Temperature Basics
This temperature site gives the most accurate core temperature in adults.
Rectal
This pulse site is used when rhythm is irregular.
Apical
One respiration includes what two actions?
One inhalation and one exhalation
Blood pressure is the force of blood against what?
Arterial walls
Objective data are best described as data you can do what with.
Measure or observe
Why are oral temperatures unreliable right after smoking or chewing gum?
Vasoconstriction and airflow alter readings. How long should you wait?
A normal adult pulse strength is documented as:
2+
Normal adult breathing with a steady rhythm is called:
Eupnea
The systolic blood pressure represents pressure when the heart is doing what?
Contracting
Why should vital signs be taken before administering medications that affect the heart or blood pressure?
To establish a baseline and ensure it is safe to give the medication. Do you understand baseline and trending of vitals?
When taking a tympanic temperature, why should the nurse pull the pinna up and back for adults and down and back for children under 3 years old?
To straighten the ear canal so the thermometer can accurately measure heat from the tympanic membrane.
Pulse rhythm should be assessed for how long if irregular?
One full minute
Hypoventilation causes CO₂ to do what?
Increase (CO₂ retention)
A BP of 110/72 has a pulse pressure of:
38 mm Hg. Are you concerned?
Why is it important to reassess and report vital signs that do not match the patient’s appearance?
Because abnormal or inconsistent findings may indicate measurement error or clinical deterioration.
Why are rectal temperatures not routinely measured in infants younger than 3 months old unless specifically ordered by a healthcare provider?
Because rectal tissue is fragile in young infants, and the procedure carries a risk of rectal injury or perforation, making it unsafe without provider direction.
Why should peripheral pulses always be assessed bilaterally?
To compare for equality; unequal pulses may indicate impaired circulation, arterial narrowing, or obstruction.
Why should respirations be counted before telling the patient?
Awareness may alter breathing pattern
Orthostatic hypotension is diagnosed when systolic BP drops by how much?
20 mm Hg
After delegating vital signs to a UAP, what responsibility remains with the RN?
Interpreting the vital signs, reassessing abnormal findings, and taking appropriate action. Do you understand the 5 rights of delegation?
At what body temperatures is a patient considered to have hypothermia and hyperthermia?
Hypothermia: Core temperature below 35°C (95°F) Hyperthermia: Core temperature above 40°C (104°F). When do we say a patient is febrile?
Where is the correct landmark for assessing the apical pulse in an adult?
At the 5th intercostal space, left midclavicular line.
Shallow, rapid breathing is often seen in patients experiencing what?
Pain or anxiety
Why does blood pressure tend to increase with age?
Arteries become stiffer and less elastic
Why should BP not be taken on an arm with a running IV?
It can stop infusion, cause infiltration, and alter readings. What other factors would make you not use a specific arm?