CNA Chapter 29 Memorial

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When taking an axillary temperature, the axilla must be

dry

millimeters

mm

millimeter of Mercury

mm Hg

The apical pulse rate is never less than the

radial pulse rate

List words to describe a forceful pulse

strong, full, or bounding

An electronic thermometer is inserted into the rectum

1/2 inch

Which blood pressure is normal for an adult?

112/78 mm Hg

A healthy adult has how many respirations per minute?

12 - 20

In an adult, normal respirations are

12 to 20 per minute

How long does a glass thermometer remain in place rectally?

2 minutes

How long does a glass thermometer remain in place orally?

2-3 minutes

Respirations are counted for

30 seconds or 1 minute if they are irregular

How long does a glass thermometer remain in place axillary

5-10 minutes

The adult pulse rate is between

60 and 100

An apical pulse of 72 is recorded as

72Ap

If you take a rectal temperature, the normal range of the temperature would be

98.6°F to 100.6°F

Sphygmomanometer

A cuff and measuring device used to measure blood pressure.

Thermometer

A device used to measure temperature.

Tachycardia

A rapid heart rate more than 100 beats per minute

Which should report at once?

A rectal temperature of 101.6° F

For an adult, which pulse do you report at once?

An irregular pulse at 124 beats per minute

Which pulse is found with a stethoscope?

Apical

When measuring BP

Apply the cuff to the bare upper arm

BP

Blood Pressure

Which pulse is used when placing the stethoscope to take the blood pressure?

Brachial

This is a slow heart rate; the rate is less than 60 beats per minute

Bradycardia

Respiration

Breathing air into and out of the lungs.

C

Centigrade

Doppler Ultrasound Stethescope

DUS

The period of heart muscle relaxation is

Diastole

This is the pressure in the arteries when the heart is at rest

Diastolic pressure

When listening to the blood pressure, the point where the sound disappears is the

Diastolic pressure

When taking a BP, the sound disappears at the 1st short line above 70. You record the

Diastolic pressure as 72

DUS

Doppler Ultrasound Stethescope

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 temperature

Elevated body temperature is

Fever

The apical pulse is taken

For a full minute

You need to feel the pulse to determine the

Force

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.

This is when the blood pressure measurements remain above a systolic pressure of 140 mm Hg or a diastolic pressure of 90 mm Hg.

Hypertension

When the systolic blood pressure is below 90 mm Hg and the diastolic pressure is below 60 mm Hg it is called

Hypotension

Identification

ID

Intravenous

IV

A rectal temperature is taken when the person

Is unconscious

When getting ready to take the blood pressure, position the person's arm

Level with the heart

Hg

Mercury

Body temperature is lower in the

Morning

The blood pressure may not be taken

On an arm that has a dialysis access site

A pedal pulse is found

Over a foot bone

When taking the blood pressure, you place the stethoscope diaphragm

Over the brachial artery at the inner aspect of the elbow.

The beat of the heart felt at an artery as a wave of blood passes through the artery is the

Pulse

The difference between the apical and radial pulse rates is the

Pulse deficit

This is the number of heartbeats or pulses felt in 1 minute

Pulse rate

Which pulse is most commonly taken?

Radial

Which pulse is most commonly used?

Radial

When you are taking a blood pressure, the person should be

Sitting or lying

The cuff and measuring device used to measure blood pressure is a

Sphygmomanometer

Sometimes the doctor orders blood pressure in what position?

Standing

To read a glass thermometer you should hold it at the

Stem and bring it to eye level to read it

An instrument used to listen to the sounds produced by the hear, lungs, and other body organs is a

Stethescope

This is the period of heart muscle contraction

Systole

The amount of force it takes to pump blood out of the heart into the arterial circulation is the

Systolic pressure

Temperature, Pulse, Respirations

TPR

This a rapid heart rate that is over 100 beats per minute

Tachycardia

Apical-radial pulse

Taking the apical and radial pulses at the same time.

TPR

Temperature, pulse, and respirations

Vital signs

Temperature, pulse, respirations, and blood pressure; and pain in some agencies.

Body temperature

The amount of heat in the body that is a balance between the amount of heat produced and the amount lost by the body.

Pulse

The beat of the heart felt at an artery as a wave of blood passes through the artery.

Pulse deficit

The difference between the apical and radial pulse rates.

Pulse rate

The number of heartbeats or pulses in one minute.

Systole

The period of heart muscle contraction; the heart is pumping blood.

Systolic pressure

The pressure in the arteries when the heart contracts.

Which is usually used to take an adult's pulse?

The radial pulse

This is a device used to measure temperature

Thermometer

When taking an oral temperature, place the bulb end of the thermometer

Under the tongue and to one side

Temperature, pulse, respirations, and blood pressure are

Vital signs

Persons in nursing centers usually have vital signs measured

Weekly

Hypertension

When the systolic pressure is 140 mm Hg or higher or the diastolic pressure is 90 mm Hg or higher.

Hypotension

When the systolic pressure is below 90 mm Hg or the diastolic pressure is below 60 mm Hg.

The systolic blood pressure is the point

Where the first sound is heard

When using a stethoscopem you can help to prevent infection by

Wiping the ear-pieces and diaphragm with antiseptic wipes before and after use.

If you are taking vital signs on a person with dementia, it may be better if

You take the pulse and respirations at one time, and the temperature and blood pressure at another time

The nurse may mark the skin with an X where the

dorsalis pedis pulse is found

mm

millimeter

mm Hg

millimeter of mercury

One respiration is counted for each

rise and fall of the chest

When you read a Fahrenheit thermometer, the short lines mean

0.2 or 2 tenths

When taking apical pulse, each lub-dub sound is counted as

1 beat

Each respiration involves

1 inhalation and 1 exhalation

If the pulse is irregular, count the pulse for

1 minute

The pulse rate is the number of heartbeats or pulses felt in

1 minute

When vital signs are taken, report to the nurse at once if

1. Any vital sign that is changed from a prior measurement. 2. An abnormal vital sign.

Respirations are usually counted

After taking the pulse

Mercury

Hg

When it comes to vital signs, you are responsible for

1. Knowing vital sign ranges 2. Reporting abnormal ranges

Sites for measuring temperature are the

1. Oral 2. Rectal 3. Axillary 4. Tympanic 5. Temporal

When you take a pulse what observations should be reported and recorded?

1. Pulse site 2. Pulse rate 3. Pulse deficit 4. If regular or irregular 5. Pulse force

What observations should be reported and recorded when counting respirations?

1. Respiratory rate 2. Equality and depth of respirations 3. pain or difficulty breathing 4. respiratory noises 5. abnormal respiratory pattern 6. regular or irregular respirations

Report blood pressures that are

1. Systolic over 120 mm Hg or under 90 mm Hg 2. Diastolic over 80 mm Hg or under 60 mm Hg

Name the eight pulse sites

1. Temporal 2. Carotid 3. Apical 4. Brachial 5. Radial 6. Femoral 7. Popliteal 8. Dorsalis Pedis

Blood pressure is controlled by

1. The force of heart contractions 2. The amount of blood pumped with each heartbeat 3. How easily the blood flows through the blood vessels

The blood pressure cuff is inflated how much beyond the point where you last felt the radial pulse?

30 mm Hg

Bradycardia

A slow heart rate; less than 60 beats per minute

A glass rectal thermometer has

A stubby tip color-coded in red

Without a fever is

Afebrile

Stethescope

An instrument used to listen to the sounds produced by the heart, lungs, and other body organs.

This is taking the apical and radial pulse at the same time.

Apical-radial pulse

Which site has the lowest baseline temperature

Axillary

Blood Pressure

BP

This is the amount of force exerted against the walls of an artery by the blood

Blood pressure

The blood pressure may be higher in older persons because

Blood pressure increases with age

When using an electronic thermometer, what does the color of the probe mean?

Blue - oral and axillary thermometers Red - rectal thermometers

The amount of heat in the body that is a balance between the amount of heat produced and amount lost by the body is the

Body temperature

Centigrade

C

Fahrenhite

F

F

Fahrenheit

Tympanic membrane and temporal artery thermometers are used for confused persons because they are

Fast and comfortable

This means with a fever

Febrile

You count a regular pulse for 30 seconds. Which is true?

If you count 44 beats, you record a pulse rate of 88

You allow the person to have this when you use the arm for blood pressure or pulse that the person prefers.

Independence

IV

Intravenous

Unless otherwise ordered, take vital signs when the person

Is lying or sitting

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.

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 do this to the tip of the thermometer or the end of the covered probe before inserting it into the rectum

Lubricate

When a pulse rate is 120 beats per minute, you

Report that the person has tachycardia

Breathing air into and out of the lungs is

Respiration

Which statement about the apical-radial pulse is true?

The apical pulse can be greater than the radial pulse.

Diastole

The period of heart muscle relaxation; the heart is at rest.

Let the person rest for how long before taking the blood pressure

10 - 20 minutes

You will find out the size of blood pressure cuff needed

By asking the nurse

This pulse is taken during cardiopulmonary resuscitation (CPR).

Carotid

Which pulse is used during CPR?

Carotid

When using an electronic thermometer

Cover the probe with a probe cover

ID

Identification

If you cannot feel a pulse or hear a blood pressure, you should never

Make up a measurement

You are not sure you heard an accurate BP measurement. You should

Measure the BP again after 60 seconds

Measurements of the vital signs is important because they help the nurse

Plan for and evaluate the person's care.

Which site has the highest normal range for temperature?

Rectal

Which site is used to take an infant's temperature?

Rectal site

When listening to the blood pressure, the first sound you hear is the

Systolic pressure

If a glass thermometer breaks you should

Tell the nurse because it may contain mercury which is a hazardous chemical.

Blood pressure

The amount of force exerted against the walls of an artery by the blood.

Diastolic pressure

The pressure in the arteries when the heart is at rest.

You may count the radial pulse for 30 seconds and multiply by 2 if

The pulse is regular

When taking the radial pulse, place

Two or three fingers on the thumb side of the wrist over the radial artery

When taking a temperature for persons who are confused and resist care, the best choice would be to

Use a tympanic or temporal artery thermometer

Febrile

With a fever.

Afebrile

Without a fever

What should you do if a person asks for the vital sign measurements?

You can tell the person the measurements if center policy allows

When taking a tympanic membrane temperature on an adult, pull up and back on the ear to

straighten the ear canal

Vital signs are taken when the person takes drugs that affect

the respiratory or circulatory systems

Do not use your thumb to take a pulse because

the thumb has a pulse and you could mistake the pulse in your thumb for the person's pulse.

List words to describe a hard-to-feel pulse

weak, thready, or feeble


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