Vital Signs

1. What is blood pressure?

The force of blood pushing against artery walls.

2. What unit measures blood pressure?

Millimeters of mercury, or mm Hg.

3. What does systolic blood pressure measure?

Pressure when the heart contracts or squeezes.

4. What does diastolic blood pressure measure?

Pressure when the heart relaxes between beats.

5. Which blood pressure number is systolic?

The top number.

6. Which blood pressure number is diastolic?

The bottom number.

7. What is cardiac output?

The amount of blood the heart pumps in one minute.

8. What is stroke volume?

The amount of blood pumped out of a ventricle with one heartbeat.

9. What is the cardiac output formula?

Cardiac output = stroke volume × heart rate.

10. What is cardiac output if stroke volume is 70 mL and heart rate is 70/min?

4,900 mL/min, or 4.9 L/min.

11. How can blood loss affect blood pressure?

It reduces blood volume and can lower blood pressure.

12. What is blood viscosity?

The thickness of blood.

13. How does increased blood viscosity affect blood flow?

It increases resistance and can raise blood pressure.

14. What is vascular elasticity?

The ability of blood vessels to stretch and return to their shape.

15. How do stiff arteries affect blood pressure?

They tend to increase blood pressure.

16. What is peripheral vascular resistance?

The resistance blood encounters as it flows through vessels.

17. What is contractility?

The strength of the heart muscle’s contraction.

18. What is ejection fraction?

The percentage of blood in a ventricle pumped out with each beat.

19. What is preload?

The stretch of the ventricle as it fills before contracting.

20. What is afterload?

The resistance the heart must overcome to pump blood out.

21. What does the right side of the heart do?

Pumps blood to the lungs to receive oxygen.

22. What does the left side of the heart do?

Pumps oxygen-rich blood to the body.

23. How does blood travel from the body to the lungs?

Venae cavae → right atrium → tricuspid valve → right ventricle → pulmonary valve → pulmonary arteries → lungs.

24. How does blood travel from the lungs to the body?

Pulmonary veins → left atrium → mitral valve → left ventricle → aortic valve → aorta → body.

25. What equipment is used to measure blood pressure manually?

A blood pressure cuff with a pressure gauge and a stethoscope.

26. How should a seated patient be positioned for blood pressure measurement?

Back supported, feet flat, legs uncrossed, and arm supported at heart level.

27. Where is the upper-arm blood pressure cuff placed?

Snugly on the bare upper arm, about 1 inch above the elbow crease.

28. What happens if the blood pressure cuff is too small?

The reading may be falsely high.

29. What happens if the blood pressure cuff is too large?

The reading may be falsely low.

30. What are Korotkoff sounds?

Sounds heard over an artery as a blood pressure cuff slowly deflates.

31. Which Korotkoff sounds identify systolic and diastolic pressure?

The first sound identifies systolic; disappearance of sounds identifies diastolic.

32. How quickly should cuff pressure be released during a manual reading?

About 2 mm Hg per second.

33. Which arm conditions require avoiding or checking restrictions before taking blood pressure?

Dialysis access, injury, certain IV lines, or lymph-node surgery on that side.

34. Where can blood pressure be measured if the arms cannot be used?

The thigh, using an appropriate cuff and the popliteal artery behind the knee.

35. What factors can temporarily raise blood pressure?

Pain, anxiety, fear, exercise, caffeine, and nicotine.

36. What is normal adult blood pressure?

Systolic below 120 AND diastolic below 80 mm Hg.

37. What is elevated adult blood pressure?

Systolic 120–129 AND diastolic below 80 mm Hg.

38. What is stage 1 hypertension?

Systolic 130–139 OR diastolic 80–89 mm Hg.

39. What is stage 2 hypertension?

Systolic 140 or higher OR diastolic 90 or higher.

40. What makes severely elevated blood pressure a hypertensive emergency?

Acute organ damage, often with symptoms such as chest pain, breathing difficulty, or neurologic changes.

41. What is hypotension?

Blood pressure below the expected baseline; commonly below 90 systolic or 60 diastolic in adults.

42. What are common causes and symptoms of hypotension?

Causes include dehydration and bleeding; symptoms include dizziness, weakness, blurred vision, and fainting.

43. What is orthostatic hypotension?

A drop of at least 20 mm Hg systolic or 10 mm Hg diastolic within 3 minutes of standing.

44. How can the nurse reduce falls related to orthostatic hypotension?

Help the patient rise slowly and assist with standing and walking.

45. What is the usual resting adult pulse range?

60–100 beats/min.

46. What do tachycardia and bradycardia mean in adults?

Tachycardia is above 100/min; bradycardia is below 60/min.

47. What three pulse characteristics should the nurse assess?

Rate, rhythm, and strength.

48. How are heart sounds counted when measuring an apical pulse?

Count each complete “lub-dub” as one heartbeat.

49. What is a pulse deficit?

The apical rate minus the radial rate, counted simultaneously for one minute.

50. What do pulse strength ratings mean?

0 = absent; 1+ = weak; 2+ = normal; 3+ = increased; 4+ = bounding.

51. What does body temperature measure?

The balance between heat produced and heat lost.

52. What is the difference between core and surface temperature?

Core is deep inside the body; surface is the skin and nearby tissues.

53. What is a typical average body temperature?

37°C, or 98.6°F.

54. What is thermoregulation?

The body’s control of its temperature.

55. How does shivering affect body temperature?

Muscle activity produces heat.

56. How does vasoconstriction help conserve heat?

It narrows skin blood vessels, reducing heat loss.

57. How do sweating and vasodilation help cool the body?

Sweat evaporates, and widened skin vessels allow more heat to escape.

58. What is conduction?

Heat loss through direct contact with a cooler object.

59. What is an example of conduction?

Lying on a cold surface.

60. What is convection?

Heat loss caused by moving air.

61. What is an example of convection?

A fan blowing over the skin.

62. What is evaporation?

Heat loss when liquid changes into vapor.

63. What is an example of evaporation?

Sweat drying on the skin.

64. What is radiation?

Heat transfer to cooler surroundings without direct contact.

65. What is a fever?

An increased temperature caused by the brain raising the body’s temperature set point.

66. What temperature commonly indicates a fever?

About 38°C (100.4°F) or higher, depending on the measurement route and setting.

67. What do febrile and afebrile mean?

Febrile means having a fever; afebrile means not having a fever.

68. Why can a patient shiver while having a fever?

The brain’s higher temperature target makes the body produce more heat.

69. What does diaphoretic mean?

Sweating.

70. What is hyperthermia?

Overheating because the body gains or produces more heat than it can release.

71. What findings can occur with severe hyperthermia?

Weakness, thirst, dizziness, confusion, fainting, and a rapid pulse.

72. What nursing actions can help a patient with hyperthermia?

Move them to a cooler area, remove excess clothing, cool as directed, and monitor closely.

73. What is hypothermia?

A core temperature below 35°C, or 95°F.

74. What findings can occur with hypothermia?

Shivering, poor coordination, confusion, and slowed breathing as it worsens.

75. What are the five common temperature measurement sites?

Oral, axillary, tympanic, temporal, and rectal.

76. Where should an oral temperature probe be placed?

In a pocket under the tongue, with the lips closed.

77. How long do your notes recommend waiting after hot or cold intake or smoking before taking an oral temperature?

About 30 minutes.

78. How is an axillary temperature measured?

Place the covered probe against skin in the center of the armpit and lower the arm.

79. How is the ear positioned for tympanic temperature measurement in your notes?

Up and back for older children and adults; down and back for children under 3. Follow device instructions.

80. What can interfere with a temporal temperature reading?

Sweat, hair, or a head covering.

81. When should rectal temperature measurement be avoided?

When contraindicated, such as with certain rectal conditions, rectal surgery, or bleeding risks.

82. What temperature information should the nurse document?

The reading, measurement route, and relevant interventions or response.

83. What are inspiration and expiration?

Inspiration is breathing in; expiration is breathing out.

84. What happens to the diaphragm during inspiration?

It contracts and moves downward, helping air enter the lungs.

85. Where does gas exchange occur?

Between the alveoli and nearby pulmonary capillaries.

86. What counts as one respiration?

One breath in and one breath out.

87. What is the usual resting adult respiratory rate?

12–20 breaths/min.

88. What does eupnea mean?

Normal, comfortable breathing.

89. What does tachypnea mean?

Breathing faster than expected for the patient’s age.

90. What does bradypnea mean?

Breathing slower than expected for the patient’s age.

91. What does apnea mean?

Breathing stops.

92. What does dyspnea mean?

Feeling short of breath or having difficulty breathing.

93. When should respirations be counted for a full minute?

When the patient is ill or breathing is irregular or abnormal.

94. What should the nurse assess besides respiratory rate?

Rhythm, depth, breathing sounds, and effort.

95. What are retractions?

Skin pulling inward around the ribs or neck during breathing, showing increased breathing effort.

96. What are Cheyne–Stokes respirations?

Breaths deepen, become shallower, then pause in a repeating cycle.

97. What are Kussmaul respirations?

Deep, rapid, regular breathing associated with severe metabolic acidosis, such as diabetic ketoacidosis.

98. What is SpO₂, and what usual range is listed in your notes?

A pulse oximeter’s estimate of oxygen saturation; usually 95%–100%, unless another target is prescribed.

99. What can make pulse oximeter readings inaccurate?

Movement, cold skin, poor circulation, nail products, incorrect probe placement, and skin pigmentation.

100. What is the difference between hypoxemia and hypoxia?

Hypoxemia means low oxygen in the blood; hypoxia means inadequate oxygen in the tissues.