Chapter 29: Measuring Vital Signs
Let the person rest for ____________________ before taking the blood pressure.
10 to 20 minutes
A healthy adult has ___________________ respirations per minutes.
12 to 20
If you take a rectal temperature, the normal range of the temperature would be
98.6F to 100.6F (37.0C to 38.1 C)
Report blood pressure that have these readings. A. Systolic over ________________ Systolic below _____________ B. Diastolic over __________ Diastolic below __________
A. 120 mm Hg; 90 mm Hg B. 80 mm Hg; 60 mm Hg
BP
Blood pressure
_________________ is a slow heart rate; the rate is less than 60 beats per minute
Bradycardia
C
Centigrade
The period of heart muscle relaxation is
Diastole
________________ is the pressure in the arteries when the heart is at rest.
Diastolic pressure
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. 1
When the systolic blood pressure is below 90mm Hg and the diastolic pressure is below 60mm Hg it is called
Hypotension
ID
Identification
mm
Millimeters
mm Hg
Millimeters of 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 nurse may mark the skin with an X where the ____________________ is found.
Pedal pulse
Which pulse is most commonly used?
Radial
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. Sometimes the doctor orders blood pressure in the ___________________ position.
- Sitting - lying - standing
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
Blood pressure is controlled by
- The force of heart contractions - The amount of blood pumped with each heartbeat - How easily the blood flows through the vessels
When you read a Fahrenheit thermometer, the short lines mean _________________
0.2 (two-tenths) of a degree
Each respiration involves
1 Inhalation and 1 exhalation
The pulse rate is the number of heartbeats or pulses felt in
1 Minute
When taking an apical pulse, each lub-dub sound is counted as
1 beat
If a pulse is irregular, count the oulse for
1 minute
Respirations are counted for ____________________ if they are abnormal or irregular.
1 minute
An electronic thermometer is inserted into the rectum
1/2 inch
The blood pressure cuff is inflated _________________ beyond the point where you last felt the radial pulse.
30mm Hg
The adult pulse rate is between ___________________________ beats per minute.
60 and 100
The apical pulse of 72 is recorded as
72Ap
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
You are responsible for A. Knowing B. Reporting
A. Normal vital sign ranges B. Abnormal measurements
List words used to describe: A. Forceful pulse B. Hard to feel pulse
A. Strong, full, bounding B. Weak, thready, feeble
You will find out the size of blood pressure cuff needed
By asking the nurse
A ___________________ pulse is taken during cardiopulmonary resuscitation.
Carotid
DUS
Doppler ultrasound stethoscope
When taking an axillary temperature, the axilla must be
Dry
If you are preparing to take an oral temperature, ask the person not to
Eat, drink, smoke, or chew gum for a least 15 to 20 mins.
_____________ Means with a fever.
Febrile
Elevated body temperature is
Fever
The apical pulse is taken
For a full minute
You need to feel the pulse to determine the
Force
___________________ is when the blood pressure measurements remain above a systolic pressure of 140mm Hg or a diastolic pressure of 90mm Hg.
Hypertension
Unless otherwise ordered, take vital signs when the person
Is lying or sitting
When getting ready to take the blood pressure, position the person's arm
Level with the heart
If you cannot feel a pulse or hear a blood pressure, you should never ____________________
Make up a measurement
You allow the person to have ________________ when you use the are for blood pressure or pulse that the person prefers
Personal choice and feel independent
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
The ______________ is the number of heartbeats or pulses felt in 1 min.
Pulse rate
The apical pulse rate is never less than the
Radial pulse rate
Which site has the highest normal range temperature?
Rectum
The cuff and measuring device used to measure blood pressure is a
Sphygmomanometer
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 heart, lungs, and other body organs is a
Stethoscope
When taking a tympanic membrane temperature on an adult, pull up and back on the ear to
Straighten the ear canal
_____________ 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
Systolic pressure
A rapid heart rate is ____________________. The heart rate is over 100 beats per minute.
Tachycardia
TPR
Temperature, pulse, respirations
You may count the radial pulse from 30 seconds and multiply by 2 if
The pulse is irregular
Vital signs are taken when the person takes drugs that affect
The respiratory or circulatory system
A ______________________ is a device used to measure temperature.
Thermometer
When taking the radial pulse, place
Two or three fingers on the thumb side of the wrist over the radial artery.
When taking an oral temperature, place the bulb end of the thermometer
Under the tongue and to one side
When taking a temperature for persons who are confused and resist care, the best choice would be
Use a tympanic or temporal artery thermometer
Temperature, pulse, respirations, and blood pressure are
Vital signs
Persons in nursing centers usually have vital signs measured
Weekly
When using a stethoscope, you can help to prevent infection by
Wiping the ear-pieces and diaphragm with antiseptic wipes before and after use.
What should you do if a person asks for their vital sign measurements?
You can tell the person the measurements if center policy allows.
If you are taking vital signs on a person with dementia, it may be better if
You take the pulse and respiration at one time, and the temperature and blood pressure at another time.
Sites for measuring temperature are the
- Mouth - Rectum - Axilla (underarm) - Ear (tympanic membrane) - Temporal artery (forehead)
Without a fever is
Afebrile
When vital signs are taken, report to the nurse at once if
- Any vital sign has changed from a prior measurement - Vital signs are above or below the normal range
Measurements of the vital signs is important because they help the nurse ________________ and __________________ the person's care.
- Plan for - evaluate
If a glass thermometer breaks, ____________ at once because it may contain ___________ which is a ____________________.
- Report it to the nurse; - mercury; - hazardous substance
What observations should be reported and recorded when counting respirations?
- Respiratory rate - Equality and depth of respirations - If the respirations were regular or irregular - If the person experienced pain or difficulty in breathing - Any respiratory noises - Any abnormal respiratory pattern
When you take a pulse, what observations should be reported and recorded?
- The pulse site - Pulse rate less than 60 or more than 100 beats per minute (report at once) - Pulse deficit for an apical-radial pulse - If the pulse is regular or irregular - Pulse force—strong, full, bounding, weak, thready, or feeble
A glass rectal thermometer has
A stubby tip color-coded in red.
When using an electronic thermometer, what does the color of the probe mean? A. Blue B. Red
A. Used for oral or axillary temperature B. Used for rectal temperature
The ________________________ is taking the apical and radial pulse at the same time.
Apical-radical pulse
Which site has the lowest baseline temperature?
Axilla
The blood pressure may be higher in older persons because
Blood pressure increases with age
_____________ is the amount of force exerted against the walls of an artery by the blood.
Blood pressure.
The amount of heat in the body that is balance between the amount of heat produced and amount lost by the body is the
Body temperature
F
Fahrenheit
Tympanic membrane and temporal artery thermometers are used for confused persons because they are
Fast and comfortable
IV
Intravenous
Do not use your thumb to take a pulse because
It has a pulse
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 ___________________ the tip of the thermometer or the end of the covered probe before inserting it into the rectum
Lubricate
HG
Mercury
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
