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Which pulse is used during cardiopulmonary resuscitation (CPR)?
carotid pulse
Unless otherwise ordered, take vital signs when the person
is lying or sitting down
Hg means
mercury
Body temperature is lower in the
morning
If the thermometer registers between 2 short lines, record the temperature to the
nearest tenth of a degree (short line)
Each respiration involves
one inhalation and one exhalation
When using an electronic thermometer, what does the blue probe mean?
oral or axillary
When taking the blood pressure, you place the stethoscope diaphragm
over the brachial artery at the inner aspect of the elbow
When taking the radial pulse place
place two or three fingers on the thumb side of the wrist
Which pulse is most commonly taken?
radial
The apical pulse rate is never less than the
radial pulse rate
When using an electronic thermometer, what does the red probe mean?
rectal
Which site has the highest baseline temperature?
rectum; temporal artery
When a pulse rate is 120 beats per minute, you
report that the person has tachycardia
You cannot get info about the pulse__ with electronic blood pressure equipment
rhythm and force
One respiration is counted for each
rise and fall of the chest
When you take a thermometer from a container, it reads 97.8 F. What should you do?
shake it down below 94 F (34 C)
To read a glass thermometer, you should hold it at the
stem and bring it to eye level to read it
List the words to describe forceful pulse
strong, full, bounding
How do you find the pulse deficit?
subtract the radial rate from the apical rate
If the mercury glass thermometer breaks, what should you do and why?
tell the nurse immediately because mercury is a hazardous substance
Blood pressure
the amount of force exerted against the walls of an artery by the blood
Pulse
the beat of the heart felt at an artery as a wave of blood passes through the artery
Sphygmomanometer
the cuff and measuring device used to measure blood pressure
Vital signs are taken when drugs are taken that affect
the respiratory or circulatory systems
If you are taking vital signs on person who has dementia, it may be better if
you take the pulse and respirations at one time, and the temperature and blood pressure at another time
If a person has been exercising, let the person rest for _____ before taking blood pressure
10-20 min
A healthy adult has __ respirations per minute
12-20
If you take a rectal temperature, the normal range would be
98.6 to 100.6 F (37 to 38.1 C)
Body temperature
The amount of heat in the body that is a balance between the amount of heat produced and amount lost by the body
Hypotension
When the systolic blood pressure is below 90 mm Hg and the diastolic pressure is below 60 mm Hg
When taking an axillary temperature, the axilla must
be dry
Which pulse is used when taking the blood pressure?
brachial
Respiration
breathing air into and out of the lungs
An oral temperature may be taken with a glass thermometer for a person who
is alert and needs a routine temperature taken
mm means
millimeters
When using a stethoscope, you can prevent infection by
wiping the earpieces and diaphragm with alcohol and before and after use
When you read a Fahrenheit thermometer the short lines mean
.2 (two tenths)
A glass thermometer is inserted into the rectum
1 inch
How long is the apical-radial pulse counted?
1 minute
Respirations are counted for ____ if they are abnormal or irregular
1 minute
The pulse rate is the number of heartbeats or pulses felt in
1 minute
When vital signs are taken, immediately report to the nurse if (3)
1. any vital sign that is changed from a prior measurement 2. vital signs above the normal range 3. vital signs below the normal range
The apical pulse is taken (3)
1. for a full minute 2 on infants and children up to 2 years of age 3. on persons who have an irregular heartbeat
The blood pressure should not be taken on an arm (3)
1.If the person has had breast surgery on that side 2. with an IV 3. that has dialysis access site
Blood pressure is controlled by (3)
1.the force of heart contractions 2. the amt of blood pumped with each heart beat 3. how easily the blood flows through the blood vessels
How long does the glass thermometer stay in the rectal site?
2 min
How long does the glass thermometer stay in the oral site?
2-3 min
You should deflate the cuff at an even rate of
2-4 per seconds
The blood pressure cuff is inflated ___ beyond the point where you last felt the radial pulse
30 mm Hg
You note the patient has a regular pulse rate and respirations, so you take each one for ___ When you complete counting the pulse, you keep your _____ and count ____. This is done so that Mrs. Sanchez will __________.
30 seconds; fingers in place; respirations; assume you are taking the pulse
The adults pulse rate is between
60 - 100 beats per minute
An apical pulse of 72 is recorded as
72Ap
How would you record these temperatures? An oral temp of 97.4 F (36.5 C)
97.4 36.5 with a little o up top
When recording an axillary temperature of 97.6 F it is written as
97.6 A
How would you record a rectal temperature of 99.8 F 38.1 C
99.8 38.1 with a little R up top
Tachycardia
A rapid heart rate that it over 100 beats per minute
Stethoscope
An instrument used to listen to the sounds produced by the heart, lungs, and other body organs
Which pulse is most commonly use?
Radial
Apical-radial pulse
Taking the apical and radial pulse at the same time
Vital signs
Temperature, pulse, respirations, and blood pressure
Pulse rate
The number of heart beats or pulses felt in one minute
Systole
The period of heart muscle contraction
What should you do if a person asks for their vital signs?
You can tell the person their measurements if the agency allows it
Bradycardia
a slow heart rate that is less than 60 beats per minute
A rectal temperature is taken with
a stubby tip
A glass rectal thermometer has
a stubby tip color coded in red
What site has the lowest baseline temperature?
axilla
BP means
blood pressure
You will find out the size of the blood pressure cuff needed
by asking the nurse
A ____ pulse is taken during cardiopulmonary resuscitation (CPR)
carotid
C means
celcius; centigrade
If the pulse is irregular
count the pulse for one minute
People in nursing centers usually have their vital signs measured
daily or weekly
When using an electronic thermometer, you can prevent the spread of infection by
discarding the probe after each use
If you are preparing to take an oral temperature, ask the person not to
eat, drink, smoke, or chew gum for at least 15 to 20 minutes
Fever
elevated body temperatures
Tympanic membrane and temporal artery thermometers are used for confused persons because they are
fast and more comfortable
An apical radial pulse is taken by
having one staff member take the apical pulse and a second staff member take the radial pulse at the same time
When counting respirations, the best way is to
keep your fingers or stethoscope over the pulse site so the person thinks you are still counting the pulse
When getting ready to take the blood pressure, position the person's arm
level with the heart
An oral temperature can be taken with
long, pear shaped, stubby tip
If you are taking the temperature of an older person, you would expect the temperature to be
lower than the normal range
When you take a rectal temperature, you have to
lubricate the tip of the thermometer or the end of the covered probe before inserting it into the rectum
In what positions is the person placed to take the blood pressure?
lying or sitting down
Sometimes the doctor orders blood pressure in the
standing position
When listening to blood pressure, the first sound you hear is the _____, and the point where the sound disappears is the _____
systolic pressure diastolic pressure
TPR means
temperature, pulse, and respirations
Systolic pressure
the amount of force it takes to pump blood out of the heart into the arterial circulation
Pulse deficit
the difference between the apical pulse and the radial pulse rates
Diastole
the period of heart muscle relaxation
Diastolic pressure
the pressure in the arteries when the heart is at rest
When taking a tympanic membrane temperature on an adult, pull up and back on the ear
to straighten the canal
When taking an oral temperature, place the bulb end of the thermometer
under the tongue and to the side
When taking a temperature on a resident with dementia the best choice would be to
use a tympanic or temporal artery thermometer
List the words to describe hard-to-feel pulse
weak, thread, feeble
You know a patient goes for dialysis 3x a week. What do you need to know before you take his blood pressure and why?
where his dialysis site is and because you cannot take the blood pressure where the dialysis site is
Do not use your thumb to take a pulse because
you may mistake the pulse in your thumb for the person's pulse
Report blood pressures that have these readings:
1. Systolic over 120 mm Hg; systolic below 90 mm Hg 2. Diastolic over 80 mm Hg; diastolic below 60 mm Hg
What observations should you record and report when counting respirations? (6)
1. any respiration noises 2. respiratory rate 3. if respirations are regular/irregular 4. any abnormal respiratory pattern 5. equality/depth of respirations 6. if person has pain/difficulty breathing
Sites for measuring temperature are the (5)
1. oral site (mouth) 2. rectal site (rectum) 3. axillary site (underarm) 4. tympanic membrane (ear) 5. temporal (forehead)
When you take a pulse, what observations should be recorded and reported? (5)
1. the pulse site 2. if it was regular or irregular 3. pulse - strong/weak? 4. pulse deficit for an apical-radial pulse 5. pulse less than 60 or higher than 100 beats per minute
How long does the glass thermometer stay in the axillary site?
5-10 min
Ho would you record an axillary temperature of 96.2 F 36.1 C
96.2 36.1 with a little A at the top
F means
Fahrenheit
Hypertension
When the blood pressure measurements remain above a systolic pressure of 140 mm Hg or a diastolic pressure of 90 mm Hg
Ap means
apical pulse
Which pulse is found with a stethoscope?
apical pulse
When taking an apical pulse, each lub-dub sound is counted
as one beat
The blood pressure may be higher in older people because
blood pressure increases with age