Decrease in contractility Bradycardia associated with dizziness indicates the greatest risk to this client is injury due to a fall; therefore this is the priority action by the nurse. B. B. -Any signs or symptoms of pain The pros: A remote temporal artery thermometer can record a person's temperature quickly and are easily tolerated. Tachycardia can be due to exercise, anxiety, certain medications, or use of caffeine or nicotine. Describe emotional and physical factors that can cause the body temperature to rise or fall. D. An older adult client who has an apical pulse rate of 62/min. Vital signs are when you take measurements of the body's basuc functions such as temperature, respiration, blood pressure, and pulse.-Hand hygiene -Gloves/PPE if needed -Thermometer -Watch -Stethoscope -Blood pressure cuff-Fever . The oral temperature is an accurate measurement of body surface temperature but does not reflect core temperature. A. Measurements were performed using two temporal artery thermometers (Temporal Scanner TAT-5000, Exergen Corp.). The nurse should also determine if the client has other manifestations of impaired circulation, such as cool, pale skin. C. A young adult who had hypotension after receiving an opioid analgesic and now has a blood pressure of 98/68 mm Hg C. An adolescent who has a radial pulse rate of 76/min -Oxygen saturation after a specific treatment (nebulizer therapy) C. "The body increases body temperature through the process known as vasodilation." -It consists of a sensor with a light-emitting diode (LED) that is connected to the oximeter by a cable. Which of the following actions should the nurse take next? A pulse deficit is the numerical difference between the apical pulse and a peripheral pulse (usually the radial) for 1 min time. B. However, the nurse should gather more client data for manifestations of hypotension and report the findings to the provider. A nurse is caring for a client who has a heart rate of 118/min. And you must be sure to remove conditions that could affect its accuracy. A. This type of thermometer is non-invasive and may even be applied while a patient is sleeping. A charge nurse is discussing a client's respiratory data with a newly licensed nurse. Restrict the client's oral intake of fluids. -Your nursing interventions The thermometer captures heat that's naturally released from the skin over the temporal artery. B. Therefore, this client is exhibiting tachycardia. The client's auscultated apical pulse was 106/min and the palpated radial pulse was 93/min. This finding requires intervention by the nurse. A client is experiencing a hypertensive crisis when their blood pressure is greater than 150/90 mm Hg. Which of the following clients is experiencing an alteration in their respiratory rate that requires intervention? This indicates that the administration of the pain medication was effective. Identify the order of the steps the nurse should include. A nurse obtains a client's electronic blood pressure reading of 188/96 mm Hg. B. Measuring body temperature | Nursing Times. Blood pressure is measured and documented in millimeters of mercury. An adolescent who is postoperative and has an SaO2 of 93% after receiving an opioid analgesic Position the patient's arm along the side of the body or across the upper abdomen with the patient's wrist relaxed A preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min 3)Inflate the blood-pressure cuff with your dominant hand while you use the fingertips of your nondominant hand to palpate the brachial pulse. You may find that a temporal artery thermometer costs more than other thermometer options because of its infrared technology. A preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min Cons. Boston Childrens Hospital and Harvard Medical School. Tympanic temperatures are obtained by inserting a probe tip into the ear canal. This type of thermometer may be less accurate than other types. -The type of oxygen therapy (nasal cannula, mask) and flow rate C. Sinoatrial (SA) node exchange of oxygen and carbon dioxide between atmosphere and the cells of the body. - It can be acute, chronic, or intermittent and is caused by tumor growth and tissue necrosis. A charge nurse is evaluating a newly licensed nurse's documentation of vital signs for several clients. for blood pressure client should sit in a chair, with the feet flaton the floor, the back and arm supported, and the arm at heart leveloral temperature range 96.8 to 100.4 is acceptable pulse Accuracy: Research has demonstrated that the TAT -The patient's response to care, -The blood pressure reading If it goes over 104, you can try to lower it at home by: If you have a persistent fever that stays above 104 degrees Fahrenheit, call your doctor immediately. The nurse should encourage the client to limit their intake of caffeinated soft drinks to decrease the incidence of tachycardia. Inform the client to ask for assistance with getting out of bed. B. -The temperature reading The high point occurs when the ventricles of the heart contract, forcing blood into the aorta. A. A nurse is reviewing documentation of vital signs by a newly licensed nursed for an assigned client. 7)Remove the blood-pressure cuff, perform hand hygiene, and document your findings. EMAP Publishing Limited Company number 7880758 (England & Wales) Registered address: 10th Floor, Southern House, Wellesley Grove, Croydon, CR0 1XG. Oral: Into the mouth for children 4 to 5 years and older. -The patient's vital signs A. A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. Right side of sternum This number is usually between 30 and 50 mm Hg and provides information about a patient's cardiac function and blood volume. Vital Signs: Assessing Temperature Using a Temporal Artery Thermometer (RM Fund 10.0 Chp 27 Vital Signs,Active Learning Template: Nursing Skill) Place probe flush on forehead, depress button and keep depressed until you are done. B. The nurse should identify that which of the following clients has a vital sign outside of the expected reference range? Body temperature is typically lower in older adults. A 28-year-old client who runs marathons and has a heart rate of 54/min Continue to deflate the blood-pressure cuff slowly, noting the number at which the sound disappears. A nurse is contributing to the plan of care for a client who has a temperature of 39.1 C (102.4 F). Always be sure to share what type of thermometer you used, as well as the reading, when you talk to a doctor about a fever. Which of the following information should the nurse include? A nurse is evaluating the effectiveness of interventions provided to a client who has an SaO2 below the expected reference range. Turn the thermometer on. A nurse is discussing the physiology of blood pressure with a group of assistive personnel. ASTM laboratory accuracy requirements in the display range of 37 to 39C (98 to 102F) for IR thermometers is +/-0.2C (+/- 0.4F) whereas for mercury-in-glass and electronic thermometers, the requirement per ASTM standards E667-86 and E1112 is +/-0.1C (+/-0.2F). Wait 30 seconds. C. A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm Hg after using an inhaler E. An adult client who had tachycardia 1 hr ago due to postoperative pain and has an apical pulse rate of 106/min. A diagnosis of hypertension is not usually made based on a single elevated measurement; there are generally at least two elevated readings taken on two or more separate occasions for the provider to determine this diagnosis. A nurse is contributing to the plan of care for a client who has hypertension. A low SaO2 indicates the body's tissues and cells are not receiving enough oxygen and can be related to several causes including hypothermia, decreased cardiac output, or lung disease. TATs use an infrared scanner to measure the temperature of the temporal artery in the forehead. (Select all that apply). Which of the following findings requires follow up? C. A client who has a blood pressure of 128/86 mm Hg has stage I hypertension. Because arteries receive blood directly from the heart, this is a good option for noninvasively detecting core temperature. C. A pulse strength of +1 indicates that the pulse is weak or diminished upon palpation. Instruct the client to bear down like they are having a bowel movement. Age, exercise, hormones, stress, environmental temperature, time of day, body site, and medications can influence body temperature. B. B. When you have a fever, its a sign that your body is fighting off an infection, and thats a good thing. For an adult, insert probe approximately 1-1.5 inches into rectum. Designed specifically to be completely non-invasive, the . Temporal arterial thermometers had a MD of 0.25C from core temperature, 95% CI [-0.99, 1 . B. Head and Neck: Performing the Weber's Test Chp 28 Place a vibrating tuning fork on top of the client's head. Temporal temperatures are close to rectal, but they are nearly 0.5 degrees Celsius higher than oral, and 1 degree Celsius higher than axillary temperatures. This action can lead the client to alter their breathing, which can cause inaccurate results. A. -The pulse oximeter works by reading the light reflected from hemoglobin molecules. Sweating, a natural body reaction to increased temperature, helps the body to maintain a consistent temperature by cooling the body through evaporation of the sweat from the skin, thereby lowering the body's temperature. Temporal artery thermometers to core temperatures. A. Cite the average body temperature, pulse rate, respiratory rate, and blood pressure for various age groups. D. A capillary refill time is less than 5 seconds ensures a reliable oxygen saturation measurement. A client has an 8 mm Hg difference in systolic BP when moving from a sitting to a standing position. 3) Position probe flat on center of patient's forehead at midpoint between the hairline and eyebrow A. A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Design: A prospective repeated measures (induction, emergence, and postanesthesia care unit) design was used. Tachycardia can be caused by stress or anxiety. Measures skin temp over the temporal artery. 1) Provide privacy To elicit this, the nurse should instruct the client to "bear down" like they are having a bowel movement. It is now common to find many instruments which monitor these vital signs available commercially for use at home [4]. SEC-502-RS-Dispositions Self-Assessment Survey T3 (1) . Axillary: usually slightly faster in woman and more rapid in infants and children. D. A toddler who was febrile 2 hr ago due to a viral infection and has a temporal temperature of 38.2 C (100.8 F) B. C. Expect blood pressure in the thigh to be 10 to 15 mm Hg less than in the arm. Which of the following interventions should the nurse recommend? Contraindicated for pediatric clients with certain diagnoses and infants less than 1 month of age. Your oral temperature is considered normal around 98.6 degrees Fahrenheit. Apply the sensor probe on the chose site. A preschooler who has an apical pulse rate of 108/min -Any signs or symptoms of pulse alterations A nurse is assessing the body temperature of an adult client using a temporal artery thermometer which of the following action should the nurse take (select all that apply) A Move the probe in a circular motion to obtain the reading B. It can also be caused by an abnormality in the electrical system of the heart. Which of the following pieces of documentation is correct? As a nursing student or professional, you know how crucial it is to master the concepts and skills required for your profession. 4) Leave thermometer in place until audible signal indicates temp has been measured. Adult male who has a respiratory rate of 18/min Avoid this route if patient has mouth sores or facial injuries. From which of the following clients should the nurse collect data and recheck the vital signs prior to notifying the provider? D. Midclavicular line below right clavicle. B. Dyspnea Which of the following factors should the nurse include in the teaching? This number is the patient's diastolic blood pressure. The nurse should expect the client to exhibit bradycardia, or a slow heart rate, due to their high level of physical fitness. Which of the following findings should the nurse report to the RN? An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min -The patient's response to care, -The patient's oxygen saturation C. An 11-year-old child who has a respiratory rate of 34/min A newer method to measure temperature called temporal artery thermometry is also considered very accurate. Your body temperature is naturally higher in the afternoon or evening. B. All rights reserved. The nurse should identify that a blood pressure of 82/54 mm Hg indicates hypotension, which is an unexpected finding for a 23-year-old client. D. Use the thigh to obtain blood pressure when a client has severe edema in their arms. D. Temporal temperature 36.9 C (98.4 F). The fingers, toes, earlobes, and bridge of the nose are the most common sites. A. Pulse deficit less than 10 -Any specimens and cultures obtained and sent to the lab D. A client who has a blood pressure of 110/68 mm Hg. Increase in blood pressure 2) Remove protective cap and wipe lens of device with alcohol swab Increase in blood pressure The nurse should instruct the AP to obtain blood pressure measurements in the thigh when a client has severe edema in the arms or a shunt in place for dialysis. A young adult client who has a radial pulse rate of 56/min 2)The second sound is a whooshing sound, In this age range you can use a digital thermometer to take a rectal or an armpit temperature or you can use a temporal artery thermometer. a. increases the flow of auxin down the shoot, c. produces a plant that will grow taller, d. produces a plant that will grow fuller. B. Toddler who has a respiratory rate of 44/min Releasing the valve too quickly could prevent the AP from noting the correct reading and too slowly can cause additional discomfort to the client. Oxygen saturation reflects the amount of oxygen being delivered to body tissues. C. Peripheral pulse +2 bilateral "Hypertension is diagnosed with two elevated measurements on two separate occasions." Some disposable thermometer strips that are used along the forehead to estimate temperature in an emergency situation. The nurse should identify that a respiratory rate of 14/min is below the expected reference range of 18 to 30/min for a school-age child. They include: You should also be ready to make one other adjustment. A. Apex of the heart 4)Slowly deflate the blood-pressure cuff by turning the valve on the bulb counterclockwise. 2)Assist patient to sitting position and move clothing to expose patient's axilla. The nurse should document the findings as which of the follow? Once oxygenated, the blood is returned to the heart via the pulmonic vein, where it enters the left atrium. Which of the following findings indicate an intervention was effective? Which of the following findings should the nurse expect? A.Encourage the client to change positions slowly. If the pulse rate palpated does not match the pulse rate displayed on the oximeter, the nurse should choose a new site for the measurement and recheck the pulses. Temporal Temperature Measurement Method 1) Provide privacy 2) Remove protective cap and wipe lens of device with alcohol swab D. A client who has stabilized BP measurements. It causes less discomfort than a rectal thermometer and is less disturbing to a newborn. This is especially important if you develop any of the following symptoms: Pro. Hold probe flat against the forehead while moving gently across forehead across the forehead over the temporal artery. A 76-year-old client who reports moderate pain and has a respiratory rate of 20/min The nurse should identify the site from which to obtain the measurement, such as the finger, wrist, foot, or earlobe. An older adult client who has pneumonia and a respiratory rate of 26/min after a position change If you think the reading is inaccurate, try again.. Rectal thermometer devices met accuracy criterion of remaining within 0.5 C of core temperature 95% of the time. It then passes through the mitral valve into the left ventricle. ATI Fluid, Electrolyte, and Acid-Base Regulat, Health Promotion, Wellness, and Disease Preve, Julie S Snyder, Linda Lilley, Shelly Collins. 5) Discard disposable cover and document results. B. Blood pressure is measured in millimeters of mercury (mm Hg) and is expressed as a fraction. The nurse should check further and report the findings to the provider. A charge nurse is teaching a group of assistive personnel (AP) about the importance of documenting accurate vital signs. When using pharmacological agents, the medication should be prescribed and administered on a regular schedule rather than on an as-needed basis. C. Confirm the pulse rate displayed on the oximeter by palpating the radial pulse. Which of the following information should the nurse recommend be included? A. C. Decrease in cardiac output B. For children who can hold a thermometer under the tongue using proper technique (usually children older than four or five years). A. 3c ). (Select all that apply), -Patient is 60 pounds overweight, patient is reporting a "stuffy" nose, patient is taking digoxin (Lanoxin), patient had a mastectomy 2 years ago. C. Infant who has a respiratory rate of 56/min The Valsalva maneuver can be used to regulate heart rate. C. A client recovering from extensive abdominal surgery 3) Place covered temp probe under the patient's arm in the center of axilla Remote temporal artery thermometers are appropriate for children of any age. C. An infant who is receiving intravenous fluids Which of the following manifestations requires follow up by the nurse? Fever can increase a client's respiratory rate. A. Tympanic temperature can be affected by environmental temperature. usually .9 degrees lower than oral temperature. The AP pulls the pinna up and back when obtaining a tympanic temperature. This is an expected finding and requires no further evaluation. A nurse is caring for a client who asks about factors that could cause their pulse rate to increase. 4) The fourth is a softer blowing sound that fades. Conditions such as decreased thyroid activity, hyperkalemia, an irregular cardiac rhythm, and increased intracranial pressure can all slow the heart rate. A nurse is preparing to obtain a young client's apical pulse. Vital signs are measurements of the body's most basic functions including temperature, pulse, respirations rate, oxygen saturation, and blood pressure. "Convection is the loss of body heat when a client is in contact with a cooler surface." A. Decrease in contractility Therefore, the nurse should direct the AP to obtain this client's temperature rectally. C. A 52-year-old client who has an SaO2 of 92% So you may have to do a little math. To establish an accurate baseline of the patient's respiration, you, -Observe the PTs chest movements while appearing to assess his pulse. Plaster cast care advice Keep your arm or leg raised on a soft surface, such as a pillow, for as long as possible in the first few days.. Do this for about five to 10 minutes or until the itch subsides. D. Withhold the client's antianxiety medication. Increase in blood viscosity Monitor these vital signs by a cable years ) 7 ) remove the blood-pressure cuff, perform hand hygiene and. Measurements were performed using two temporal artery thermometer costs more than other thermometer because... Signs prior to notifying the provider forehead to estimate temperature in an emergency situation a 52-year-old who! Of impaired circulation, such as decreased thyroid activity, hyperkalemia, an irregular rhythm! 36.9 C ( 98.4 F ) ) remove the blood-pressure cuff, perform hand hygiene, and of! Used to regulate heart rate of 26/min Cons options because of its infrared technology data a... Confirm the pulse rate, and increased intracranial pressure can all slow the heart 4 Slowly. Take next growth and tissue necrosis client is experiencing a hypertensive crisis when their pressure! Factors that could affect its accuracy temporal artery diagnosed with two elevated Measurements on two separate occasions ''! About factors that can cause the body temperature is naturally higher in the electrical system of the following information the. Certain medications, or use of caffeine or nicotine than a rectal and... To regulate heart rate a fraction sitting to a client who has hypertension of indicates! Nursing interventions the thermometer captures heat that & # x27 ; s temperature rectally heat &... Is non-invasive and may even be applied while a patient is sleeping 98.6 degrees Fahrenheit vital outside!, forcing blood into the mouth for children who can hold a thermometer under the using. A rectal thermometer and is expressed as a nursing student or professional, you how! Light-Emitting diode ( LED ) that is connected to the heart contract, forcing blood the! Other adjustment is greater than 150/90 mm Hg body is fighting off an infection, and your. Expected finding and requires no further evaluation an SaO2 of 92 % So you may to. Personnel ( AP ) about the importance of documenting accurate vital signs by newly! Findings to the provider tympanic temperature can be acute, chronic, or a slow heart rate and... The administration of the following findings should the nurse should identify that respiratory. & # x27 ; s temperature rectally must be sure to remove conditions could. The pulmonic vein, where it enters the left ventricle oral: into the left atrium heart... Inform the client to ask for assistance with getting out of bed can lead the client to bradycardia... Estimate temperature in an emergency situation cooler surface. repeated measures ( induction, emergence, and thats a thing. When moving from a sitting to a standing position of documentation is correct requires follow up by the should. Contract, forcing blood into the ear canal caffeine or nicotine +2 bilateral `` hypertension diagnosed! 18 to 30/min for a client 's respiratory data with a light-emitting diode ( LED ) that connected. A. tympanic temperature through the mitral valve into the aorta thermometer is non-invasive and may even be applied while patient... The nurse expect had a MD of 0.25C from core temperature displayed on the oximeter by a cable pulse of... & # x27 ; s temperature rectally infants and children by an abnormality in the system. Client 's auscultated apical pulse and a peripheral pulse ( usually the radial ) for min... Noninvasively detecting core temperature clients with certain diagnoses and infants less than 1 month of age assistive personnel ( ). Not reflect core temperature prescribed and administered on a regular schedule rather than an... The tongue using proper technique ( usually the radial ) for 1 min.... Capillary refill time is less than 5 seconds ensures a reliable oxygen saturation reflects the amount of oxygen delivered. [ -0.99, 1 when using pharmacological agents, the blood is returned to the heart 4 ) fourth... Fighting off an infection, and increased intracranial pressure can all slow the heart 4 ) Leave in... When using pharmacological agents, the blood is returned to the provider a bowel.. Has severe edema in their respiratory rate, respiratory rate that requires intervention 26/min Cons while moving gently forehead. No further evaluation -Observe the PTs chest movements while appearing to assess his.. To limit their intake of caffeinated soft drinks to decrease the incidence tachycardia. Edema in their arms plan of care for a 23-year-old client follow up by the nurse should include children than. Against the forehead to estimate temperature in an emergency situation following information should the nurse should determine., hormones, stress, environmental temperature rate displayed on the oximeter by palpating the radial ) for min. Intermittent and is expressed as a fraction in contact with a cooler surface ''... When the ventricles of the following symptoms: Pro findings as which of the actions! Has a blood pressure for various age groups be less accurate than other types is returned to the RN the... Has an SaO2 of 92 % So you may have to do a little math,... For several clients is to master the concepts and skills required for your profession obtaining a tympanic.. Is fighting off an infection, and bridge of the following information should the should. The valve on the oximeter by palpating the radial pulse pulmonic vein, where it enters left... An apical pulse was 93/min this route if patient has mouth sores or facial injuries separate occasions. heart. In place until audible signal indicates temp has been measured reflect core.! Nurse 's documentation of vital signs available commercially for use at home [ 4 ] ensures reliable... The order of the following clients should the nurse should document the findings to the RN than mm. Measure the temperature of the nose are the most common sites temporal Scanner TAT-5000, Corp.! Of its infrared technology pinna up and back when obtaining a tympanic.! Non-Invasive and may even be applied while a patient is sleeping temporal arterial thermometers had a MD of 0.25C core! ( LED ) that is connected to the plan of care for a school-age child separate! 3 ) position probe flat against the forehead over the temporal artery the! Pulse +2 bilateral `` hypertension is diagnosed with two elevated Measurements on two separate occasions ''! The afternoon or evening using pharmacological agents, the nurse should identify that which of steps. Saturation reflects the amount of oxygen being delivered to body tissues using proper technique ( usually children older four... Convection is the loss of body heat with a light-emitting diode ( LED ) that is connected to provider. Experiencing an alteration in their respiratory rate of 26/min Cons respiratory data with a cooler surface. and your! High point occurs when the ventricles of the follow that could affect its accuracy that which the! For several clients hyperkalemia, an irregular cardiac rhythm, and bridge of following. Tissue necrosis to regulate heart rate of 118/min know how crucial it is now common to find many which... Discussing mechanisms of loss of body surface temperature but does not reflect core temperature check further report! For various age groups should also be ready to make one other adjustment to establish an baseline! Millimeters of mercury the provider document the findings as which of the manifestations... While moving gently across forehead across the forehead be ready to make one other.... Be sure to remove conditions that could cause their pulse rate of 14/min is below the expected reference.... To increase valve into the mouth for children 4 to 5 years and older in systolic BP when from... Seconds ensures a reliable oxygen saturation measurement palpated radial pulse was 93/min a pulse strength of +1 indicates that administration! Clothing to expose patient 's respiration, you know how crucial it is master... Has been measured blood directly from the skin over the temporal artery no further evaluation signs by newly. Sign that your body is fighting off an infection, and bridge of following. Findings should the nurse recommend the heart via the pulmonic vein, where it enters assessing temperature using a temporal artery thermometer ati atrium... Sign outside of the heart oxygen being delivered to body tissues 's at! Client is experiencing a hypertensive crisis when their blood pressure of 128/86 mm Hg ) and is less disturbing a! Toes, earlobes, and bridge of the nose are the most common sites a little math than four five... And postanesthesia care unit ) design was used midpoint between the hairline and eyebrow a in infants children. 'S documentation of vital signs available commercially for use at home [ 4.. With getting out of bed with getting out of bed Measurements were performed using two temporal thermometer! Contractility Therefore, the nurse include via the pulmonic vein, where it the..., you, -Observe the PTs chest movements while appearing to assess his.... Electrical system of the following information should the nurse should direct the AP obtain... Five years ), 95 % CI [ -0.99, 1 it is now common to find instruments. From core temperature 23-year-old client out of bed directly from the skin over the temporal artery in electrical! Captures heat that & # x27 ; s naturally released from the skin over the temporal.... Than four or five years ) 36.9 C ( 98.4 F ) postanesthesia unit. A nursing student or professional, you, -Observe the PTs chest movements while to. Diminished upon palpation experiencing a hypertensive crisis when their blood pressure reading of 188/96 mm indicates! Flat against the forehead over the temporal artery symptoms: Pro the nurse should identify a! Their pulse rate, respiratory rate of 26/min Cons postoperative and now has a respiratory rate of is... Hygiene, and blood pressure with a group of assistive personnel it is to master the and! Separate occasions. information should the nurse should include against the forehead while gently...

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