NSG-300 Vital Signs (Ch. 29)-Topic 1 Review Questions and Answers
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Course
NSG 300
Institution
NSG 300
What are guidelines nurses should consider when measuring vital signs? -It's the nurses responsibility -It is nurses responsibility to interpret data -Clean devices -Assess equipment is functioning -Select equipment on the basis of the patient's condition and characteristics -Know patient's baselin...
NSG-300 Vital Signs (Ch. 29)-Topic 1
Review Questions and Answers
What are guidelines nurses should consider when measuring vital signs? ✅-It's the
nurses responsibility
-It is nurses responsibility to interpret data
-Clean devices
-Assess equipment is functioning
-Select equipment on the basis of the patient's condition and characteristics
-Know patient's baseline
-Know your patient's health history, therapies, and prescribed and over-the-counter
medications.
-Control environmental factors
-Use systematic approach
-Work with health care providers to determine frequency needed
-Use vitals to determine medication administration
-Analyze results on basis of patient's condition and past health history
-Verify and communicate changes
-Educate patient and family
What is an average oral and tympanic temperature? ✅37°C (98.6°F)
What is an average temperature range? ✅36° to 38°C (96.8° to 100.4°F)
What is an average rectal temperature? ✅37.5°C (99.5°F)
What is an average axillary temperature? ✅36.5°C (97.7°F)
What is the average core temperature in older adults? ✅35° to 36.1°C (95° to 97°F)
What is the acceptable range for adult pulse? ✅60 to 100 beats/min, strong and
regular
What is the acceptable range for adult pulse oximetry (SpO2)? ✅SpO2 ≥95%
What is the acceptable range for adult respirations? ✅12 to 20 breaths/min, deep and
regular
What is the acceptable range for adult blood pressure? ✅Systolic <120 mm Hg
Diastolic <80 mm Hg
Pulse pressure: 30 to 50 mm Hg
, What is the acceptable range for capnography (EtCO2)? ✅35-45 mm Hg
When should you measure vitals? ✅-Upon admission
-During home care visits
-Before prover examines the patient
-Before, during, after invasive or surgical procedure
-Routine schedule
-Before, during, after blood transfusion
-Before, during, after medication administration that affect cardiovascular, respiratory, or
temperature-control functions
-Before, during, after nursing interventions
-When a patient reports nonspecific symptoms of physical distress ("I feel funny")
-When a patient's general physical condition changes (loss of consciousness)
What affects temperature? ✅-Age (infant immature temperature control mechanisms
and unstable until puberty, drops in older adults)
-Exercise
-Hormone level (menstrual cycle, if progesterone levels are low, the body temperature is
a few tenths of a degree below the baseline level, during ovulation, temperature rises,
menopause, increase of 4°C (7.2°F) during "hot flash")
-Circadian rhythm 0.5° to 1°C (0.9° to 1.8°F) during a 24-hour period (lowest from 1-4
AM and maximum at 4pm)
-Stress (causes increase)
-Environment (in warm environment, unable to regulate heat-loss and in cold
environment, extensive radiant and conductive heat loss).
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.)
Nursing process for temperature assessment ✅1) Identify your patient's values,
beliefs, current treatments, preferences, and expectations regarding fever management
(e.g. allowing patient to pick temperature site, giving cooling blanket, tepid bath, or fan).
2. Determine temperature site that is safest and most accurate for patient (ICU uses
core temperature of pulmonary artery, urinary bladder, and esophagus; tympanic
reading is core temperature; other oral, rectal, and skin temperature sites rely on
effective blood circulation).
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