NURS 202 Fundamentals of nursing
practice first test
What are the vital signs? - answer temperature, pulse, respiration, blood pressure, and
sometimes pain (annotated as T-P-R-BP)
Normal pulse rate for healthy adults - answer60-100 bpm (80 average)
normal respirations for healthy adults - answer12-20 breaths/minute
normal blood pressure for healthy adults - answerless than 120/80
Guidelines for measuring vital signs - answer- Establish a baseline for future
assessments.
- Be able to understand and interpret values.
- Appropriately delegate measurement.
- Communicate findings.
- Ensure equipment is in working order.
- Accurately document findings.
When to access vital signs - answer- On admission to any health care facility or
institution
- Based on agency or institutional policy and procedures
- Any time there is a change in the patient's condition
- Any time there is a loss of consciousness
- Before and after any surgical or invasive diagnostic procedure
- Before and after activity that may increase risk, such as ambulation after surgery
- Before administering medications that affect cardiovascular and respiratory function
What is body temperature? - answerheat produced, heat lost
,Normal temperature range for adults - answer96.4 F - 99.5 F or 35.8 C - 37.5 C
Temperature sites - answerOral, rectal, axillary, tympanic membrane, temporal artery
factors affecting temperature - answer-circadian rhythm
-age and gender
-physical activity
-state of health
-environment
what is pyrexia? - answerfever
What is febrile? - answerwith fever
What is afebrile? - answerwithout fever
What is a fever? - answerupward displacement of thermoregulatory set point/ elevated
body temperature that signals infection and increases immune function
Normal oral temperature for healthy adults - answer98.6 F or 37 C
Normal rectal temperature for healthy adults - answer37.5°C, 99.5°F
Normal axillary temperature for healthy adults - answer36.5°C, 97.7°F
Normal forehead temperature for healthy adults - answer34.4°C, 94.0°F
Normal Tympanic Temperature for healthy adults - answer37.5ºC, 99.5°F
what is tympanic temperature? - answerTemperature taken in the ear
what is a neurogenic fever? - answernon-infectious source of fever in head injury patient
that can cause brain damage, too much pressure on hypothalamus in the brain stem
What is an FUO? - answerA fever of 101 F that lasts for 3 weeks or longer with an
identified cause.
Hypothermia - answerabnormally low body temperature
Hyperthermia - answerAbnormally high body temperature (not a fever)
Temperature assessment equipment - answer- Mercury Glass Thermometers
,- Electronic & Digital Thermometers
(Oral, Rectal, Axillary)
- Tympanic Membrane Thermometers
- Single Use (Chemical dot/tape) Thermometers
- Temporal Artery Thermometers
- Automated Monitoring Devices
Oral temp thermometer placement - answerposterior sublingual
rectal temp thermometer placement - answerSims position and insert 2.5-3.5 cm
axillary temp thermometer placement - answerin central axilla with adducted humerus
tympanic temp thermometer placement - answerAdult pinna up and out
*If under 3 years old it is pinna down and back
pinna - answerthe visible part of the ear
factors affecting temperature assessment - answer- Smoking
- Eating/Drinking
- Chewing gum
- Exercise
physical effects of fever - answer- loss of appetite.
- headache.
- hot, dry skin.
- flushed face.
- thirst.
- muscle aches.
- fatigue
- increased respirations and pulse rate *to maintain homeostasis
- seizures *young children
- confusion and delirium *older adults
fever complications - answerFluid, electrolyte, & acid-base imbalances
What is a pulse? - answerThe indicator of circulatory status
, Pulse Rate - answerNumber of contractions over one minute
what regulates ventricular contraction and stroke volume? - answerMechanical, neural,
and chemical factors
Where do electrical impulses originate? - answersinoatrial node (SA)
Factors Influencing Pulse - answer- Age & Gender
- Physical activity
- Pyrexia & Stress
- Disease (COPD, infection)
- Medication
- Caffeine
- Smoking
Pulse measurement equipment - answer- Palpation ~ Wrist watch with second hand
- Auscultation ~ Stethoscope
- Electronic ~ Doppler
palpated pulse - answer- Client in supine or sitting position with arm supported - Use
tips of middle and ring fingers
- If regular (30 seconds X 2 = beats per minute)
- If irregular (60 seconds = beats per minute)
Apical (Auscultated) Pulse - answer- Client in supine position
- Locate 5th Intercostal Space (ICS) at the Midclavicular Line (MCL)
- Stethoscope orientation
- Position stethoscope and listen for S1and S2 (lub dub)
- If regular (30 seconds X 2 = beats per minute)
- If irregular (60 seconds = beats per minute)
Pulse sites - answertemporal, carotid, apical, brachial, radial, femoral, popliteal,
posterior tibial, dorsalis pedis
pulse rhythm - answerRegularity versus irregularity (Dysrhythmia)
dysrhythmia - answeran abnormal cardiac rhythm
Pulse amplitude (strength) - answer0 Absent, unable to palpate
+1 Diminished, weaker than expected
+2 Brisk, expected (normal)
practice first test
What are the vital signs? - answer temperature, pulse, respiration, blood pressure, and
sometimes pain (annotated as T-P-R-BP)
Normal pulse rate for healthy adults - answer60-100 bpm (80 average)
normal respirations for healthy adults - answer12-20 breaths/minute
normal blood pressure for healthy adults - answerless than 120/80
Guidelines for measuring vital signs - answer- Establish a baseline for future
assessments.
- Be able to understand and interpret values.
- Appropriately delegate measurement.
- Communicate findings.
- Ensure equipment is in working order.
- Accurately document findings.
When to access vital signs - answer- On admission to any health care facility or
institution
- Based on agency or institutional policy and procedures
- Any time there is a change in the patient's condition
- Any time there is a loss of consciousness
- Before and after any surgical or invasive diagnostic procedure
- Before and after activity that may increase risk, such as ambulation after surgery
- Before administering medications that affect cardiovascular and respiratory function
What is body temperature? - answerheat produced, heat lost
,Normal temperature range for adults - answer96.4 F - 99.5 F or 35.8 C - 37.5 C
Temperature sites - answerOral, rectal, axillary, tympanic membrane, temporal artery
factors affecting temperature - answer-circadian rhythm
-age and gender
-physical activity
-state of health
-environment
what is pyrexia? - answerfever
What is febrile? - answerwith fever
What is afebrile? - answerwithout fever
What is a fever? - answerupward displacement of thermoregulatory set point/ elevated
body temperature that signals infection and increases immune function
Normal oral temperature for healthy adults - answer98.6 F or 37 C
Normal rectal temperature for healthy adults - answer37.5°C, 99.5°F
Normal axillary temperature for healthy adults - answer36.5°C, 97.7°F
Normal forehead temperature for healthy adults - answer34.4°C, 94.0°F
Normal Tympanic Temperature for healthy adults - answer37.5ºC, 99.5°F
what is tympanic temperature? - answerTemperature taken in the ear
what is a neurogenic fever? - answernon-infectious source of fever in head injury patient
that can cause brain damage, too much pressure on hypothalamus in the brain stem
What is an FUO? - answerA fever of 101 F that lasts for 3 weeks or longer with an
identified cause.
Hypothermia - answerabnormally low body temperature
Hyperthermia - answerAbnormally high body temperature (not a fever)
Temperature assessment equipment - answer- Mercury Glass Thermometers
,- Electronic & Digital Thermometers
(Oral, Rectal, Axillary)
- Tympanic Membrane Thermometers
- Single Use (Chemical dot/tape) Thermometers
- Temporal Artery Thermometers
- Automated Monitoring Devices
Oral temp thermometer placement - answerposterior sublingual
rectal temp thermometer placement - answerSims position and insert 2.5-3.5 cm
axillary temp thermometer placement - answerin central axilla with adducted humerus
tympanic temp thermometer placement - answerAdult pinna up and out
*If under 3 years old it is pinna down and back
pinna - answerthe visible part of the ear
factors affecting temperature assessment - answer- Smoking
- Eating/Drinking
- Chewing gum
- Exercise
physical effects of fever - answer- loss of appetite.
- headache.
- hot, dry skin.
- flushed face.
- thirst.
- muscle aches.
- fatigue
- increased respirations and pulse rate *to maintain homeostasis
- seizures *young children
- confusion and delirium *older adults
fever complications - answerFluid, electrolyte, & acid-base imbalances
What is a pulse? - answerThe indicator of circulatory status
, Pulse Rate - answerNumber of contractions over one minute
what regulates ventricular contraction and stroke volume? - answerMechanical, neural,
and chemical factors
Where do electrical impulses originate? - answersinoatrial node (SA)
Factors Influencing Pulse - answer- Age & Gender
- Physical activity
- Pyrexia & Stress
- Disease (COPD, infection)
- Medication
- Caffeine
- Smoking
Pulse measurement equipment - answer- Palpation ~ Wrist watch with second hand
- Auscultation ~ Stethoscope
- Electronic ~ Doppler
palpated pulse - answer- Client in supine or sitting position with arm supported - Use
tips of middle and ring fingers
- If regular (30 seconds X 2 = beats per minute)
- If irregular (60 seconds = beats per minute)
Apical (Auscultated) Pulse - answer- Client in supine position
- Locate 5th Intercostal Space (ICS) at the Midclavicular Line (MCL)
- Stethoscope orientation
- Position stethoscope and listen for S1and S2 (lub dub)
- If regular (30 seconds X 2 = beats per minute)
- If irregular (60 seconds = beats per minute)
Pulse sites - answertemporal, carotid, apical, brachial, radial, femoral, popliteal,
posterior tibial, dorsalis pedis
pulse rhythm - answerRegularity versus irregularity (Dysrhythmia)
dysrhythmia - answeran abnormal cardiac rhythm
Pulse amplitude (strength) - answer0 Absent, unable to palpate
+1 Diminished, weaker than expected
+2 Brisk, expected (normal)
