EXAM 2
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