Nursing 2410 Exam 1 UPDATED
QUESTIONS AND CORRECT ANSWERS
What are the vital signs? - CORRECT ANSWER -Temperature
-Pulse
-Respiratory Rate
-Blood Pressure
-Oxygen Saturation
-Pain (extra)
Normal body temperature - CORRECT ANSWER 96.4-99.1
Average: 98.6
What are the changes in Body Temp during the day - CORRECT ANSWER lower in the AM
Higher in the PM
Age related variables on body temp - CORRECT ANSWER elderly: less likely to develop a
fever (thermoregulatory center not efficient, decreased subcutaneous fat)
Children: reduced capacity to regulate body temp (immaturity of the nervous system)
Position of Pinna When Taking Tympanic Temperature - CORRECT ANSWER <3 years old -
hold pinna down and back
>3 year old - hold pinna up and back
How long do you wait to take tympanic temp if there are hearing aids? - CORRECT
ANSWER remove and wait 15 mins
Difference in Axillary Temperature - CORRECT ANSWER 1 degree less than oral
*must add one degree to axillary temperature
Difference in rectal temperature - CORRECT ANSWER 1 degree higher than oral
,*must subtract one
What is considered a temperature? - CORRECT ANSWER >100.4
What is a normal pulse? - CORRECT ANSWER Adults: 60-90
Newborns: 120-160
Children: 75-100
What is bradycardia? - CORRECT ANSWER slow heart
- pulse <50-60 bpm
- athletes, cardiac medications, hypothermia
What is tachycardia? - CORRECT ANSWER Fast heart
-pulse: 90-100 bpm
-anxiety, exercise, fever, dehydration
-decreased oxygen to tissue (shock/hemorrhage)
What is sinus arrhythmia? - CORRECT ANSWER heart rate increases with inspiration and
decreases with expiration
- compliance of blood vessels
-common in infants/children
Effects of exercise on pulse - CORRECT ANSWER moderate exercise= increase by 20-30 bpm
Consistent athletic exercise= decrease resting heart rate
What two fingers do you use to find radial pulse? - CORRECT ANSWER pads of two middle
fingers
How long do you count when finding pulse? - CORRECT ANSWER count for 30 seconds
multiply x2
,How long do you count if pulse is irregular? - CORRECT ANSWER a full minute and check
apical pulse
What is another name for apical pulse? - CORRECT ANSWER point of maximal impulse
(PMI)
Where is the apical pulse located? - CORRECT ANSWER 5th intercostal space, left mid-
clavicular line
How long do you count when finding the apical pulse? - CORRECT ANSWER 60 seconds
What does it mean if the apical pulse is greater than the radial pulse? - CORRECT
ANSWER pulse deficit (all the beats don't get to the periphery)
-conditions: heart failure, myocardial infection, atrial fibrillation
-ineffective heart contractions
3 point pulse grade scale - CORRECT ANSWER 3+= bounding
2+ = normal
1+= weak, thready
0=absent
Regular pulse means - CORRECT ANSWER time between beats is consistent
Irregular pulse means - CORRECT ANSWER time between beats varies
How long do you count respirations? - CORRECT ANSWER normal - 30 secs x 2
Irregular - full minute
Normal respiration rate - CORRECT ANSWER adults: 12-20/min
Infants: 30-60/min
Children: 18-30/min
, Eupnea - CORRECT ANSWER normal respiration
Bradypnea - CORRECT ANSWER < 12 breaths/min
Tachypnea - CORRECT ANSWER > 20 breaths/min
Apnea - CORRECT ANSWER absence of breathing
Hypoventilation - CORRECT ANSWER decreased rate and depth of air movement into the
lungs
Hyperventilation - CORRECT ANSWER increased rate and depth of breathing
Dyspnea - CORRECT ANSWER shortness of breath
Orthopnea - CORRECT ANSWER difficulty breathing when lying down
What does blood pressure measure? - CORRECT ANSWER measures the pressure of the blood
against the arterial wall
What is systolic BP - CORRECT ANSWER ventricular contraction, maximal pressure on the
artery
- top #
What is diastolic BP - CORRECT ANSWER ventricular relaxation, resting pressure between
contractions
- bottom #
What is pulse pressure - CORRECT ANSWER reflects stroke volume, the difference between
the two
QUESTIONS AND CORRECT ANSWERS
What are the vital signs? - CORRECT ANSWER -Temperature
-Pulse
-Respiratory Rate
-Blood Pressure
-Oxygen Saturation
-Pain (extra)
Normal body temperature - CORRECT ANSWER 96.4-99.1
Average: 98.6
What are the changes in Body Temp during the day - CORRECT ANSWER lower in the AM
Higher in the PM
Age related variables on body temp - CORRECT ANSWER elderly: less likely to develop a
fever (thermoregulatory center not efficient, decreased subcutaneous fat)
Children: reduced capacity to regulate body temp (immaturity of the nervous system)
Position of Pinna When Taking Tympanic Temperature - CORRECT ANSWER <3 years old -
hold pinna down and back
>3 year old - hold pinna up and back
How long do you wait to take tympanic temp if there are hearing aids? - CORRECT
ANSWER remove and wait 15 mins
Difference in Axillary Temperature - CORRECT ANSWER 1 degree less than oral
*must add one degree to axillary temperature
Difference in rectal temperature - CORRECT ANSWER 1 degree higher than oral
,*must subtract one
What is considered a temperature? - CORRECT ANSWER >100.4
What is a normal pulse? - CORRECT ANSWER Adults: 60-90
Newborns: 120-160
Children: 75-100
What is bradycardia? - CORRECT ANSWER slow heart
- pulse <50-60 bpm
- athletes, cardiac medications, hypothermia
What is tachycardia? - CORRECT ANSWER Fast heart
-pulse: 90-100 bpm
-anxiety, exercise, fever, dehydration
-decreased oxygen to tissue (shock/hemorrhage)
What is sinus arrhythmia? - CORRECT ANSWER heart rate increases with inspiration and
decreases with expiration
- compliance of blood vessels
-common in infants/children
Effects of exercise on pulse - CORRECT ANSWER moderate exercise= increase by 20-30 bpm
Consistent athletic exercise= decrease resting heart rate
What two fingers do you use to find radial pulse? - CORRECT ANSWER pads of two middle
fingers
How long do you count when finding pulse? - CORRECT ANSWER count for 30 seconds
multiply x2
,How long do you count if pulse is irregular? - CORRECT ANSWER a full minute and check
apical pulse
What is another name for apical pulse? - CORRECT ANSWER point of maximal impulse
(PMI)
Where is the apical pulse located? - CORRECT ANSWER 5th intercostal space, left mid-
clavicular line
How long do you count when finding the apical pulse? - CORRECT ANSWER 60 seconds
What does it mean if the apical pulse is greater than the radial pulse? - CORRECT
ANSWER pulse deficit (all the beats don't get to the periphery)
-conditions: heart failure, myocardial infection, atrial fibrillation
-ineffective heart contractions
3 point pulse grade scale - CORRECT ANSWER 3+= bounding
2+ = normal
1+= weak, thready
0=absent
Regular pulse means - CORRECT ANSWER time between beats is consistent
Irregular pulse means - CORRECT ANSWER time between beats varies
How long do you count respirations? - CORRECT ANSWER normal - 30 secs x 2
Irregular - full minute
Normal respiration rate - CORRECT ANSWER adults: 12-20/min
Infants: 30-60/min
Children: 18-30/min
, Eupnea - CORRECT ANSWER normal respiration
Bradypnea - CORRECT ANSWER < 12 breaths/min
Tachypnea - CORRECT ANSWER > 20 breaths/min
Apnea - CORRECT ANSWER absence of breathing
Hypoventilation - CORRECT ANSWER decreased rate and depth of air movement into the
lungs
Hyperventilation - CORRECT ANSWER increased rate and depth of breathing
Dyspnea - CORRECT ANSWER shortness of breath
Orthopnea - CORRECT ANSWER difficulty breathing when lying down
What does blood pressure measure? - CORRECT ANSWER measures the pressure of the blood
against the arterial wall
What is systolic BP - CORRECT ANSWER ventricular contraction, maximal pressure on the
artery
- top #
What is diastolic BP - CORRECT ANSWER ventricular relaxation, resting pressure between
contractions
- bottom #
What is pulse pressure - CORRECT ANSWER reflects stroke volume, the difference between
the two
