-The patient's response to care, -The patient's oxygen saturation Sixteen temperature samples compared temporal artery thermometers to core temperatures. C. Expect blood pressure in the thigh to be 10 to 15 mm Hg less than in the arm. B. Decrease in contractility "The first step in checking for orthostatic hypotension is obtaining a client's blood pressure while they are standing." When using a digital oral thermometer, you want to place it under the tongue. The nurse should identify that a blood pressure of 116/72 mm Hg is within the expected reference range for a young adult. A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Using the airway, breathing, circulation approach to client care, the nurse should identify that the priority finding is the low SaO2. 1. The tip does not fit into the ear canal of smaller patients, limiting their use in pediatric populations. Cite the average body temperature, pulse rate, respiratory rate, and blood pressure for various age groups. Which of the following pieces of documentation is correct? C. Encourage the client to practice relaxation techniques each day. A nurse is assisting with the care of a client who has orthostatic hypotension. an active process that involves the diaphragm moving down, the external intercostal muscles contracting, and the chest cavity expanding to allow air to move into the lungs. Design: A prospective repeated measures (induction, emergence, and postanesthesia care unit) design was used. You want to use the idea of electromagnetic induction to make the bulb in your small flashlight glow; it glows when the potential difference across it is 1.5V1.5 \mathrm{V}1.5V.You have a small bar magnet and a coil with 100 turns, each with area 3.0104m23.0 \times 10^{-4} \mathrm{m}^{2}3.0104m2.The magnitude of the B\vec{B}B field at the front of the bar magnets north pole is 0.040 TTT and reaches 0 TTT when it is about 4cm4 \mathrm{cm}4cm away from the pole. a. increases the flow of auxin down the shoot, c. produces a plant that will grow taller, d. produces a plant that will grow fuller. 3. Hold probe flat against the forehead while moving gently across forehead across the forehead over the temporal artery. Which of the following information should the nurse include? Cmo aprobar el examen ATI de salud mental? (Move the steps into the box on the right, placing them in the order of performance. Recording vital signs provides critical information regarding a client's condition. D. The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second. "The body lowers body temperature through sweating." C. Place the stethoscope over the 4th intercostal space to the left of the sternum. A. This type of thermometer is non-invasive and may even be applied while a patient is sleeping. The screen displays your temperature based on the reading. A nurse is contributing to the planning of an in-service about factors affecting respiratory rate for a group of assistive personnel. C. "The body increases body temperature through the process known as vasodilation." D. Increase in preload. A nurse is reviewing the vital signs of four clients. 1) Provide Privacy B. Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall. A nurse is planning care for a group of clients and is reviewing the recent vital signs obtained by an assistive personnel. -Your nursing interventions D. A client who has stabilized BP measurements Use a regular digital thermometer to take a rectal temperature. C. "Cardiac output is the ability of the muscle fibers in the ventricles to stretch." Pulmonary artery D. An older adult client who has an infection and a pulse rate of 110/min after using relaxation techniques. Fever can increase a client's respiratory rate. Rectal thermometer devices met accuracy criterion of remaining within 0.5 C of core temperature 95% of the time. A. B. Cons. To auscultate a patient's apical pulse accurately you position the bell or the diaphragm of your stethoscope over the point of maximal impulse, which is located, -At the 5th intercostal space at the left midclavicular line, The best way to determine the depth of a patient's respiration is to, -Observe the degree of chest wall movement during inspiration & expiration, You are measuring a patient's temperature orally. Oxygen saturation is an indication of the amount of oxygen being transported to body tissues and is a direct reflection of a client's respiratory status. Your body temperature is naturally higher in the afternoon or evening. Especially because of COVID, researchers studied TATs along with more traditional thermometer types that involve more contact and read temperatures from other body parts: Temperature readings vary by body part, but doctors generally agree on these: And doctors still consider rectal temperature to be the most accurate.. Which of the following assessment values requires immediate attention? C. An infant who has a respiratory rate of 52/min For an infant, this temperature is more of a concern than it may be for an adult.. A nurse is reviewing documentation of vital signs by a newly licensed nurse. thready pulse Introduction to Vital Signs Vital signs are objective guideposts that provide data to determine a person's state of health. -Any specimens and cultures obtained and sent to the lab 5) Discard disposable cover and document results. Instruct the client to bear down like they are having a bowel movement. Which of the following interventions should the nurse plan to recommend? This finding indicates that interventions were effective. B. A 1-month-old infant who has a respiratory rate of 58/min D. A pedal pulse that is weak upon palpation is an expected finding in an older adult. D. Ensure the client has been taking medications as prescribed. B. A. Tricuspid valve Which of the following clients' vital signs indicate that interventions were effective? B. The client's diaphoresis will make it difficult to obtain an accurate temperature via the tympanic membrane or temporal artery. This number is the patient's diastolic blood pressure. "Conduction is the loss of body heat when sweat dries from a client's skin." B. B. EMAP Publishing Limited Company number 7880758 (England & Wales) Registered address: 10th Floor, Southern House, Wellesley Grove, Croydon, CR0 1XG. U.S. STD Cases Increased During COVIDs 2nd Year, Have IBD and Insomnia? A 45-year-old client who is postoperative and has a BP of 130/82 mm Hg B. Which of the following statements should the charge nurse include? Measurements were performed using two temporal artery thermometers (Temporal Scanner TAT-5000, Exergen Corp.). Evidence-based practice dictates that if a client's blood pressure is not within the expected reference range when it is taken with an electronic blood pressure machine, then the nurse should recheck the blood pressure by obtaining a manual blood pressure reading to ensure accuracy. D. Palpate the infant's sternum for the presence of a murmur. A. One of problems that w.. Increase in blood viscosity The patient has a temperature of 102 degrees F. Which of the following do you expect to find? Tachycardia. usually .9 degrees lower than oral temperature. Data was analyzed to assess bias and limits using scatterplots and Bland-Altman charts while sensitivity analysis was done using ROC curves. Digital multiuse thermometers read body temperature when the sensor located at the tip of the thermometer . A. a passive process that involves the diaphragm moving up, the external intercostal muscles relaxing, and the chest cavity returning to its normal resting state. -Any signs or symptoms of pulse alterations Age, exercise, hormones, stress, environmental temperature, time of day, body site, and medications can influence body temperature. "Cardiac output is the amount of blood flow through the heart in 1 minute." Windows, Doors & Conservatories. An older adult client who has pneumonia and a respiratory rate of 26/min after a position change A nurse is caring for a client who has a heart rate of 120/min. D. SaO2 of 96%. Offer the client hot caffeinated tea to drink early in the morning. D. A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg Which of the following actions should the nurse take next? As the ventricle contracts, the blood is forced into the aorta and systemic circulation. A. A. If the pulse rate palpated does not match the pulse rate displayed on the oximeter, the nurse should choose a new site for the measurement and recheck the pulses. Ensure it is ready for use.. If measurements are outside normal ranges, ensure that the device being used is functioning properly and used properly applying pulse oximeter, assure that the finger has no cuts or lesions and . 4) Leave thermometer in place until audible signal indicates temp has been measured. A client who has an apical pulse rate of 120/min As we discussed earlier is a snapshot graph of a wave at t=0st=0 \mathrm{~s}t=0s. Draw the history graph for this wave at x=6mx=6 \mathrm{~m}x=6m, for t=0st=0 \mathrm{~s}t=0s to 6s6 \mathrm{~s}6s. Cuff width= 20% greater than the diameter of the limb at its midpoint or 40% of circumference. electronic thermometers, tympanic thermometers, and temporal thermometers. -You might not hear a 5th Korotkoff sound, You are assessing the vital signs of a newly admitted patient. D. Reinforce client teaching regarding medications to control blood pressure. -The route you used to measure the temperature A. 3c ). Results obtained indicate that measurement of the automated temperature device calibrated against standard mercury-in-glass thermometer returned a correlation coefficient of 0.790996276 . D. Use the thigh to obtain blood pressure when a client has severe edema in their arms. Contractility is the ability of the heart muscle to contract effectively. Select a blood pressure cuff width that is 25% of the circumference of the client's thigh. For an adult, insert probe approximately 1-1.5 inches into rectum. D. A school-age child who has a respiratory rate of 14/min. D. Oral temperature is easily accessible despite a client's position. A nurse is reinforcing teaching with a group of newly licensed nurses about vital sign measurements. The TemporalScanner Thermometer, TAT-2000C, for home use is a totally non-invasive system with advanced infrared technology providing maximum ease of use with quick, consistently accurate. Systematic review and meta-analysis on the diagnostic accuracy of temporal artery thermometers (TAT). The client's diaphoresis will make it difficult to obtain an accurate temperature via the tympanic membrane or temporal artery. The charge nurse should include that a blood pressure of 162/102 mm Hg meets the diagnostic criteria for stage II hypertension. So you may have to do a little math. B. Ask them to keep their lips closed and breathe through their nose ( Fig. D. Brachial pulses are symmetrical. Inform the client to ask for assistance with getting out of bed. A nurse is obtaining vital signs for a group of clients. D. Discontinue IV fluids. A. Apex of the heart The factors that can alter a patient's respiratory rate, Exercise, anxiety, fever, and a low hemoglobin level can all increase respiratory rate, The depth of a patient's breathing. A rectal temperature is 0.5 F (0.3 C) to 1 F (0.6 C) higher than an oral temperature. This finding indicates that interventions were effective. 5) Discard disposable cover and document results. D. Respiratory rate 18/min via observation, client sitting in chair. Therefore, the intervention of using an inhaler was effective. Casement Windows; Sash Windows; Tilt & Turn Windows B. Respirations observed as even, nonlabored at 20/min with client in supine position The SA node is the pacemaker of the heart. A temporal artery thermometer may be more expensive than other types of thermometers. 2) Apply light pressure with the pads of the fingers in the groove along the radial or thumb side of the patients inner wrist. A. It is passed over the temporal artery in the forehead. New research suggests that a temporal artery thermometer might also provide accurate readings in newborns. "The body lowers body temperature through sweating." In addition to gender and age, exercise, medications, decreased oxygen saturation, blood loss, and body temperature can all influence a patient's pulse rate. Oral temperatures should not be obtained in clients who have consumed foods or liquids or smoked tobacco products within the previous 30 min. C. A young adult who has an apical pulse rate of 104/min The nurse should identify that a respiratory rate of 34/min is above the expected reference range of 18 to 30/min for a school-age child. C. An older adult client has a tympanic temperature of 35.9 C (96.6 F). A young adult client who has a radial pulse rate of 56/min Oxygen saturation reflects the amount of oxygen being delivered to body tissues. A toddler who has diarrhea Most appropriate measurement for adults and children including infants. Which of the following statements should the nurse include? This indicates the interventions provided by the nurse have not been successful and require further evaluation and notification of the provider. 2) Remove protective cap and wipe lens of device with alcohol swab -Abnormal respiratory sounds B. A charge nurse is discussing a client's respiratory data with a newly licensed nurse. You place the covered probe, -In the posterior lingual pocket lateral to the midline, NURS 3440 Exam 2 Gastrointestinal and Hepatob, Promoting Health: The Middle and Older Adult, NURS 3631 Pediatrics Module 4 CH 18 The rectal or ear reading may be closer to 102 degrees Fahrenheit. A temporal thermometer which measure temperature in the forehead. 5. C. BP 124/82 mm Hg, lying in bed B. The nurse should identify that orthostatic hypotension is a drop in systolic pressure of at least 20 mm Hg, or a drop in diastolic pressure of at least 10 mm Hg, within 1 min of moving to a sitting or standing position after lying down. The nurse should encourage the client to participate in relaxation techniques such as guided imagery, meditation, or yoga as these can decrease heart rate and blood pressure. For a healthy adult, a respiratory rate between 12 and 20 breaths per minute is considered normal. C. Encourage the client to practice relaxation techniques each day. A. oral temperature-keep probe under tongue until you hear it beep. Usually described as absent, weak, diminished, strong, or bounding. D. A client who was recently admitted and reports chest pain. b. . B. The nurse should identify that the apical pulse is auscultated over the apex of the client's heart for a client who is older than 7 years of age. B. A client who has an apical pulse rate of 120/min Mobility and Immobility: Evaluating a Client's Use of a Walker (CP card #107) -DO NOT use walker to stand up -Flex elbows 20-30 degrees -advance walker approximately 12 inches, advance affected leg (LEFT), then move unaffected leg (RIGHT) Students also viewed Chapter 6. pg.162-164 Monitoring Intake and O 45 terms Andrea_Messer NUR 115 exam 1 Wait 30 seconds. Which of the following findings should the nurse expect? Which of the following factors should the nurse include in their response? C. A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm Hg after using an inhaler A. When you have a fever, its a sign that your body is fighting off an infection, and thats a good thing. A nurse is caring for a client who asks about factors that could cause their pulse rate to increase. "The body loses heat through shivering." Decrease in contractility It consists of a small group of special cells in the right atrium which initiates electrical impulses that travel to the AV node and sets the rate of the contraction of the ventricles. Although recognized as a generally sound reflection of core body temperature, rectal temperature can lag behind changes in core temperature and is affected by depth of measurement, presence of feces and local blood flow. The nurse should include that radiation is the loss of body heat that occurs when a client is in close proximity to a cooler surface. This is located between the 5th intercostal space to the left of the client's sternum. C. A 52-year-old client who has an SaO2 of 92% A nurse is discussing the physiology of blood pressure with a group of assistive personnel. 3. The best sites to use varies with age of patient, the situation, and agency policy. C. A 52-year-old client who has an SaO2 of 92% Expected finding is the client hears sound equally in both ears (negative weber test) 9. The average normal oral temperature is 98.6 F (37 C). If the radial pulse and pulse rate displayed on the oximeter are the same, the nurse should wait approximately 15 to 30 seconds, until a consistent SaO2 and pulse rate are displayed. The nurse should instruct the AP to obtain blood pressure measurements in the thigh when a client has severe edema in the arms or a shunt in place for dialysis. A. C. BP 124/82 mm Hg, lying in bed Which of the following information should the nurse include? Maintaining contact with your skin, drag the thermometer up your forehead to your hairline. C. A client who has a blood pressure of 128/86 mm Hg has stage I hypertension. A. -The patient's response to care, -The rate, rhythm, and depth of respirations 3) If pulse is regular, count for 30 seconds, then multiply that number by 2. (Select all that apply), -Patient is 60 pounds overweight, patient is reporting a "stuffy" nose, patient is taking digoxin (Lanoxin), patient had a mastectomy 2 years ago. Restrict the client's oral intake of fluids. Direct sunlight, cold temperatures or a sweaty forehead can affect temperature readings. Which of the following actions should the nurse take to improve the client's heart rate? -It consists of a sensor with a light-emitting diode (LED) that is connected to the oximeter by a cable. -Any signs or symptoms of temperature alterations They include: You should also be ready to make one other adjustment. Our MCQ book is the key to achieving exam success and advancing your career. A. D. A client who is diaphoretic and frequently chewing ice to relieve dry mouth. Identify the order of the steps the nurse should include. B. A. for adult will palpate radial pulse. An adolescent who has a respiratory rate of 20/min 2. An infant who has an apical pulse rate of 132/min Inform the client to ambulate in the hallway for 10 min prior to taking vital signs. You may find that a temporal artery thermometer costs more than other thermometer options because of its infrared technology. Which of the following clients should the nurse see first? Since theres no wait for results and the devices do not cause discomfort, TATs are excellent for use on children. D. The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second. B. Right side of sternum C. A pulse strength of +1 indicates that the pulse is weak or diminished upon palpation. D. A capillary refill time is less than 5 seconds ensures a reliable oxygen saturation measurement. Align the sensor with the middle of your forehead for the most accurate reading.. Provide the client with low-sodium meals and snacks. And you must be sure to remove conditions that could affect its accuracy. Teach the client how to take their pulse so they can keep the provider informed of variations. A. Boston Childrens Hospital and Harvard Medical School. If sitting, instruct the patient to keep feet flat on the floor without crossing legs. in the medulla of the brain and the level of carbon dioxide in the blood help regulate breathing. The nurse should reassess the vital signs to ensure previous readings were accurate and evaluate the client to determine a potential cause for the increased respiratory rate, such as anxiety, crying, or physical exertion. Which of the following is the nurse's priority action? 2)The second sound is a whooshing sound, -Its own category A nurse is obtaining vital signs for a group of clients. Appropriate for patients who are comatose, have facial injuries or deformities, or critically ill or injured. A charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. -The site you used to palpate the pulse Besides body heat, signs that you may have a fever include:, A body temperature of 100.4 degrees Fahrenheit or higher signals a fever. In an adult client, a heart rate greater than 100/min is known as tachycardia. 1 When ambient temperature changes or animals undergo . 4. Temperature measurements were taken from each patient using the tympanic, temporal artery and contactless thermometers and oral electronic thermometer. Can you make the bulb light? Temperature-Keep probe under tongue until you hear it beep pressure for various groups! 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'S sternum radial, standing, immediately following 10 min of ambulating in hall stretch. who have consumed or. Children including infants and oral electronic thermometer their nose ( Fig amount of oxygen being delivered to body.! The process known as vasodilation. breaths per minute is considered normal you... Of newly hired nurses, respiratory rate for a group of newly nurses... Assessing the vital signs for a group of newly hired nurses specimens and cultures obtained and sent to the by! Client, a heart rate minute. automated temperature device calibrated against standard mercury-in-glass returned... At its midpoint or 40 % of circumference client 's position thermometer returned correlation. Prospective repeated measures ( induction, emergence, and temporal thermometers, temporal artery in the.! Limiting their use in pediatric populations Hg per second dioxide in the forehead sounds. Caring for a client who has an infection, and blood pressure of mm. Factors affecting respiratory rate between 12 and 20 breaths per minute is considered normal stage I hypertension remaining within C! Between the 5th intercostal space to the left of the client to practice techniques... You used to measure the temperature a diarrhea Most appropriate measurement for adults and children including.. Of body heat when sweat dries from a client 's skin. to reduce pressure within the bladder cuff a... Getting out of bed hear it beep situation, and agency policy out of bed patient...