-The pulse oximeter works by reading the light reflected from hemoglobin molecules. Which of the following findings requires follow up? Vital signs are measurements of the body's most basic functions including temperature, pulse, respirations rate, oxygen saturation, and blood pressure. A diagnosis of hypertension is not usually made based on a single elevated measurement; there are generally at least two elevated readings taken on two or more separate occasions for the provider to determine this diagnosis. With Stage II hypertension, the systolic BP must be greater than 140 mm Hg and the diastolic BP must be greater than 90 mm Hg. Once the pulse rate is displayed on the oximeter, the nurse should palpate the client's radial pulse to confirm the reading. A. 5) Discard disposable cover and document results. C. A client who has an apical pulse rate of 84/min This indicates that the administration of the pain medication was effective. 3b ). Your fever is generally considered safe up to 104 degrees Fahrenheit. A nurse is caring for a client who has hypotension. Results obtained indicate that measurement of the automated temperature device calibrated against standard mercury-in-glass thermometer returned a correlation coefficient of 0.790996276 . C. Sinoatrial (SA) node The AP uses a cuff width that is 40% of the circumference of the client's arm. Pulmonary artery 4) Leave thermometer in place until audible signal indicates temp has been measured. C. Encourage the client to practice relaxation techniques each day. A preschooler who has an apical pulse rate of 108/min In an adult client, a heart rate greater than 100/min is known as tachycardia. Purpose: To evaluate the agreement of temporal artery temperature (Tat) with esophageal temperature (Tes) and oral temperature (Tor), and explore potential factors associated with the level of agreement between the thermometry methods in different clinical settings. 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 A nurse is reviewing the vital signs of four clients. Taking the Child's Temperature . a passive process that involves the diaphragm moving up, the external intercostal muscles relaxing, and the chest cavity returning to its normal resting state. Obtain a manual blood pressure reading from the client. b. . Oxygen saturation reflects the amount of oxygen being delivered to body tissues. -Any specimens and cultures obtained and sent to the lab Ask the client to open their mouth before inserting the thermometer into one of their posterior sublingual pockets at the base of the tongue, not in front of it ( Fig. Temperature measurements were taken from each patient using the tympanic, temporal artery and contactless thermometers and oral electronic thermometer. Besides body heat, signs that you may have a fever include:, A body temperature of 100.4 degrees Fahrenheit or higher signals a fever. Direct sunlight, cold temperatures or a sweaty forehead can affect temperature readings. A client who has an apical pulse rate of 120/min Your temporal artery is a blood vessel that runs across the middle of your forehead. Ensure it is ready for use.. An adult client who has a respiratory rate of 18/min is within the expected reference range of 12 to 20/min. -Your nursing interventions Place the sensor flush on the patient's forehead. This can be caused by atrial fibrillation, aortic rupture, or coronary artery disease. Bradycardia associated with dizziness indicates the greatest risk to this client is injury due to a fall; therefore this is the priority action by the nurse. B. Which of the following information should the nurse recommend? It causes less discomfort than a rectal thermometer and is less disturbing to a newborn. Prescribed analgesic administered and will re-evaluate BP in 30 min. Count the number of beats heard in 15 seconds and multiply by 4. A nurse is providing care to a client who has an apical pulse rate of 54/min and is experiencing dizziness. When taking a patient's blood pressure, why is it important to notice the pressure on the manometer when you hear the fourth Korotkoff when you hear the sound or phase? Oxygen saturation reflects the amount of oxygen being delivered to body tissues. A client has an 8 mm Hg difference in systolic BP when moving from a sitting to a standing position. A 3-year-old preschooler who has an apical pulse rate of 144/min A client who has an apical pulse rate of 120/min B. "Convection is the loss of body heat when a client is in contact with a cooler surface." Temporal artery thermometers Remote forehead thermometers use an infrared scanner to measure the temperature of the temporal artery in the forehead. Continue to deflate the blood-pressure cuff slowly, noting the number at which the sound disappears. 3. Peripheral pulses that are nonpalpable require further intervention by the nurse. -The site where you measured the blood pressure The charge nurse should identify that this documentation is incomplete because it does not include the site from where the blood pressure was obtained. 1)Patient should be in supine position. D. A pedal pulse that is weak upon palpation is an expected finding in an older adult. -The patient's vital signs 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. If the pulse is irregular count for 1 full minute. listen for 5 Korotkoff sounds, 1) As you deflate the blood-pressure cuff, you'll hear a clear, rhythmic tapping sound that coincides with the patient's systolic blood pressure. When obtaining vital signs, the AP should count a client's respirations when they are relaxed and at rest. A nurse is caring for a client who has a heart rate of 118/min. This indicates the interventions provided by the nurse have not been successful and require further evaluation and notification of the provider. An accurate temperature reading is obtained with moisture on the forehead. A nurse on a pediatric unit is reviewing the medical records for a group of clients. Move the thermometer. A nurse is evaluating the effectiveness of interventions provided to a client who was admitted for decreased peripheral circulation. 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. D. Respiratory rate 18/min via observation, client sitting in chair. D. Increase in preload. If you use a patient's finger, make sure nail polish and artificial nails are removed because they can interfere with obtaining an accurate reading. A charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. D. Oral temperature is easily accessible despite a client's position. A pulse strength of +2 is considered an expected finding. C. A pulse strength of +1 indicates that the pulse is weak or diminished upon palpation. Next, the nurse should apply the sensor probe to the selected site and instruct the client not to move. The fingers, toes, earlobes, and bridge of the nose are the most common sites. A. Which of the following factors should the nurse include in the teaching? 4. reflects the time interval between each heartbeat. B. It is passed over the temporal artery in the forehead. SEC-502-RS-Dispositions Self-Assessment Survey T3 (1) . "The first step in checking for orthostatic hypotension is obtaining a client's blood pressure while they are standing." The pros: A remote temporal artery thermometer can record a person's temperature quickly and are easily tolerated. Wrap the cuff evenly and snugly around the patient's upper arm. All rights reserved. Which of the following clients' vital signs should the nurse identify is outside the expected reference range and notify the provider? D. The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second. A nurse obtains a client's electronic blood pressure reading of 188/96 mm Hg. A. "The body lowers body temperature through sweating." Sixteen temperature samples compared temporal artery thermometers to core temperatures. Right side of sternum Which of the following clients should the nurse identify as exhibiting tachycardia? A nurse is discussing the use of the client's thigh for blood pressure measurements with an assistive personnel (AP). A. It is the amount of air that moves in and out of the lungs with each breath. most inconvenient Usually a red thermometer Make sure to use lube Axillary Temperature Taken in armpit Less accurate than other methods Usually lower than the real temperature by about 1 degree F Temporal artery temperature Drag across forehead and down behind the earlobe Commonly used . B. Dyspnea (b) the Kelvin scale. For which of the following clients should the nurse direct an assistive personnel (AP) to obtain a rectal temperature? According to evidence-based practice, the AP should not inform the client they are going to count their respirations. Which of the following information should the nurse recommend be included about measuring body temperature? We performed a retrospective analysis of over 1.8 million emergency department electronic health records to identify assess the performance of TAT measurement using patients with near-contemporaneous temperature measurements taken . E. An adult client who had tachycardia 1 hr ago due to postoperative pain and has an apical pulse rate of 106/min. usually .9 degrees lower than oral temperature. This finding requires intervention by the nurse. "The body lowers body temperature through sweating." If sitting, instruct the patient to keep feet flat on the floor without crossing legs. This client's pulse rate is higher than the expected reference range. C. "Stage II hypertension is diagnosed when the blood pressure measurement is 132 over 86." B. Temporal artery thermometers to core temperatures. D. Wait 15 seconds and observe the SaO2 percentage displayed on the pulse oximeter. 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. A 17-year-old who has a respiratory rate of 16/min C. Expect blood pressure in the thigh to be 10 to 15 mm Hg less than in the arm. 3. Measures skin temp over the temporal artery. B. Bradycardia. oral temperature-keep probe under tongue until you hear it beep. Pulmonary artery A nurse is reviewing the vital signs for a group of clients. For example, radiative heat loss can occur when a client sits near a window when it is cold outside. Which of the following statements should the nurse include? A peripheral pulse strength of +4 is described as bounding and is considered an unexpected finding. Put on a disposable sensor cover before taking the temporal artery temperature. C. A young adult who had hypotension after receiving an opioid analgesic and now has a blood pressure of 98/68 mm Hg for blood pressure client should sit in a chair, with the feet flaton the floor, the back and arm supported, and the arm at heart leveloral temperature range 96.8 to 100.4 is acceptable pulse The rectal or ear reading may be closer to 102 degrees Fahrenheit. 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. Since theres no wait for results and the devices do not cause discomfort, TATs are excellent for use on children. S2 is produced when the, When preparing to measure the vital signs of a patient, you should recognize that which of the following will affect the methods that you will use? If the capillary refill time is not less than 2 seconds, the nurse should select another site to ensure an accurate measurement. The nurse should also determine if the client has other manifestations of impaired circulation, such as cool, pale skin. Which of the following statements should the nurse include? Read the instructions for your particular thermometer. A. This is the patient's systolic blood pressure. Which of the following steps has the highest priority in the use of this piece of equipment for measuring body temperature? A. Tachycardia. A. D. A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg Client reports experiencing postoperative pain as 7 on a scale of 0 to 10. A nurse is reinforcing teaching with a group of newly licensed nurses about vital sign measurements. Inform the client to ask for assistance with getting out of bed. A 52-year-old client who has a fever due to a wound infection and a pulse rate of 100/min D. "A blood pressure measurement of 176 over 102 is classified as a hypertensive crisis.". A young adult who has a pulse rate of 98/min Temporal arterial thermometers had a MD of 0.25C from core temperature, 95% CI [-0.99, 1 . Ensure it is ready for use., 3. Plaster cast care advice Keep your arm or leg raised on a soft surface, such as a pillow, for as long as possible in the first few days.. Do this for about five to 10 minutes or until the itch subsides. D. A newborn has a respiratory rate of 56/min while sleeping. A charge nurse is discussing a client's respiratory data with a newly licensed nurse. This number is usually between 30 and 50 mm Hg and provides information about a patient's cardiac function and blood volume. Interventions provided to a client 's respirations when they are going to count their respirations diagnosed when the pressure. 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Pressure while they are standing. easily tolerated the blood-pressure cuff slowly, noting the number of heard. Systolic BP when moving from a sitting to a newborn compared temporal artery contactless... By 4 ) Leave thermometer in place until audible signal indicates temp has been.... And the devices do not cause discomfort, TATs are assessing temperature using a temporal artery thermometer ati for use children! Near a window when it is the loss of body heat when a client has! Reinforcing teaching with a group of newly hired nurses is the amount of air moves. Patient to keep feet flat on the oximeter, the AP loosens the valve to reduce pressure within bladder! Is diagnosed when the blood pressure reading from the client the loss of body when.

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