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GNRS 555 - Exam 1 (1)
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GNRS 555 - Exam 1 (1)
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The certified nursing assistant (CNA) provides you with change-of-shift vitals on yourpatients. Which patient should you see FIRST?
A.84 year-old male with pneumonia, respiratory rate (RR) 28, oxygen saturation (O2)
89%
B.54 year-old woman admitted after surgery for fractured arm, blood pressure (BP)
160/86 mmHg, heart rate (HR) 72
C.63 year-old male with venous ulcers from diabetes temp 37.3C, HR 84
✅✅
D.77 year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62 mmHg -
-A.84 year-old male with pneumonia, respiratory rate (RR) 28, oxygen
saturation (O2) 89%
What are the normal vital sign ranges for an adult? - ✅✅-BP: 120/80, RR: 12-20,
Pulse: 60-100, Temp: 36-38C, SpO2: 95%+
When do you measure vital signs? - ✅✅ --When assessing a patient during home
care visits
-In a clinic setting before a health care provider examines the patient and after any
invasive procedures
-In a hospital on a routine schedule according to the health care provider's order or
hospital standards of practice
-Before, during, and after a surgical procedure or invasive diagnostic/treatment
procedure
-Before, during, and after a transfusion of any type of blood product
-Before, during, and after the administration of medication or therapies that affect
cardiovascular, respiratory, or temperature-control functions
-When a patient's general physical condition changes (e.g., loss of consciousness or
increased intensity of pain)
-Before, during, and after nursing interventions influencing a vital sign (e.g., before a
patient previously on bed rest ambulates or before a patient performs
range-of-motion exercises)
-When a patient reports nonspecific symptoms of physical distress (e.g., feeling
"funny" or "different")
What are factors that cause a change in body temp? - ✅✅-Age, exercise,
hormonal level, environment/stress, circadian rhythm, temperature alterations
You have delegated vital signs to assistive personnel. The assistant informs you that
the patient has just finished a bowl of hot soup, but appears to be in no apparent
distress. The nurse's most appropriate advice would be to do what?
A. Take a rectal temperature.
B. Take the oral temperature as planned.
✅✅
C. Advise the patient to drink a glass of cold water.
D. Wait 30 minutes and take an oral temperature. - -D. Wait 30 minutes and
take an oral temperature.
,Where are the pulse sites? - ✅✅ -Temporal, carotid, brachial, radial, ulnar, apical,
femoral, popliteal, tibial, dorsal pedis
Discuss physiological changes associated with fever. - ✅✅ -Vasodilation, sweating,
inhibition of heat production. Hypothalamus raises set point of internal temp and
body produces/conserves heat. Chills, shivers, and feeling cold as body goes to new
set point. Increased heart and respiratory rates
What is radiation in heat loss? - ✅✅ -The transfer of heat from the surface of one
object to the surface of another without direct contact between the two.
(vasodilation/vasoconstriction)
What is conduction in heat loss? - ✅✅ -The transfer of heat from one object to
another with direct contact. (touching a cold table with warm hand)
What is convection in heat loss? - ✅✅
-The transfer of heat away by air movement.
A fan promotes heat loss through convection. (moistened skin in moving air)
What is evaporation in heat loss? - ✅✅
-The transfer of heat energy when a liquid
is changed to a gas. The body continuously loses heat by evaporation.
(perspiration/sweating)
What is diaphoresis in heat loss? - ✅✅-Visible perspiration primarily occurring on
the forehead and upper thorax, although it occurs in other places on the body.
What are the patterns of fever? - ✅✅ --Sustained: A constant body temperature
continuously above 38°C (100.4°F) that has little fluctuation
-Intermittent: Fever spikes interspersed with usual temperature levels (Temperature
returns to acceptable value at least once in 24 hours.)
-Remittent: Fever spikes and falls without a return to acceptable temperature levels.
-Relapsing: Periods of febrile episodes and periods with acceptable temperature
values (Febrile episodes and periods of normothermia are often longer than 24
hours.)
Describe nursing measures that promote heat loss and heat conservation. - ✅✅
-•
Education
• Obtain cultures of body fluids such as urine, sputum, or blood (before beginning
antibiotics) if ordered. Obtain blood specimens to coincide with temperature spikes,
when the antigen-producing organism is most prevalent.
• Minimize heat production: reduce frequency of activities that increase oxygen
demand such as excessive turning and ambulation; allow rest periods; limit physical
activity.
, • Maximize heat loss: reduce external covering on patient's body without causing
shivering; keep patient, clothing, and bed linen dry.
• Satisfy requirements for increased metabolic rate: provide supplemental oxygen
therapy as ordered to improve oxygen delivery to body cells; provide measures to
stimulate appetite and offer well-balanced meals; provide fluids (at least 8 to 10
[8-oz] glasses for patients with normal cardiac and renal function) to replace fluids
lost through insensible water loss and sweating.
• Promote patient comfort: encourage oral hygiene because oral mucous
membranes dry easily from dehydration; control temperature of the environment
without inducing shivering; apply damp cloth to patient's forehead.
• Identify onset and duration of febrile episode phases: examine previous
temperature measurements for trends,
• Control environmental temperature to 21° to 27°C (70° to 80°F)
You notice that a teenager has an irregular pulse. The best first action you should
take includes which one of the following?
A. Reading the history and physical.
B. Assessing the apical pulse rate for 1 full minute.
✅✅
C. Auscultating for strength and depth of pulse.
D. Asking whether the patient feels any palpitations or faintness of breath. - -B.
Assessing the apical pulse rate for 1 full minute.
What are the steps of respiration? -✅✅-Ventilation, Diffusion, Perfusion
What factors influence respirations? - ✅✅-Exercise, acute pain, anxiety, smoking,
body position, medications, neurological injury, hemoglobin function
What impedes SpO2 measurement? - ✅✅-Dark and/or sparkly nail polish,
jaundice, carbon monoxide, patient motion, outside light, darker skin, cold hands
Upon assessment, you find your postoperative patient to be breathing rapidly. You
should immediately do which one of the following?
A. Call the physician.
B. Count the respirations.
✅✅
C. Assess the oxygen saturation.
D. Ask the patient if he feels uncomfortable. - -C. Assess the oxygen
saturation.
What is pulse pressure and what is the normal range? - ✅✅-Difference between
systolic and diastolic pressures. Normal range = 30-50
What factors influence blood pressure? - ✅✅ -Age, stress, ethnicity, sex, daily
variation, medications, activity, weight, smoking
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