module 9 40-44 (except 41&)

2-4 hours

When a fever or known infection is present vital signs should be measured every

blood transfusion

vital signs should be checked before, during, and after a

97.5° to 99.5° F

what is a normal body temperature range

mouth, rectum, axilla, ear, and across the forehead (temporal artery site)

what are the common places to measure body temperature

rectal

what temperature site is usually 1° F higher than the other sites; the

axillary

which temperature site is usually 1° F lower than the other sites

low-normal range at the time of awakening

as a result of muscle inactivity temperature is usually

time of day, age, menstruation, pregnant, stress, illness and environment temperature

what factors affect temperature

wait 15-30 minutes

a client whom has just eaten ice cream and chewed gum needs his temperature checked, the nurse should wait how long before taking his temp

chewing gum, ice cream, coffee and hot/cold foods and liquids

what can affect body temperature

left lateral recumbent position

before taking the patients rectal temperature, the nurse should place the pt in what position

the rectal

when an accurate temperature cannot be obtained orally and a tympanic or temporal artery thermometer is not available, the nurse can take the pts temperature through what route

rectal

if the patient has nasal congestion, has undergone nasal or oral surgery, is unable to keep the mouth closed, or is at risk for seizures the nurse should take the temperature of the pt through what route

cardiac patients

what patients is rectal contraindicated in due to stimulation of the vagus nerve

1.5 inches; the umbilicus

how many inches is the thermometer inserted; towards what

axillary

if the oral or rectal temperature measurement is contraindicated, the nurse can take the patients temperature through what site

redness, swelling, discharge, or any foreign body

before checking the temperature of the pts ear, the nurse should check the tympanic membrane for

ear infections or excessive wax blocking the ear canal

what affects tympanic temperature readings

on the neck, just behind the earlobe

the nurse is trying to take the patients temperature (temporal artery), the patient is sweating, the nurse should the place the thermometer

pulse

a palpable bounding of blood flow in the peripheral artery is called a

the pedal pulse

what pulse is checked to determine whether the circulation is blocked in the artery up to that pulse point

doppler ultrasound stethoscope

when the pedal pulse is difficult to locate, the nurse must use what device; a

emotions, hemorrhage, pain and exercise

what can increase heart rate

medications and age

what can decrease heart rate

low heart rates

athletes or clients who regularly participate in aerobic exercise tend to have

rate, rhythm, and strength (force or amplitude)

what should be noted when the pulse is being evaluated

4+

strong and bounding pulse is

0

an absent, not palpable pulse is

1+

a weak, barely palpable pulse is

apical pulse for 1 minute

before the administration of cardiac medications such as digoxin and beta-blockers, the nurse should check the

the counting of the apical pulse

before the administration of cardiac medications such as digoxin and beta-blockers, and in children younger than 2 years what should be assessed

a lack of peripheral perfusion

A pulse deficit indicates

respirations

a mechanism the body uses to exchange gases between the atmosphere and the blood and between the blood and the cells is called

intracranial pressure, head trauma and medications

what can decrease respiratory rate

both inspiration and expiration

One respiration includes

rate, depth, pattern, and sounds

when taking RR what should be assessed and documented

95% to 100%

normal oxygen saturation reading is

percentage of hemoglobin that is bound to oxygen

The pulse oximeter measures the

jaundice, nail polish, hypotension, hypotherma, acrylic nails, and anemia

what affects the Oxygen Saturation Measurement

The ear or bridge of the nose

if the client has a history of peripheral vascular disease where should the nurse place the oximeter

blood pressure

the force on the walls of an artery exerted by the pulsating blood under pressure from the heart is

systolic pressure

the peak of maximum pressure when ejection occurs is the

diastolic pressure

the blood remaining in the arteries when the ventricles relax exerts a force known as the

postural (orthostatic) hypotension

a normotensive client exhibits signs/symptoms and low blood pressure on rising to an upright position this is called

African Americans

blood pressure is highest in what race

decrease B/P

Antihypertensive medications and opioid analgesics can

males

which gender has higher blood pressure

smoking, activity, and body weight

what affects blood pressure

irregular heartbeat

The client is being started on intravenous trastuzumab, an antineoplastic medication. Which assessment finding indicates an adverse effect of the medication?; an

3 to 5 minutes after withdrawing the needle

If the client is receiving an anticoagulant when obtaining a blood specimen, the nurse should

carotid artery

what is located in the groove between the trachea and sternocleidomastoid muscle, medial to and alongside the muscle; the

brachial pulse

what is located is located above the elbow at the antecubital fossa, between the biceps and triceps muscles; the

femoral pulse

what is located is located below the inguinal ligament, midway between the symphysis pubis and the anterosuperior iliac spine; the

popliteal

what pulse is located behind the knee

posterior tibialis

what is is located on the inner side of the ankle, behind and below the medial malleolus; the

doralis pedis

what is is located on the top of the foot, in line with the groove between the extensor tendons of the great and first toes

Pulse Deficit

the peripheral pulse rate (radial pulse) minus the ventricular contraction rate (apical pulse) is called

98-106

what is the range for chloride

21-28

what is the range for bicarbonate

aPTT testing (Activated Partial Thromboplastin Time)

what is most commonly prescribed to monitor heparin therapy and screen for coagulation disorders

30-40 seconds

what is aPTT normal range

initiate bleeding precautions

if the aPTT is prolonged (more than 90 seconds) the nurse should

11-12.5 seconds

what is the range for prothrombin time

1 to 9 minutes

The normal range for bleeding time is

150,000-450,000

what is the normal range for platelet count

<15

The erythrocyte sedimentation rate of a male is

<20

The erythrocyte sedimentation rate of a female is

hemogloin

what is the main component of erythrocytes and serves as the vehicle for the transportation of oxygen and carbon dioxide

12-16

what is a normal hemoglobin range for females

14-18

what is the normal hemoglobin range for males

42% to 52%

Normal hematocrit values range for males is

37% to 47%

Normal hematocrit values range for females is

troponin

what is a is a regulatory protein found in striated muscle (heart and skeletal)

MI

a reading higher than 1.1- 1.5 ng/mL is consistent with a

Natriuretic peptides

what are neuroendocrine peptides that are used to identify clients with congestive heart failure

the more severe the CHF

The higher the BNP level, the more

less than 100

The BNP level should be

<100

the normal value for cholesterol LDL is

>60

what is the normal value for HDL

70 to 99 mg/dL

The normal fasting glucose concentration ranges from

8-12 hours

how long should the client fast before a fasting blood glucose is done

fasting blood glucose

what is used to diagnose diabetes mellitus and hypoglycemia; a

Glycosylated hemoglobin

what is blood glucose bound to hemoglobin

less than 6%

Glycosylated Hemoglobin should be

0.6 to 1.2

Normal creatinine values range from (in males)

0.5-1.1 mg/dL

Normal creatinine values range from Iin females)

9.0 to 10.5 mg/dL.

Normal calcium values range from

3.0 to 4.5 mg/dL

Normal phosphorus values range from

high calcium

hyperparathyroidism is caused by

5,000-10,000

what is the normal range for WBCs

urinalysis

what is is performed to determine the presence of urological or renal disorders

strict aseptic and use Standard Precautions

when drawing blood, what technique should be used

0.35

normal troponin levels should be less than

recovery room

postanesthesia care uni is known as the

airway, level of consciousness, oxygen saturation, cardiac status, and vital signs frequently 9 every 15-30 min); respiratory rate

what is should be assessed after the postanesthesia care unit; what is the priority

the immediate postoperative stage, the intermediate postoperative stage, and the extended postoperative stage

what are the 3 stages of recovery

immediate postoperative stage

The period of 1 to 4 hours after surgery is called the

Intermediate postoperative stage

The period of 4 to 24 hours after surgery is called the

Extended postoperative stage

what is the period at least 1 to 4 days after surgery called

expected finding

An absence of bowel sounds 12 hours after surgery is