EXAM 2

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what nursing interventions promote safe oxygen therapy?

- checking tubing for kinks - post no smoking signs outside the clients room - refrain from the use of oil/petroleum based products (vaseline = HIGHLY FLAMMABLE)

what signs and symptoms present with a decrease in temperature of the body?

- shivering - chills - paleness/blue-ish look - Contraction of blood vessels

Normal pulse oximetry reading

95-100%

Normal temperature range

96.8-100.4 F (36-38 C)

Patterns of fever

1. sustained 2. intermittent (spikes but returns to normal) 3. remittent (spikes and falls but no return to normal) 4. relapsing

Normal female hemoglobin levels

12-16 g/dL

Normal respiration rate range

12-20 breaths per minute

normal blood pressure range

120/80 (no lower than 90 for systolic, and 60 for diastolic)

normal male hemoglobin levels

14-18 g/dL

normal female hematocrit levels

37-47%

normal male hematocrit levels

42%-52%

normal heart rate range

60-100 bpm

lateral

Away from the midline of the body

intermittent fever

Fluctuating fever that returns to or below baseline then rises again. fever returns to acceptable value at least 1x within 24hr period

remittent fever

Fluctuating, remains elevated and does not return to baseline

tachypnea

Increased breathing rate

Normal Hemoglobin levels

Male: 13-18 g/100mL Female: 12-16 g/100mL

normal hematocrit levels

Male: 45%-52% Female: 37-48%

Abduction

Movement away from the midline of the body

adduction

Movement toward the midline of the body

Hypertension levels

Normal BP = 120/80 Pre-hypertension = SBP 120 - 139 DBP = 80-89 Stage 1 hypertension SBP= 140-159 DBP= 90-99 Stage 2 hypertension SBP= >160 DBP= >100

radial pulse

Pulse felt at the wrist (thumb side)

Relapsing fever

Short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature, often no longer than 24hrs

pre-hypertension

Systolic: 120-139 Diastolic: 80-89

hypertension stage 1

Systolic: 140-159 Diastolic: 90-99

hypertension stage 2

Systolic: 160+ Diastolic: 100+

Medial

Toward the midline of the body

bradypnea

an abnormally slow rate of respiration usually of less than 10 breaths per minute

which action would the nurse take to prevent postoperative respiratory complications after abdominal surgery

assisting and education on the use of incentive spirometry

popliteal pulse

behind the knee

pulse oximetry that is considered clinically significant (NO HISTORY OF COPD)

below 95%

two pulse sites used in emergency situations

carotid, femoral

to assess circulation in the foot, which pulse sites would the nurse check?

dorsalis pedis (top of foot) posterior tibial pedis (bottom of foot)

fever

elevated body temperature

sustained fever

fever that is constant or not fluctuating

febrile

feverish

hypertension

high blood pressure

the nurse is transferring a patient to the chair, which action would the nurse first take during the transfer. (breaks are already on)

instruct the patient to dangle their legs at the edge of the bed

axillary pulse

located inferiorly of the lateral wall of the axilla

eupnea

normal breathing

eucardia

normal heart rate

hemiplegia

paralysis of one side of the body

Which measurement is a pulse oximeter used for?

percentage of oxygen-carrying hemoglobin

ulnar pulse

pulse felt at pinky side of wrist (usually faint)

femoral pulse

pulse felt in the groin

two most common pulse sites (NO LIFE SAVING MEASURES)

radial, apical

pyrexia

raised body temperature; fever.

tachycardia

rapid heart rate

hemiparesis

slight paralysis or weakness affecting one side of the body

bradycardia

slow heart rate (less than 60 bpm)

which clinical manifestations associated w/ pyrexia (Increased temperature) would the nurse monitor, 3 days after surgery

tachypnea (Increased respirations) tachycardia (Increased pulse)

brachial pulse

the pulse felt in the upper arm inside the elbow


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