"CNA--- Chapter 33: Vital Signs"
When taking an axillary temperatue, the axilla must be
dry
The apical pulse rate is never less than the
radial pulse rate
If a glass thermometer breaks, ____________ at once because it may contain ___________ which is a ____________________.
report it to the nurse; mercury; hazardous substance
One respiration is counted for each
rise and fall of the chest
When you are taking a blood pressure, the person should be in a ____ or ____position.
sitting;lying
Bradycardia
slow heart rate (less than 60 bpm)
Apical-radical pulse
taking the apical and radical pulses at the same time
vital signs
temperature, pulse, respirations, and blood pressure
Let the person rest for ____________________ before taking the blood pressure.
10 to 20 minutes
A healthy adult has _________ respirations per minute
12 to 20
The adult pulse rate is between
60-100 beats per minute
An apical pulse of 72 is recorded as
72Ap
You counted 40 heartbeats in 30 seconds. What is the person's pulse rate?
80 beats per minute
If you take a rectal temperature , the normal range of the temperature should be
98.6 F to 100.6 F (37.00 C to 38.1 C)
List how long the glass thermometer remains in place for these sites. A. Oral ____________________ or as required by center policy. B. Rectal ___________________ or as required by center policy. C. Axillary ___________________ or as required by center policy.
A. 2 to 3 minutes B. 2 minutes C. 5 to 10 minutes
Write out the abbreviations: a. BP b. C c. F d. Hg e. Id f.IV g. mm h. mm hg j. tpr
A. Blood Pressure B. Centigrade C. Farenhiet D. Mercury E. Identification F. Intravenous G. Millimeter H. Millimeters of Mercury J. Temperature, pulse , and respiration
List words to describe:
A. Forceful pulse -stong,full, bounding B. Hard -to -feel pulse : weak, thready, feeble
What observations should be reported and recorded when counting respirations?
A. Respiratory site B. Equality and depth of respirations C. If respirations are regular or irregular D. If person has experienced pan/difficulty breathing E. Any respiration noises F. Any abnormal respiratory pattern
When you take a pulse, what observations should be reported and recorded?
A. The pulse site B. A pulse rate less than 60 or more than 100 bpm C. Pulse deficit for an apical-radial pulse D. If the pulse is regular or irregular E. Pulse Force
Which site is used to take a pulse during cardiopulmonary resuscitation?
Cartiod
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
The nurse tells you to use the person's pulse was thready on the previous shift. What is the nurse describing about the pulse?
Force
An apical-radial pulse is taken by
Having one staff member take the apical pulse at the same time that another staff member takes the radial pulse
The blood pressure may not be taken in the left arm
If person has a dialysis access site in the left arm
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's
Level with the heart
If you are taking the temperature of an olderperson, youwould expect the temperatures to be
Lower than the normal range
A pedal pulse is found
Over a foot bone
If you are taking vital signs on aperson with dementia , it may be better if
Pulse and respirations are done; temperature and blood pressure are done later
Which site is most commonly used to check the pulse ?
Radial
Which site site has the highest normal range temperature?
Rectum
Diastole
Relaxation of the heart
Vital signs are taken when the person takes drugs that affect the _____ or ______ systems.
Respiratory ; Circulatory
To read a glass Thermometer you should hold it at the
Stem and bring it to the eye level to read it
When listening to the blood pressure, the first sound you hear is the _______ pressure and the point where the sound disappears is the ______ pressure.
Systolic; diastolic
A pulse rate of 120 beats perminute would be considered
Tachycardia
You may count the radial pulse from 30 seconds and multiply by 2 if
The pulse is easy to locate
When taking a temperature for persons who are confused and resist care, the best choice would be to
Use a tympanic or temporal artery therometer
Persons in nursing centers usually have vital signs measured
Weekly
What should you do if a person asks about their vital signs measurements?
You can tell the person themeasurements if center policy allows
stethoscope
a medical instrument for listening to the sounds generated inside the body
Which site has the lowest baseline temperature?
axilla
The blood pressure may be higher in older persons because
blood pressure increases with age
Respiration
breating air into and out of the lungs
You will find out the size of blood pressure cuff needed
by asking the nurse
If pulse is irregular
count for a full minute
pulse deficit
difference between the apical and radial pulse rates
fever
elevated body temperature
Tympanic memebrane and temporal artery therometers are used for confused persons because they are
fast and comfortable
The apical pulse is taken
for a full minute
Systole
heart muscle contraction; the heart is pumping blood
Hypertension
high blood pressure
Body temperature is lower in the
in the morning
sphygmomanometer
instrument to measure blood pressure
Unless otherwise ordered , take vital signs when the person
is lying or sitting
hypotension
low blood pressure
When taking a blood pressure with aneriod manometer, you place the stethoscope diaphragm
over the brachial artery at the inner aspect of the elbow
Sometimes the doctor orders blood pressure in the
standing position
When taking a tmypanic membrane temperature on an adult, pull up and back on the ear to
straigthen the ear canal
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 rate
the number of heartbeats or pulses felt in 1 minute
diastolic pressure
the pressure in the arteries when the heart is at rest
blood pressure
the pressure that is exerted by the blood against the walls of blood vessels
When taking the radial pulse, place
two or three fingers on the thumb side of the wrist
When taking an oral temperature , place the tip of the therometer
under the tongue and to one side
When using a stethoscope, you can help to prevent infection by
wiping the ear pieces and diaphragm with a antiseptic wipe before and after use
febrile
with fever
Afebrile
without fever
When you read a Fahrenheit thermometer, the short lines mean _________________
0.2 (two-tenths) of a degree
When taking an apical pulse, each lub-dub sound if counted as
1 beat
Each respirationinvolves
1 inhalation and 1 exhalation
respirations are counted for _______________ if they are abnormal or irregular.
1 minute
Sites for measuring temperature are the
- Mouth - Rectum - Axilla (underarm) - Ear (tympanic membrane) - Temporal artery (forehead)
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
An electronic ther
1/2 inch
The blood pressure cuff is inflated _______ beyond the point where you last felt the radial pulse
30 mm Hg
When vital signs are taken, report to the nurse at once if
A. Any vital signs has changed fromprior measurement B. Vital Signs are above or below normal range
When using an electronic thermometer, what does the color of the probe mean?
A. Blue used for oral or Auxillary temperature B. Red used for rectal temperature
Blood pessure is controlled by
A. the force of heart contractions B. Amount of blood pumped w/each heartbeat C. How easily blood flowa through the vessels
pulse
Beat of the heart as felt through the walls of the arteries.
systolic pressure
Blood pressure in the arteries during contraction of the ventricles.
Tachycardia
Fast heart rate (HR greater than 100bpm)
Do not use your thmb to take a pulse because
It has a pulse
When you take a rectal temperature, you ___________________ the tip of the thermometer or the end of the covered probe before inserting it into the rectum
Lubricate
themometer
an instrument that measures temperature