B - Normal values for an older adult are: average body temperature
approximately 36° C (96.8° F), heart rate 60 to 100 beats per minute,
respiratory rate 12 to 20 breaths per minute, average BP less than 120
over 80, and pulse oximetry 95% to 100%. A BP greater than 140 over
90 may be an indication of hypertension. - Which of the following vital
signs recorded for an older adult would be considered acceptable
(within normal limits)?
A) Temp 96.8° F (36 °C), P-60, R-18, BP 160/90, O2 sat 93%.
B) Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%.
C) Temp 98.6 °F (37 °C), P-56, R-20, BP 120/80, O2 sat 91%.
D) Temp 98.0 °F (36.7 °C), P-76, R-22, BP 110/70, O2 sat 88%.
Answer C - The normal respiratory rate for a newborn is 35 to 40
breaths per minute. The normal respiratory rate of a child is 20 to 30
breaths per minute. The normal respiratory rate for a teenager is 16 to
20 breaths per minute. The normal respiratory rate for an adult is 12 to
20 breaths per minute. A rate of 10 would require follow-up. - Which of
the following patients would require a follow up?
A) A child with a respiratory rate of 24 breaths per minute.
B) An adolescent with a respiratory rate of 16 breaths per minute
C) An adult with a respiratory rate of 10 breaths per minute.
D) A newborn with a respiratory rate of 40 breaths per minute
Answer B, D, and E - It is more important that the temperature be done
on time by the correct route, with the correct equipment, and that
identified changes be reported as requested. - A 56-year-old female
patient has been admitted with a diagnosis of pneumonia. Which
, information should be provided to the NAP delegated to take her
temperature? (Select all that apply.)
A) The patient's age.
B) The type of temperature required.
C) The patient's diagnosis.
D) The frequency for taking or monitoring the temperature
E) What changes to report immediately to the nurse.
Answer A, C, and D - Factors that may alter vital signs include time of
day, stress (emotional and physical), temperature alterations/weather
conditions, exercise/activity, emotions, medication, postural changes,
acute pain, smoking, disease/injury status, noise, food/liquid
consumption, and odors. The person's occupation and isolation
precautions do not alter vital signs. If a person's job requires an activity
that increases exertion or stress, the activity affects vital signs, not the
occupation. - Which of the following situations may affect a patient's
vital signs? (Select all that apply.)
A) Time of day.
B) Occupation
C) Moving from a lying to standing position.
D) Pain rated as a 7 on a 0-10 scale.
E) Isolation precautions.
Answer B, C - The patient who is going to surgery is going to experience
a change in condition and an invasive procedure. Vital signs are
necessary so that the operative team has a baseline for comparison as
well as to rule out any complications before the beginning of the
surgical event. Providing reassurance to the patient can be done
verbally. - You are supposed to take your patient's vital signs
preoperatively and record them on the patient's record as part of the
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