A. SEC-502-RS-Dispositions Self-Assessment Survey T3 (1) . D. Oral temperature is easily accessible despite a client's position. Temporal artery thermometers Remote forehead thermometers use an infrared scanner to measure the temperature of the temporal artery in the forehead. Oxygen saturation is determined by the amount of oxygen bound to white blood cells. An older adult who has a respiratory rate of 16/min Describe emotional and physical factors that can cause the body temperature to rise or fall. If the pulse is irregular count for 1 full minute. Which of the following steps has the highest priority in the use of this piece of equipment for measuring body temperature? A charge nurse is evaluating a newly licensed nurse's documentation of vital signs for several clients. "Count the respiratory rate for 1 minute for clients who have a respiratory infection." B. The factors that can alter a patient's respiratory rate, Exercise, anxiety, fever, and a low hemoglobin level can all increase respiratory rate, The depth of a patient's breathing. For which of the following clients should the nurse to instruct the AP to obtain an electronic BP measurement? D. Brachial pulses are symmetrical. The expected reference range for respiratory rate in toddlers is 24 to 40/min, so this client will need to be assessed by the nurse, as they are exhibiting tachypnea. This finding indicates that interventions were effective. 98.6 is the average oral temperatures. 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. Our MCQ book is the key to achieving exam success and advancing your career. Which of the following statements should the nurse include? To determine precise tidal volume, a spirometer is needed, Estimate tidal volume by observing the expansion and symmetry of chest-wall movement during inspiration and expiration, The force that blood exerts against the vessel wall. If the radial pulse and pulse rate displayed on the oximeter are the same, the nurse should wait approximately 15 to 30 seconds, until a consistent SaO2 and pulse rate are displayed. Which of the following clients should the nurse identify as requiring further data collection due to bradycardia? A nurse is assisting with preparing an in-service about peripheral pulses for a group of staff nurses. The nurse should auscultate the apical pulse over the apex of the heart, which is located in the 4th intercostal space to the left of the sternum in infants and children less than 7 years of age. A nurse is caring for a client who has a heart rate of 120/min. A nurse is reinforcing teaching about thermoregulation to a group of newly licensed nurses. An older adult client who has pneumonia and a respiratory rate of 26/min after a position change A. B. B. D. An older adult who has an apical pulse rate of 96/min. A. Your temporal temperature is usually 0.5 to 1 degree Fahrenheit lower than your oral temperature. One advantage of oral temperature is that it is easily accessible despite a client's position. (Move the steps into the box on the right, placing them in the order of performance. Select the site for obtaining the measurement. B. In addition to gender and age, exercise, medications, decreased oxygen saturation, blood loss, and body temperature can all influence a patient's pulse rate. The nurse should check further and report the findings to the provider. C. Confirm the pulse rate displayed on the oximeter by palpating the radial pulse. For which of the following clients should the nurse plan to intervene? D. Withhold the client's antianxiety medication. C. A client who has an apical pulse rate of 84/min B. 4 Centre for Assessment of Medical Technology in rebro, Region rebro County, . Rectal thermometer devices met accuracy criterion of remaining within 0.5 C of core temperature 95% of the time. Body temperature is typically lower in older adults. The charge nurse should identify that this documentation is incomplete because it does not include the site from where the blood pressure was obtained. The nurse should identify that which of the following clients has a vital sign outside of the expected reference range? B. C. A 52-year-old client who has an SaO2 of 92% The main advantage of using a temporal artery thermometer is how quickly you can get a reading from it. 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. Do not use if patient reports ear pain or has excessive earwax, drainage from the ear, or sores or injuries around ear. D. Increase in preload. A nurse is reviewing documentation of vital signs by a newly licensed nursed for an assigned client. 10 Because core monitoring sites and most reliable near-core sites are somewhat An adolescent who is postoperative and has an SaO2 of 93% after receiving an opioid analgesic Range is from 96.8-100.4 is acceptable. D. A temporal probe thermometer uses infrared scanning to determine a client's temperature. C. Blood pressure decreases when the blood viscosity increases. Provide the client with low-sodium meals and snacks. Which of the following interventions should the nurse plan to recommend? The nurse should use a Doppler ultrasound stethoscope to auscultate the pulse. D. A pedal pulse that is weak upon palpation is an expected finding in an older adult. It measures the temperature of the blood flowing through the temporal artery, on the forehead. If it remains elevated, the nurse should notify the provider. 2. A. Diastolic blood pressure reflects the pressure exerted during contraction of the heart. Head and Neck: Performing the Weber's Test Chp 28 Place a vibrating tuning fork on top of the client's head. A. Windows, Doors & Conservatories. A nurse is reviewing the vital signs for a group of clients obtained by an assistive personnel. Measures skin temp over the temporal artery. Students also viewed C. The AP gently presses down with the pads of two to three fingers over the radial pulse site. Which of the following clients has a vital sign outside the expected reference range and requires intervention? To auscultate a patient's apical pulse accurately you position the bell or the diaphragm of your stethoscope over the point of maximal impulse, which is located, -At the 5th intercostal space at the left midclavicular line, The best way to determine the depth of a patient's respiration is to, -Observe the degree of chest wall movement during inspiration & expiration, You are measuring a patient's temperature orally. Pull the client pinna's up and back C. Document client temperature with "AX" next to the value D. Slide the The nurse should identify that a young adult client who has a radial pulse rate of 56/min is exhibiting bradycardia. A. D. "Radiation is the loss of body heat when a client is in close proximity to a cooler surface.". B. Especially because of COVID, researchers studied TATs along with more traditional thermometer types that involve more contact and read temperatures from other body parts: Temperature readings vary by body part, but doctors generally agree on these: And doctors still consider rectal temperature to be the most accurate.. Which of the following information should the nurse recommend be included about measuring body temperature? Another indicator of a patient's health status is pulse oximetry. But body temperature is different for infants and adults. It is the amount of air that moves in and out of the lungs with each breath. The oral temperature is an accurate measurement of body surface temperature but does not reflect core temperature. The nurse should expect the client to exhibit bradycardia, or a slow heart rate, due to their high level of physical fitness. A. Many facilities also consider pain level and oxygen saturation., _____ reflects the balance between heat the body produces and heat lost from the body to the environment., _____ is the measurement of heart . C. An older adult client has a tympanic temperature of 35.9 C (96.6 F). Rectal thermometry (RT) is the most common method used for measuring body temperature in the clinical assessment of cats. 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. This client's pulse rate is higher than the expected reference range. Wear gloves when measuring temperature rectally. B. Which of the following factors should the nurse include in their response? A temporal artery thermometer may be more expensive than other types of thermometers. A nurse is contributing to the plan of care for a client who has a temperature of 39.1 C (102.4 F). A. C. "Stage II hypertension is diagnosed when the blood pressure measurement is 132 over 86." Introduction: In the emergency department, pediatric and geriatric patients who present with illnesses and are unable to participate in oral evaluation of temperature must undergo a rectal temperature (RT) assessment. - perform hand hygiene - answer-1-perform hand hygiene 2-select dont tell the patient you are counting respirations. A nurse is caring for a client who has hypotension. C. Sinoatrial (SA) node B. A nurse is reviewing the vital signs for a group of clients to determine the effectiveness of interventions. -Your nursing interventions A. BP 130/82 mm Hg left arm, lying. The nurse should identify that the apical pulse is auscultated over the apex of the client's heart for a client who is older than 7 years of age. Temperature measurements were taken from each patient using the tympanic, temporal artery and contactless thermometers and oral electronic thermometer. A nurse is evaluating the effectiveness of interventions used to address clients' vital signs that were outside of the expected reference ranges. Design: . D. Discontinue IV fluids. -Oxygen saturation after a specific treatment (nebulizer therapy) Describe an environment in which you might find such organisms. 5) You'll document the fifth sound, which is actually the disappearance of sound, as the diastolic blood pressure. 4. You are assessing a patient's vital signs. And you must be sure to remove conditions that could affect its accuracy. usually slightly faster in woman and more rapid in infants and children. B. This is especially important if you develop any of the following symptoms: Pro. Document results. Avoid this route if patient has mouth sores or facial injuries. Inform the client to ask for assistance with getting out of bed. If the capillary refill time is not less than 2 seconds, the nurse should select another site to ensure an accurate measurement. A. 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