Chapter 5
Patient Findings
Temperature 37.0°C (98.6°F)
temporal Pulse 102 beats/min and irregular
Respirations 16 breaths/min
BP right arm 162/88 mm Hg
Symptom of fast
irregular heartbeat Symptom of dizziness
What are the main vitals?
Temperature, pulse, respirations, BP, and oxygen saturation
SAFETY ALERT The nurse may call a rapid response team if they have an intuitive sense that something is going wrong with the patient or if the patient displays the following:
An acute change in mental status
Stridor
Respirations less than 10 or greater than 32 breaths/min
Increased effort to breathe Oxygen
saturation less than 92%
Pulse less than 55 or greater than 120 beats/min
Systolic BP less than 90 or greater than 170 mm Hg
Temperature less than 35°C (95°F) or greater than 39.5°C (103.1°F)
New onset of chest pain Agitation or restlessness
maintain controlled BP:
If you are more than 10% above ideal body weight, lose weight.
Limit alcohol to no more than 1 oz of ethanol per day.
Exercise regularly.
Limit sodium intake to less than 100 mmol/l/day.
Quit smoking.
Reduce dietary saturated fat and cholesterol.
What order do you check vitals in?
Temperature, pulse, respirations, and blood pressure
In which of the following situations is it protocol for the nurse to take a client's vital signs? Select all that apply.
Upon admitting a client to hospital
At a health care screening
When medications are given for a cardiac arrhythmia
Following a diagnostic procedure
Prior to an invasive procedure
What are various measurements of the human body, including height and weight, called?
Anthropometric
Which technique demonstrates the proper positioning of the client's arm by a nurse when measuring a blood pressure?
Client sitting with arm slightly flexed and even with the heart
After teaching a group of students about blood pressure and Korotkoff's sounds, the instructor determines that the teaching was successful when the students identify which of the following?
Phase II sounds appear muffled and swishing.