NUR 209 Final Exam Study Questions with Answers

Normal blood pressure 120/80 Normal pulse rate 60-100 Normal respiratory rate 12-20 Normal temperature 98.6 F or 37 C True or false: older adults may have a naturally lower body temperature True Indications for measuring vital signs Change in health status, before or after medications/interventions affecting vital signs, transfer to another unit, routine orders, before or after procedures True or false: older adults may not exhibit a fever with infections True Nursing interventions for fever Decrease activity, increase fluids, assess skin, measure intake & output, provide oral hygiene, ensure the patient and their bed is dry, monitor labs Signs of fever Loss of appetite, headache, thirst, flushed face, fatigue, muscle aches, diaphoresis, chills, increased pulse, increased respirations True or false: any thermometer can be used rectally False - only thermometers with a red probe may be used rectally How long after eating, drinking, chewing gum, or smoking can an oral temperature be taken? 15-30 minutes Contraindications to rectal temperatures Cardiac patients, neutropenic patients, diarrhea, rectal surgery, low platelets Which way must the pinna be pulled on an adult patient getting their tympanic temperature taken? Up and back What is the priority action when a nurse cannot find a pulse on a conscious patient? Use a doppler ultrasound to locate the pulse What is the location of the apical pulse? Fifth intercostal space, midclavicular line