NUR 241 Exam 1 Review Questions and Correct Answers
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Course
NUR 241
Institution
NUR 241
When to measure vital signs admission, per hospital/unit policy, before and after surgical procedures, before, during, and after medication administration affecting VS, any time patient condition changes, before and after procedures affecting VS, if stable RN may delegate
Blood Pressure measures t...
NUR 241 Exam 1 Review Questions and
Correct Answers
When to measure vital signs ✅admission, per hospital/unit policy, before and after
surgical procedures, before, during, and after medication administration affecting VS,
any time patient condition changes, before and after procedures affecting VS, if stable
RN may delegate
Blood Pressure ✅measures the force exerted by the flow of blood against the arterial
walls,
measured in mmHg (sphygomanometer and stethoscope), Normal range <120/80
Diastolic ✅ventricles are relaxed
systolic ✅ventricles are contracted
BP cuff size ✅the bladder of cuff LENGTH MUST encircle at least 80% of upper arm
circumference,
the WIDTH of bladder MUST encircle at least 40% of arm circumference
steps to ensure accurate blood pressure measurement ✅1. the patient should avoid
smoking, exercise, or caffeine for 30 minutes before pressure is measured
2. the examination room should be quiet and a comfortable temperature
3. the patient should sit quietly for at least 5 minutes in a chair, with both feet on floor
and legs uncrossed
4. the arm selected should be accessible w/out clothing, fistulas for dialysis, scars from
brachial artery that was accessed for a deep vein intravenous, or lymphedema from
axillar node dissection or radiation therapy
steps to measure BP continued ✅5. palpate the brachial artery to confirm that is has a
viable pulse
6. position the arm so that the brachial artery, at the antecubital crease, is at HEART
LEVEL- roughly level with the fourth interspace at its junction with the sternum
7. if the patient is seated, rest the arm on a table a little above the patients waist
BP Measurement simplified ✅1. select arm, remove clothing of arm
2. palpate brachial pulse
3. support arm at heart level
4. secure cuff about 2.5cm above antecubital crease
5. perform estimated systolic
6. place stethoscope on brachial artery
7. inflate to 30mmHg ABOVE estimated systolic
8. listen for Korotkoff sounds
, 9. if needed repeat in different positions for orthostasis assessment
Errors resulting in false High BP ✅-incorrect cuff size (too NARROW or too WIDE)
-cuff too lose or uneven
-arm BELOW heart level
-arm not supported
-inflating/deflating cuff at wrong speed
Errors resulting in false low BP ✅-incorrect cuff size (too WIDE)
-arm ABOVE heart level
-inaccurate inflation level
-stethoscope pressured too tightly on pulse due to occluding blood
Normal BP ✅120/80
Prehypertension BP ✅120-139/80-89
Hypertension stage 1-age >_18 to <60; diabetes or renal disease-age >_60 ✅140-
149/90-99
150-159/90-99
hypertension stage 2 ✅>_160/>_100
hypertension crisis ✅higher than 180/higher than 120
immediately go to hospital
What is a pulse ✅-pressure wave caused by each heart contraction
-reflects stroke volume, volume of blood pumped from LV w each beat
-measured in 1 minute increments
-measured over peripheral artery or apex of heart
Heart rate assessment ✅usually over radial artery, amplitude 1-3, elasticity-hard or
bouncy
no thumbs
regular heart rate ✅30 seconds x 2
irregular heart rate ✅60 seconds and assess apical pulse with stethoscope x 1 full
minute
what do i chart ✅rate, rhythm, amplitude
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