CNA Chapter 29 Memorial
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
