A nurse is contributing to the plan of care for a client who has hypertension. If sitting, instruct the patient to keep feet flat on the floor without crossing legs. B. For children who can hold a thermometer under the tongue using proper technique (usually children older than four or five years). B. This indicates the interventions provided by the nurse have not been successful and require further evaluation and notification of the provider. D. A client who has stabilized BP measurements. D. A client who is diaphoretic and frequently chewing ice to relieve dry mouth. To perform the measurements the thermometer was placed on the forehead and then moved along the hairline, after which it was removed from the skin and then place below the earlobe to provide the temperature. It captures the naturally emitted heat from the skin over the temporal artery, taking 1000 readings per second and selects the highest reading. A nurse is assisting with planning an in-service about vital signs for a group of assistive personnel. Afterload is the resistance of the ventricle to pump the heart muscle and eject blood into the client's bloodstream during systole. D. A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg. A nurse is contributing to the plan of care for a client who is experiencing tachycardia. C. Axillary temperature reflects rapid changes in a client's core body temperature. A nurse is contributing to the plan of care for a client who has a temperature of 39.1 C (102.4 F). D. "The body generates heat through evaporation.". Which of the following actions by the AP requires follow up by the nurse? D. Reinforce client teaching regarding medications to control blood pressure. A client who has a BP lower than the expected reference range C. Reinforce client education on measures to decrease blood pressure. Radial pulse irregular D. Use the thigh to obtain blood pressure when a client has severe edema in their arms. A. A nurse is caring for a client who asks about factors that could cause their pulse rate to increase. Which of the following entries in the chart requires follow up by the nurse? "The first step in checking for orthostatic hypotension is obtaining a client's blood pressure while they are standing." D. The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second. for adult will palpate radial pulse. 3) Place covered temp probe under the patient's arm in the center of axilla Align the sensor with the middle of your forehead for the most accurate reading., 4. A. You may find that a temporal artery thermometer costs more than other thermometer options because of its infrared technology. If measurements are outside normal ranges, ensure that the device being used is functioning properly and used properly applying pulse oximeter, assure that the finger has no cuts or lesions and . Most appropriate measurement for adults and children including infants. This finding indicates that interventions were effective. Which of the following statements should the charge nurse include? Prescribed analgesic administered and will re-evaluate BP in 30 min. 1)Patient should be in supine position. 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. C. Encourage the client to take a short walk. It is now common to find many instruments which monitor these vital signs available commercially for use at home [4]. Oral: Into the mouth for children 4 to 5 years and older. The Valsalva maneuver can be used to regulate heart rate. The nurse should confirm the pulse rate by auscultating the apical pulse for 1 min, as well as determining if the client is experiencing manifestations of bradycardia such as fatigue, dizziness, or shortness of breath. -Any signs or symptoms of temperature alterations Since theres no wait for results and the devices do not cause discomfort, TATs are excellent for use on children. A nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings for vital signs. 60-100 BPM. A. A. As we discussed earlier is a snapshot graph of a wave at t=0st=0 \mathrm{~s}t=0s. Draw the history graph for this wave at x=6mx=6 \mathrm{~m}x=6m, for t=0st=0 \mathrm{~s}t=0s to 6s6 \mathrm{~s}6s. Cuff width= 20% greater than the diameter of the limb at its midpoint or 40% of circumference. D. Use the thigh to obtain blood pressure when a client has severe edema in their arms. A. D. Encourage the client to engage in pattern paced breathing by panting. The charge nurse should include that a blood pressure of 162/102 mm Hg meets the diagnostic criteria for stage II hypertension. A nurse is reviewing the recent vital signs of a group of clients. 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). Which of the following clients' vital signs should the nurse identify is outside the expected reference range and notify the provider? Monitoring of the five important vital signsheart rate, blood pressure, respiratory rate, oxygen saturation, and temperature [1,2,3]allow accurate diagnosis and treatment of pathological conditions. A. You are preparing to use a tympanic thermometer. The nurse should document the findings in the client's medical record and notify the provider if a pulse deficit is present. Wear gloves when measuring temperature rectally. Tachycardia. 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. D. Right ventricle. The point at which you no longer feel the pulse is the estimated systolic pressure. D. SaO2 of 96%. Place the sensor. B. Respirations observed as even, nonlabored at 20/min with client in supine position B. Windows, Doors & Conservatories. A newer method to measure temperature called temporal artery thermometry is also considered very accurate. 5) Discard disposable cover and document results. Temporal artery thermometers Remote forehead thermometers use an infrared scanner to measure the temperature of the temporal artery in the forehead. A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. Is It (Finally) Time to Stop Calling COVID a Pandemic? B. SEC-502-RS-Dispositions Self-Assessment Survey T3 (1) Techniques DE Separation ET Analyse EN Biochimi 1 . Blood pressure is measured in millimeters of mercury (mm Hg) and is expressed as a fraction. D. The AP selects a blood pressure cuff width that is 40% the circumference of the client's arm. Can you make the bulb light? C. Sinoatrial (SA) node A tympanic thermometer which measures temperature via the external auditory canal or ear canal. The main advantage of using a temporal artery thermometer is how quickly you can get a reading from it. Therefore, the intervention of using an inhaler was effective. The screen displays your temperature based on the reading. An accurate temperature reading is obtained with moisture on the forehead. B. C. Infant who has a respiratory rate of 56/min Lastly, the nurse should remove the probe and document the measurement in the client's medical record. Count the number of beats heard in 15 seconds and multiply by 4. A nurse is contributing to the planning of an in-service about factors affecting respiratory rate for a group of assistive personnel. Releasing the valve too quickly could prevent the AP from noting the correct reading and too slowly can cause additional discomfort to the client. The nurse should identify that cardiac output is the amount of blood pumped by the ventricles through the heart within 1 min. A client has an 8 mm Hg difference in systolic BP when moving from a sitting to a standing position. -Your nursing interventions The nurse should identify that a pulse rate of 104/min is above the expected reference range of 60 to 100/min for a young adult. -Your nursing interventions A. Which of the following actions should the nurse take? A nurse is observing an assistive personnel (AP) obtain vital signs from an adult client. Which of the following findings requires intervention? C. A young adult who has an apical pulse rate of 104/min C. Apical pulse greater than radial A. Eupnea According to evidence-based practice, the AP should not inform the client they are going to count their respirations. A femoral pulse that is bounding upon palpation is an expected finding in a young adult. -Your nursing interventions 8-year-old male: respiratory rate 34/min, SaO2 97%. Temperature measurement over the temporal artery (TAT, temporal artery thermometry) is a method for temperature measurement that uses infrared technology to detect the heat that is radiated from the skin surface over the temporal artery. A nurse is assisting with the care of a client who has orthostatic hypotension. It causes less discomfort than a rectal thermometer and is less disturbing to a newborn. A nurse is reviewing the vital signs obtained by an assistive personnel at 1200. Which of the following findings indicate the intervention was effective? An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min We use cookies to personalize and improve your experience on our site. B. Temporal temperature is inaccurate in children under 3 years of age. A nurse is caring for a group of clients. D. An older adult client who received an antipyretic medication 1 hr ago now has a temperature of 38.7 C (101.6 F). Note the number at which the pulse reappears. "The body lowers body temperature through sweating." listen for 5 Korotkoff sounds, 1) As you deflate the blood-pressure cuff, you'll hear a clear, rhythmic tapping sound that coincides with the patient's systolic blood pressure. Right side of sternum This finding requires intervention by the nurse. Moreover, parents' use of a similar device resulted in inadequate agreement with rectal temperatures [37]. Encourage the client to reduce intake of caffeinated soft drinks. Tachycardia can be caused by stress or anxiety. Therefore, the nurse should direct the AP to obtain this client's temperature rectally. Data was analyzed to assess bias and limits using scatterplots and Bland-Altman charts while sensitivity analysis was done using ROC curves. B. Document results. 3. "Successive blood pressure measurements of 126 over 78 is classified as stage I hypertension." - Inject the medication. 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) For example, radiative heat loss can occur when a client sits near a window when it is cold outside. Study with Quizlet and memorize flashcards containing terms like _____ are measurements of the body's most basic functions and include temperature, pulse, respiration, and blood pressure. Via the external auditory canal or ear canal in 30 min are standing. seconds and multiply by 4 done... Artery thermometers Remote forehead thermometers use an infrared scanner to measure the temperature of 38.7 C ( F. 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