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Nursing 400 Final Exam combined study guides- |612 Questions with 100% Correct with Solutions
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Nursing 400 Final Exam combined study guides-|612 Questions with 100% Correct with Solutions
If a patient has had either hot or cold food or fluids or has been smoking or chewing gum,
the general recommendation is to wait 15 to 30 mins to allow the oral tissues to return to
normal temperature. Mouth breathing can influence the results.
Oral temperatures should not be taken in people with diseases of the oral cavity, in those
who had surgery of the nose or mouth or when there is risk of seizures.
The probe must remain in the sublingual pocket for the full period of measurement
(Temperature)
Tympanic - Ans Insert the probe snugly into the external ear using gentle but firm
pressure, angling the thermometer toward the patient's jaw line.
Pull the pinna up and back to straighten the ear canal in an adult.
If a patient has an earache, do not use the affected ear to take a tympanic temperature.
The movement of the tragus may cause severe discomfort.
Assess the patient for significant ear drainage or a scarred tympanic membrane (not good)
An ear infection or the presence of earwax in the canal will not significantly affect a tympanic
thermometer reading.
If the patient has been sleeping with the head turned to one side, take a tympanic temperature
in the other ear. Heat may be increased on the side that was against the pillow, especially if it
is a plastic-covered pillow.
,(Temperature)
Axillary - Ans Place the probe in the center of the axilla; hold the patient's arm by the
patient's side until the measurement is complete
The axillary site may be used when both oral and rectal sites are contraindicated or when these
sites are inaccessible, but should not be used where accurate temperature measurement is
required.
Axillary readings are affected by ambient temperature, local blood flow, appropriate placement
of the probe, and closure of the axillary cavity.
Do not take after shower
(Temperature)
Rectal - Ans Assist patient to side lying position
Cleanse the area
Lubricate about 1 inch of the the covered probe with water-soluble lubricant
Reassure patient and separate the buttocks until the anal sphincter is clearly visible
Insert the thermometer probe about 1.5 inches for adults and no more than 1 inch for a child
Hold the probe in place until you hear a beep.
,Dispose the probe and document the temperature
Do not use if contraindicated by neutropenic patient
Respiration measurement - Ans Do not tell patient your measuring his/her breathing
Using a watch with a second hand, count the respiration for 30 seconds and multiply by 2.
If respiration is abnormal, count it for a full minute.
Note the depth and rhythm
Common Respiratory sounds - Ans Rhonchi: resemble snoring. Large airway blocked
, Stridor: Wheeze-like sounds, Trachea/wind pipe blocked
Wheezing: high pitched, small airways
Common Breathing rates - Ans Eupnea: normal 12-18 breathes
Bradypnea: slow less than 10
Tachypnea: fast more than 24
Apnea: stop breathing
Pulse arteries (8) - Ans Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Posterior Tibialis
Dorsalis Pedis
Characteristics of peripheral pulse - Ans Rate- Normal pulse rates for adolescent to adults is
60-100 BPM
Rhythm- the pattern of pulsations and the pauses between them
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