Fundamentals : Carin and Vital Signs Quiz

At what age in years does the respiratory system begin to decline in healthy people?

25 The respiratory system begins to decline in healthy people after the age of 25. The respiratory system matures by the time a person reaches 20 years of age. Despite the decline in adults at 45 and 60 years of age, they can breathe effortlessly as long as they are healthy.

Which tympanic body temperature is normal for adults?

37°C (98.6°F) The average tympanic temperature for adults is 37°C (98.6°F). A body temperature of 96.8°F is within the normal range for adults. The average axillary temperature for adults is 36.5°C (97.7°F). The average rectal temperature for adults is 37.5°C (99.5°F).

Which vital sign can be altered because of a decrease in sweat gland reactivity in older adults?

Body temperature Body temperature may be varied when there is a decrease in sweat gland reactivity in older adults. Decreased vessel elasticity will alter the systolic blood pressure. Pulse rate, blood pressure, and respiratory rate are not altered by decreased sweat gland reactivity.

For which reason would the nurse check for cerumen in a patient's ear canal before measuring tympanic membrane temperature?

Cerumen impaction distorts temperature readings. Earwax on the lens cover blocks a clear optical pathway and distorts readings. Heat trapped in the ear facing down, not earwax, causes false high temperature readings. Returning the thermometer stem to the charger automatically causes the digital reading to disappear. Ear tug straightens the external auditory canal and allows maximum exposure of the tympanic membrane to correctly position the speculum. (p.506)

While assessing the apical pulse in a patient, the nurse places the diaphragm of the stethoscope in her palm for 10 seconds. Which rationale would direct this action?

Ensures the diaphragm is warm Placing the diaphragm in the palm for 10 seconds ensures warming of the diaphragm and prevents the patient from becoming startled. It also brings comfort to the patient. It does not reduce anxiety or prevent the transmission of germs. Explaining the procedure to the patient prevents anxiety. Cleaning the diaphragm with a disinfectant prevents the transmission of germs. It also does not increase the sensitivity of the stethoscope. (p.531-535)

The nurse is measuring the rectal temperature of an adult patient. The nurse inserts the thermometer probe into the anus of the patient up to 3 cm in the direction of the umbilicus. Which rationale would direct this nursing intervention?

Ensuring exposure to blood vessels Gentle insertion of the thermometer probe in to the anus up to 3 cm in the direction of the umbilicus ensures adequate exposure of the probe to the blood vessels in the rectal mucosa. To relax the anal sphincter, the patient is asked to breathe slowly. To minimize trauma to the rectal mucosa, a lubricant is used. To prevent dislodgement of the probe, the thermometer is held in place by the nurse. (p.521-)

The nurse locates different anatomical landmarks to identify the point of the apical impulse. Which rationale would direct this nursing action?

Hear heart sounds clearly Using anatomical landmarks allows correct placement of stethoscope over the apex of the heart, which enhances the ability to hear heart sounds clearly. The apical rate can be determined accurately only when the nurse auscultates sounds clearly. The nurse can evalute the change in contractions by comparing readings and previous baseline or acceptable range of heart rate. The nurse helps the patient to a supine or sitting position to expose the portion of the chest wall for selection of an auscultatory site. (p.531-535)

The nurse has difficulty hearing the heart sounds of a patient who is 80 years old. Which factor explains the muffled heart sounds?

Increased air space in the lungs Heart sounds may be muffled or difficult to hear in older adults because of an increase in air space in the lungs. An increase in heart rate would show differences in pulse relate, not differences in heart sounds. Older adults may experience an increase in systolic pressure because of decreased vessel elasticity. Ossification of costal cartilage for older adults results in reduced chest wall expansion. (p.524)

Which range is acceptable for the diastolic blood pressure in a healthy adult?

Less than 80mm Hg The acceptable range for diastolic blood pressure in a healthy adult is less than 80 mm Hg. Less than 120 mm Hg is the acceptable range for systolic blood pressure in a healthy adult. The normal range for pulse pressure in a healthy adult is 30 to 50 mm Hg. The normal range for capnography in a healthy adult is 35 to 45 mm Hg. (p.500)

How would the nurse determine the ventilatory rhythm in a patient?

Observing the pattern of breathing The ventilatory rhythm is a patient can be determined by observing the pattern of breathing. Diaphragmatic breathing results from the contraction and relaxation of the diaphragm. Ventilatory depth can be determined by assessing the depth of respirations by observing the degree of excursion or movement in the chest wall. The respiratory rate can be determined by observing a full expiration and inspiration when counting ventilation or respiration rate. (p.535-538)

After measuring the temperature of the temporal artery, the nurse cleans the sensor with the alcohol swab. Which rationale would direct the nurse's action?

Preventing transmission of microorganisms Cleaning the sensor with an alcohol swab after taking a patient's temperature prevents transmission of microorganisms. Proper positioning of the thermometer sensors ensures accurate reading of the temperature. Returning the handled unit to the charging base protects the sensor tip from damage. Returning the thermometer to the charger or base maintains the battery charge of the thermometer unit. (p.525-531)

While assessing the oral temperature of a patient using an electronic thermometer, for which reason would the nurse ask the patient to close the lips?

To maintain proper position of the probe Closing the lips after placing the thermometer into the mouth helps maintain the proper position of the thermometer. Accurate measurement depends on correct positioning of the thermometer under the tongue in the sublingual pockets. Instructing the patient to close the lips is not to provide comfort, nor does it reduce the transmission of organisms. (p.525-531)

Before assessing the rectal temperature of a patient, the nurse slides a plastic diaposable probe cover over the thermometer probe stem. Which rationale would direct this intervention?

Preventing transmission of microorganisms between patients Sliding a disposable plastic probe cover over the thermometer probe stem will prevent the transmission of micoorganisms between patients. Squeezing a liberal portion of lubricant on the tissue helps lubricate the rectal mucosa and minimizes trauma. Application of clean gloves between cleaning the anal region and measuring rectal temperature is important to maintain standard precautions. Inserting the thermometer probe gently into the anus 2.5 to 3.5 cm in the direction of the umbilicus helps ensure adequate exposure against blood vessels in the rectal wall. (p.525-531)

The nurse is assessing the rectal temperature of a patient with an electronic thermometer. Which patient position would promote comfort?

Side-lying position While measuring rectal temperature with an electronic thermometer, patients are positioned in Sims' position with the upper leg flexed to promote comfort. The sitting and supine positions are recommended for measuring blood pressure in patients with orthostatic hypertension, not for assessing rectal temperature. A patient with oxygen saturation (SpO2) less than 90% should be placed in a high-Fowler's position to improve ventilation.

Which body temperature would indicate a fever in the older-adult patient?

Single oral temperature of 38°C (100.4°F) A single oral temperature of more than 38°C (100.4°F) indicates fever in older adults. Therefore, the single oral temperature of 38°C (100.4°F) indicates fever. Rectal temperatures of more than 37.5°C (99.5°F) indicate fever in older adults. Rectal temperatures of 36°C (96.8°F) and 36.7°C (98°F) do not indicate fever in the patient. Repeated oral temperatures of more than 37.2°C (99°F) indicate fever. Therefore, a temperature of 97°F does not indicate fever. (p.524)

While assessing the axillary temperature, for which reason would the nurse raise the patient's arm away for the torso?

To inspect for the presence of lesions While measuring a patient's axillary temperature, the nurse should inspect the skin for lesions and excessive perspiration because lesions may alter the local skin temperature. The thermometer probe should be held in place until the audible signal is heard to ensure accurate readings. The arm is not raised to provide comfort to the patient while measuring the axillary temperature. Raising the arm away from the torso would not prevent the transmission of micoorganisms. (p.525-531)

When assessing the patient's respiration, for which reason would the nurse elevate the bed to 60 degrees in a sitting position?

To promote ventilatory movement Sitting erect promotes full ventilatory movement and ensures a clear view of the chest wall and abdominal movements. The character of ventilatory movement reveals specific disease states that restrict air from moving into and out of the lungs. The nurse observes the complete respiratory cycle to determine respiratory rate. The nurse should observe for any increased effort of the patient to inhale and exhale because patients with lung disease may experience difficulty breathing all the time and can best describe their discomfort related to shortness of breath. (p. 535-538)