | oral |
| A person is receiving oxygen. When measuring temperature, you cannot use the _______ site. | oral |
| A person is unconscious. When measuring temperature, you cannot use the ________ site. | oral |
| A person is paralyzed on the right side. When measuring temperature, you cannot use the _________ site. | rectal |
| A person has a convulsive disorder. When measuring temperature, you cannot use the ______ site. | oral |
| A person has diarrhea. When measuring temperature, you will need to avoid the _______ site. | rectal |
| A person has heart disease. When measuring temperature, you should avoid using the ______ site. | rectal |
| For an accurate measurement, the axillary site needs to be | dry |
| To measure a temporal artery temperature, gently stroke the device across the | forehead |
| A resident smokes. The person just had a cigarette. How long do you need to wait before taking the person’s temperature orally? | 15-20 minutes |
| To take a rectal temperature, the person needs to be | in sims' position |
| Before inserting a rectal thermometer, you need to | lubricate it |
| The tympanic membrane thermometer is inserted | into the ear |
| A person has dementia. Which site should you use to measure temperature? | tympanic membrane |
| Temperature-sensitive tape is usually applied to the | forehead |
| Which is the most common site for taking a pulse? | radial |
| The apical pulse is found | just below the left nipple |
| Which pulse site requires the use of a stethoscope? | apical |
| What should you use to clean a stethoscope? | antiseptic wipes |
| Before placing the stethoscope on the person, you need to warm the diaphragm | in your hand |
| For an adult, pulse rate of 50 is reported to the nurse at once. | true |
| For an adult, pulse rate of 110 is reported to the nurse at once. | true |
| You are taking a resident’s pulse. The beats are not spaced evenly. How would you describe the person’s pulse when reporting to the nurse? | irregular |
| Your center uses electronic blood pressure equipment. Why do you still need to feel pulses? | the rate is given but not the force or rythm |
| A radial pulse is counted for how many seconds? | 30 seconds |
| When taking a radial pulse, you need to use | your first 2 or 3 fingers |
| An apical pulse is usually counted for __________________seconds. | 60 |
| When taking an apical pulse, you need to use | a stethoscope |
| You are taking an apical pulse. The _______________ is counted as one beat. | the lub-dub |
| Apical-radial pulses should be | equal |
| How many staff members are needed to take an apical-radial pulse? | 2 |
| To obtain the pulse deficit, | subtract the radial pulse rate from the apical pulse rate |
| When taking an apical-radial pulse, the pulses are counted for _____ seconds. | 60 |
| Respirations usually are counted | after taking the pulse |
| The healthy adult has _____ respirations per minute. | 12-20 |
| You are counting a resident’s respirations, both sides of the persons chest should | rise and fall equally |
| You measured a resident’s blood pressure. His diastolic pressure was 78 mm Hg. His systolic pressure was 144 mm Hg. How do you record these measurements? | 144/78 mm Hg |
| What factors increase blood pressure? | pain, alcohol, male sex |
| Normal Systolic pressure | less than 120 |
| Normal Diastolic pressure | less than 80 |
| To measure blood pressure you need a | sphygmomanometer |
| You are measuring blood pressure. How far should you inflate the cuff beyond the point where you last felt the person’s pulse? | 30 mm Hg |
| The systolic pressure is the _____ sound you hear. | first |
| You are measuring blood pressure. How fast should you deflate the cuff? | 2-4 millimeters per second |
| You cannot hear a person’s blood pressure. What should you do? | tell the nurse at once |
| The blood pressure cuff is applied over the | brachial |
| A resident has a cast on his left wrist. Blood pressure is measured in | the right arm |
| Ten years ago a resident had breast surgery on her right side. Blood pressure is measured in the | left arm |
| A resident has an IV in her left arm. Blood pressure is measured in the | right arm |
| A resident just finished his daily exercise program. You need to measure his blood pressure. How long does he need to rest before the measurement? | 10-20 minutes |
| The diastolic pressure is the _____ sound you hear. | last |
Created by:
heatherhibbs