NUR 213 EXAM #2 QUESTIONS WITH DETAILED VERIFIED
ANSWERS (100% CORRECT ANSWERS) /ALREADY GRADED
What are vital signs
The vital signs + Reference range Ans✓✓✓Clinical measurements that
guide treatment decisions and interventions; know patient's baseline to
compare to future findings
1) Blood pressure: measurement of the force or pressure of the
circulating blood on the interior walls of the blood vessels (120/80 mm
Hg)
2) Pulse: the rhythmic dilation of the arteries that occurs with the beating
of the heart (60-100 BPM) (can be regular or irregular)
3) Body Temperature: balance of heat produced by the body and heat
lost to the environment (96.8-100.4 F) (36-38 C)
-avg: 37 C or 98.6 F
4) Respiratory rate (RR): number of breaths per minute (12-20 BMP)
-measure for rate, depth and rhythm*
-can be irregular/regular, shallow/deep
5) Oxygen Saturation (SaO2): estimated amount of oxygen bound to the
hemoglobin molecule in RBCs, indicating the amount of oxygen being
transported (95-100%)
,6) Pain* sometimes
Blood Pressure
Systolic vs Diastolic
Pulse pressure Ans✓✓✓Systolic BP: the maximum amount of pressure
exerted when the heart contracts and forces blood into the aorta
Diastolic BP: the minimum amount of pressure exerted when the heart is
relaxed
reported in mm Hg, expressed in systolic over diastolic
Pulse pressure: the difference between the systolic and diastolic
pressures
Hypertension Ans✓✓✓A BP above the expected reference range,
sigificantly increases a clients risk for major health problems like heart
attack and stroke
Elevated:
-systolic of 120 to 129 mm Hg
-Diastolic of less than 80
,Stage 1:
-systolic pressure: 130 to 139mm Hg
-diastolic pressure: 80 to 89 mm Hg
Stage 2:
-systolic pressure > 140mm Hg
-diastolic pressure > 90mm Hg
Hypertensive crisis:
-systolic > 180mm Hg
-diastolic > 120 mm Hg
Nursing interventions for hypertension Ans✓✓✓-Encourage the client
to adopt lifestyle interventions such as exercise, stress reduction
techniques, a low-sodium diet, and weight loss if needed.
-Provide the client with information about
antihypertensive medications, if prescribed by the provider, including
expected adverse effects and when the provider should be notified
Predisposing factors:
-genetics, poor diet, lack of exercise, stress, alcohol, certain medications
Hypotension
, manifestations
interventions Ans✓✓✓A BP that is below the expected reference range
as determined by a client's usual baseline measurement
In absence of a baseline:
-systolic pressure < 90mm Hg
-diastolic pressure <60mm Hg
Manifestations:
-dizziness, nausea, blurred vision, increased pulse, fatigue
-*major fall risk (might pass out or from dizziness)
Causes:
-can be caused from vasodilation (allergic reactions), dehydration,
medications, blood loss, shock, significant illness
Interventions:
-Increase fluids, stay well hydrated
-Place in an upright position unless medically contraindicated
-Evaluate the medications the client is taking
-Instruct the client about the risk for dizziness and falling
-Encourage the client to change positions slowly
-Avoid extremes in temperature
ANSWERS (100% CORRECT ANSWERS) /ALREADY GRADED
What are vital signs
The vital signs + Reference range Ans✓✓✓Clinical measurements that
guide treatment decisions and interventions; know patient's baseline to
compare to future findings
1) Blood pressure: measurement of the force or pressure of the
circulating blood on the interior walls of the blood vessels (120/80 mm
Hg)
2) Pulse: the rhythmic dilation of the arteries that occurs with the beating
of the heart (60-100 BPM) (can be regular or irregular)
3) Body Temperature: balance of heat produced by the body and heat
lost to the environment (96.8-100.4 F) (36-38 C)
-avg: 37 C or 98.6 F
4) Respiratory rate (RR): number of breaths per minute (12-20 BMP)
-measure for rate, depth and rhythm*
-can be irregular/regular, shallow/deep
5) Oxygen Saturation (SaO2): estimated amount of oxygen bound to the
hemoglobin molecule in RBCs, indicating the amount of oxygen being
transported (95-100%)
,6) Pain* sometimes
Blood Pressure
Systolic vs Diastolic
Pulse pressure Ans✓✓✓Systolic BP: the maximum amount of pressure
exerted when the heart contracts and forces blood into the aorta
Diastolic BP: the minimum amount of pressure exerted when the heart is
relaxed
reported in mm Hg, expressed in systolic over diastolic
Pulse pressure: the difference between the systolic and diastolic
pressures
Hypertension Ans✓✓✓A BP above the expected reference range,
sigificantly increases a clients risk for major health problems like heart
attack and stroke
Elevated:
-systolic of 120 to 129 mm Hg
-Diastolic of less than 80
,Stage 1:
-systolic pressure: 130 to 139mm Hg
-diastolic pressure: 80 to 89 mm Hg
Stage 2:
-systolic pressure > 140mm Hg
-diastolic pressure > 90mm Hg
Hypertensive crisis:
-systolic > 180mm Hg
-diastolic > 120 mm Hg
Nursing interventions for hypertension Ans✓✓✓-Encourage the client
to adopt lifestyle interventions such as exercise, stress reduction
techniques, a low-sodium diet, and weight loss if needed.
-Provide the client with information about
antihypertensive medications, if prescribed by the provider, including
expected adverse effects and when the provider should be notified
Predisposing factors:
-genetics, poor diet, lack of exercise, stress, alcohol, certain medications
Hypotension
, manifestations
interventions Ans✓✓✓A BP that is below the expected reference range
as determined by a client's usual baseline measurement
In absence of a baseline:
-systolic pressure < 90mm Hg
-diastolic pressure <60mm Hg
Manifestations:
-dizziness, nausea, blurred vision, increased pulse, fatigue
-*major fall risk (might pass out or from dizziness)
Causes:
-can be caused from vasodilation (allergic reactions), dehydration,
medications, blood loss, shock, significant illness
Interventions:
-Increase fluids, stay well hydrated
-Place in an upright position unless medically contraindicated
-Evaluate the medications the client is taking
-Instruct the client about the risk for dizziness and falling
-Encourage the client to change positions slowly
-Avoid extremes in temperature
