Vital Signs & Measurements
The expected normal core body temperature range for an adult client.
What is 36°C to 38°C (96.8°F to 100.4°F)?
In the PQRST pain assessment tool, the letter "P" stands for these factors
What are Precipitating or Provoking factors?
When monitoring a client receiving opioids, this clinical sign typically precedes severe respiratory depression
What is sedation?
The ethical principle defined as duty to do good and actively relieve suffering
What is Beneficence?
Older adults typically exhibit this difference in baseline body temperature compared to younger adults
What is a slightly lower baseline temperature?
The expected normal resting respiratory rate range for an adult
What is 12 to 20 breaths per minute?
This behavioral pain observation scale (Face, Legs, Activity, Cry, Consolability) is used for clients who cannot reliably self-report
What is the FLACC scale?
When administering a medication with a prescribed range order (e.g., Morphine 2–4 mg IV), the nurse should initially adopt this dosing approach
What is starting conservatively?
The legal term designating professional negligence by a licensed nurse
What is malpractice?
In older adults, the absence of a fever does not rule out this severe condition
What is an infection?
The required duration for measuring an apical pulse if the radial rate is irregular or outside expected limits.
What is 1 full minute?
Pain originating from tissue or organ damage that is typically described as aching or throbbing
What is nociceptive pain?
Two common adverse systemic effects of opioids besides respiratory depression and sedation
What are constipation, nausea, itching, or orthostatic hypotension?
The ethical principle of "doing no harm," which obligates nurses to avoid both unsafe medication administration and leaving pain undertreated
What is Nonmaleficence?
The difference calculated by subtracting the radial pulse rate from the apical pulse rate
What is a pulse deficit?
The clinical error in blood pressure measurement caused by applying a cuff that is too narrow or small for the client's arm.
What is a falsely elevated blood pressure reading?
Normal vital signs prove that a client is not experiencing pain.
Hint: T/F
What is False? (Chronic pain often exists without dramatic vital sign changes; normal vitals are supporting data and do not rule out pain
If pain remains uncontrolled after administering prescribed analgesics, the nurse must reassess, document, and report findings to this individual
What is the RN or primary healthcare provider?
The ethical principle that protects a client's right to make autonomous, informed decisions about their healthcare
What is Autonomy?
Before assisting a client to stand during an orthostatic blood pressure assessment, the nurse monitors for these safety risks to prevent falls
What are dizziness, weakness, syncope, or blood pressure drops?
This abnormal respiratory pattern features alternating cycles of shallow-to-deep breathing followed by periods of apnea, often associated with heart failure or stroke.
What are Cheyne-Stokes respirations?
A nonpharmacological cutaneous therapy that uses mild electrical currents to relieve pain.
What is TENS (Transcutaneous Electrical Nerve Stimulation)?
This noninvasive monitoring tool tracks carbon dioxide exhaled by the patient and helps detect opioid-induced ventilatory impairment in post-op clients
What is capnography?
The continuous four-step nursing sequence required for safe pain management and legal documentation
What is Assessment → Intervention → Reassessment → Documentation?
Nonverbal behavioral cues indicative of pain in a client with advanced dementia
What are guarding, grimacing, agitation, withdrawal, or changes in sleep/appetite?