Foundations of Nursing - Skill Set
The nurse will take the patient's vital signs preoperatively and record them as part of the patient's preparation for surgery. Why is it necessary to take vital signs preoperatively? (Select all that apply.) A. To determine whether the patient is "feeling funny" or "different". B. To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention. C. To provide the patient with reassurance that he or she is being cared for by a competent staff. D. To ensure the equiptment is appropriatly calibrated and function. E. To provide a set of vital signs to use for comparison during and after surgery.
B,E B. To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention. E. To provide a set of vital signs to use for comparison during and after surgery. Rational: The patient who is going to surgery is going to experience a change in condition and an invasive procedure. Vital signs are necessary so that the operative team has a baseline for comparison as well as to rule out any complications before the beginning of the surgical event. Providing reassurance to the patient can be done verbally. If a patient reports feeling different, assessing vital signs is appropriate. There is no indication the patient is feeling different. Equipment should be maintained in a functional state at all times.
Normal respiratory rate for an adult
12-20 breaths per minute
Normal Pulse Range for Infant (6 months)
120-160
optimal blood pressure for adults
120/80
Normal respiratory rate for infant (6 months)
30-50
Normal Pulse Range for an adult
60-100
Optimal blood pressure for 1 year old
86/40
Normal temperature range
96.8-100.4 F (36-38 C)
Which of the following situations may affect a patient's vital signs? (Select all that apply.) A. Pain rated as a 7 on 0-10 pain scale. B. Time of day. C. Isolation precautions. D. Moving from lying to standing position. E. Occupation.
A,B,D A. Pain rated as a 7 on 0-10 pain scale. B. Time of day. D. Moving from lying to standing position. Rational: Factors that may alter vital signs include time of day, stress (emotional and physical), temperature alterations/weather conditions, exercise/activity, emotions, medication, postural changes, acute pain, smoking, disease/injury status, noise, food/liquid consumption, and odors. The person's occupation and isolation precautions do not alter vital signs. If a person's job requires an activity that increases exertion or stress, the activity affects vital signs, not the occupation.
The nurse has delegated the task of temperature assessment to the NAP. Which information should be provided to the NAP? (Select all that apply.) A. What changes to report immediately to the nurse. B. The type of temperature required. C. The patient's age. D. 4 The frequency for taking or monitoring the temperature. E. The patient's diagnosis.
A,B,D A. What changes to report immediately to the nurse. B. The type of temperature required. C. The frequency for taking or monitoring the temperature. Rational: It is more important that the temperature be done on time by the correct route, with the correct equipment, and that identified changes be reported as requested.
Which patient would it be appropriate for the nurse to delegate vital signs? A. Elderly nursing home resident. B. Patient with recent complaint of headache. C. New admission to the hospital. D. Patient transferred from ICU.
A. Elderly nursing home resident. Rational: The nurse may delegate routine vital signs of stable patients. Obtaining a baseline upon admission or transfer patient should be completed by the nurse. If a patient has a change in condition, such as a headache which could be reflective of hypertension, the nurse should assess the patient's vital signs.
Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? A. Temp 98.0 °F (36.7 °C), P-76, R-22, BP 110/70, O2, sat 88%. B. Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%. C. Temp 98.6 °F (37 °C), P-56, R-20, BP 120/80, O2 sat 91%. D. Temp 96.8° F (36 °C). P-60, R-18. BP 160/90. O, sat 93%.
B. Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%. Rational: Normal values for an older adult are: average body temperature approximately 36° C (96.8° F), heart rate 60 to 100 beats per minute, respiratory rate 16 to 25 breaths per minute, average BP less than 120 over 80, and pulse oximetry 95% to 100%. A BP greater than 140 over 90 may be an indication of hypertension.
Which of the following patients would require follow-up? A. A child with a respiratory rate of 20 breaths per minute. B. newborn with a respiratory rate of 40 breaths per minute. C. An adult with respiratory rate of 10 breaths per minute. D. An adolescent with a respiratory rate of 16 breaths per minute.
C. An adult with a respiratory rate of 10 breaths per minute. Rational: The normal respiratory rate for a newborn is 30 to 60 breaths per minute. The normal respiratory rate of a child is 20 breaths per minute. The normal respiratory rate for a teenager is 16 to 20 breaths per minute. The normal respiratory rate for an adult is 12 to 20 breaths per minute. A rate of 10 would require follow-up.
The NAP reports to the nurse a 65-year-old patient s blood pressure is 160/98. What is the appropriate initial response of the nurse? A. Document this as a normal finding in an elderly adult. B. Ask the NAP if the patient is nauseous. C. Instruct the NAP to obtain a full set of vital signs. D. Assess the patient, s blood pressure.
D. Assess the patient, s blood pressure. Rational: This is out of normal range. If there is a question regarding a patient's vital signs or a suspected change in the patient's condition that may require further assessment, the nurse should take the patient's vital signs rather than delegating the task.
Normal SpO2 level
Greater than or equal to 95
