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N110 Assess/Vitals
Review of Assessment and vital signs
| Question | Answer |
|---|---|
| What is the normal range for oral body temperature? | 97-99.6 degrees F |
| What part of the brain controls body temperature? | hypothalamus |
| What should the nurse do before taking an oral temperature on someone who has just ingested hot or cold liquids? | Wait 15-30 minutes before taking the temperature |
| Your adult patient is experiencing severe diarrhea. Which method of temperature measurement is contraindicated? | Rectal |
| What should the nurse do when taking a tympanic temperature on a person older than 3 years? | Pull the ear up and back |
| What does afebrible mean? | Normal temperature/without fever |
| Your patient presents with headache, diaphoresis, photophobia, restlessness, and increased thirst. What is likely to be happening with this patient? | Fever |
| What would be appropriate nursing interventions for a fever? | give antipyretics as ordered, change gowns and linens, encourage fluids, keep oral mucous membranes moist, monitor for signs of infection, monitor vitals |
| What is the normal pulse rate for an adult? | 60-100 bpm |
| If the radial pulse is irregular, what should the nurse do next? | Check the apical pulse for one full minute |
| What is pulse volume? | The strength of the pulse wave |
| What are the three pulse characteristics? | rate, rhythm, volume |
| How would fever affect the pulse rate? | Increase |
| What is a pulse deficit? | Apical rate minus the radial rate |
| What is the normal respiratory rate for an adult? | 12-20 breaths/min |
| What is dyspnea? | difficulty breathing |
| What are Cheyne Stokes respirations? | periods of rapid, deep breathing alternating with periods of apnea |
| What is orthopnea? | The ability to breath effectively only in an upright sitting or standing position |
| What is a normal blood pressure? | Less than 120/80 |
| What is essential or primary hypertension? | hypertension of unknown cause |
| Your patient's pulse ox is 88%. Is this within the normal range? | No |
| A blood pressure cuff that is too small for your patient's arm will have what affect on the BP reading? | False high |
| True or false: if your patient has a fistula for dialysis in the right arm, you cannot take the blood pressure on that arm. | True |
| True or false: limiting alcohol consumption is an appropriate lifestyle modification for the prevention of hypertension. | True |
| What is acute pain? | Pain that lasts only through the expected recovery time |
| True or false: According to Joint Commission standards for the treatment of pain, patients are not to be taught that pain management is part of treatment. | False! |
| What does the "R" in PQRST pain assessment stand for? | Region/radiation |
| What is the best way to document the client's chief complaint? | In their own words, using quotation marks |
| What is a sign? | Objective data, detected by the examiner, can be seen, heard, measured, felt |
| What is the correct order in which to examine the abdomen? | Inspection, auscultation, palpation |
| Your patient has thick, opaque, greenish/yellow drainage seeping from their wound. How would you describe the drainage? | purulent |
| What is alopecia? | hair loss |
| How should normal oral mucous membranes appear? | pink, moist, and intact |
| If someone is oriented x 4, they are oriented to: | person, place, time, and purpose |
| What does PERRLA stand for? | Pupils Equal Round Reactive to Light and Accomodating |
| What is the direct pupil response? | When light is shone into one pupil, that pupil constricts |
| What is dysphagia? | difficulty swallowing |
| What is hemiplegia? | one sided paralysis |
| What is a normal capillary refill time? | less than 3 seconds |
| Where is the apical pulse? | 5th intercostal, left mid-clavicular line |
| The pulse on the top of the foot is called: | dorsalis pedis (pedal) pulse. |
| Which portion of the stethoscope should be used to assess breath sounds? | diaphragm |
| How would you describe fine crackles? | High pitched, non-continuous crackling sounds. Generally not cleared by a cough. |
| What is the cause of a pleural friction rub? | inflammation of the visceral and parietal pleura (covering of the lungs, and lining of the thoracic cavity) |
| Why do nurses assess peripheral pulses? | To gain information about perfusion (distribution of oxygen and nutrients to the periphery of the body via the blood flow). |
| What should the nurse do before shining light into the eyes to assess the pupils? | Assess baseline pupil size |
| True or false: It is best to listen to lung sounds over clothing. | False! |
| What should the nurse do during the interview portion of the assessment? | Introduce self, explain, give estimate of time, good eye contact and body language, listen closely to what patient is saying, be relaxed and unhurried. |
| Sign or symptom: chest x-ray report | Sign |
| Sign or symptom: skin tear | Sign |
| Sign or symptom: numbness | Symptom |
| Sign or symptom: burning upon urination | Symptom |
| Which pulse is found behind the knee? | Popliteal Pulse |
| Which pulse is found on the neck? | Carotid Pulse |
| Where is the posterior tibial pulse found? | Behind and below the medial malleolus (inner ankle) |
Created by:
ProfessorGemmel
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