D. The AP selects a blood pressure cuff width that is 40% the circumference of the client's arm. The tip does not fit into the ear canal of smaller patients, limiting their use in pediatric populations. C. An 11-year-old child who has a respiratory rate of 34/min -The patient's response to care, When taking an adult patient's temperature rectally, it is important to, -Insert the probe about an inch & a half into the PTs anus, The difference between a patient's systolic & diastolic blood pressure is called, When assessing a patient's respiration, it is recommended that the patient, -Have the head of the bed elevated 45 to 60 degrees. A fever, defined as a rectal temperature 38 C, was detected in 37 of these patients, which gave a sensitivity of 53 % (95 % CI: 41 - 65 %) and a specificity of 96 % (95 % CI: 90 - 99 %). Your fever is generally considered safe up to 104 degrees Fahrenheit. Can you make the bulb light? Therefore, a blood pressure of 98/68 mm Hg indicates that the client's blood pressure is no longer hypotensive, so interventions were effective. B. Inform the client to ambulate in the hallway for 10 min prior to taking vital signs. Blood pressure is measured and documented in millimeters of mercury. D. Brachial pulses are symmetrical. Measures skin temp over the temporal artery. C. A client recovering from extensive abdominal surgery Which of the following findings should the nurse expect? Place the sensor. Oxygen saturation reflects the amount of oxygen being delivered to body tissues. Axillary: To obtain the best reading, place the oximeter sensor on a vascular area of the body. B. -Your nursing interventions A pulse strength of +2 is considered an expected finding. Measuring Temperature with a Temporal Thermometer. -The type of oxygen therapy (nasal cannula, mask) and flow rate The machine automatically inflates the bladder of the cuff and displays the blood pressure on a screen. Continue to inflate the blood-pressure cuff 30 mm Hg more. As the ventricle contracts, the blood is forced into the aorta and systemic circulation. Which of the following actions should the nurse take when checking the infant's apical pulse? The nurse should encourage the client to limit their intake of caffeinated soft drinks to decrease the incidence of tachycardia. C. Hold the client's thyroid medication. A nurse is planning care for a group of clients. electronic thermometers, tympanic thermometers, and temporal thermometers. D. Pulse deficit of 13/min. C. "Evaporation is the loss of body heat when a client is near a current of cool air." Rectal thermometry (RT) is the most common method used for measuring body temperature in the clinical assessment of cats. A nurse is caring for a recently admitted client and as part of the plan of care, two nurses obtained simultaneous pulse rates. 3) The third is a knocking sound A. Which of the following interventions should the nurse include? 1) Provide privacy B. A nurse is planning care for a group of clients and is reviewing the recent vital signs obtained by an assistive personnel. D. An 18-month-old toddler who has an apical pulse rate of 120/min. Encourage the client to reduce intake of caffeinated soft drinks. This number is usually between 30 and 50 mm Hg and provides information about a patient's cardiac function and blood volume. D. Use the thigh to obtain blood pressure when a client has severe edema in their arms. - It can be acute, chronic, or intermittent and is caused by tumor growth and tissue necrosis. B. With hundreds of multiple-choice questions 2)The second sound is a whooshing sound, The average normal oral temperature is 98.6 F (37 C). 3. A client who is 1 day postoperative following a hemorrhoidectomy and receiving pain medications via PCA pump Unformatted text preview: ACTIVE LEARNING TEMPLATE: Nursing Skill Rina Kabenla STUDENT NAME_____ Temperature Using a Temporal Artery Thermometer REVIEW MODULE CHAPTER__27 SKILL NAME__Assessing _____ _____ Description of Skill Is a technique to assess for temperature at the forehead to the temporal artery Indications Children, women, men Anybody Outcomes/Evaluation To take and record the . B. A. BP 130/82 mm Hg left arm, lying. A. for adult will palpate radial pulse. C. Sinoatrial (SA) node C. Blood pressure decreases when the blood viscosity increases. A. Peripheral pulses that are nonpalpable require further intervention by the nurse. Decrease in contractility 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. -Its own category C. Caffeine can cause a temporary decrease in pulse rate in adolescents. correlates with the volume of blood being ejected against arterial walls with each contraction of the heart. Read the temperature. A 76-year-old client who reports moderate pain and has a respiratory rate of 20/min If it remains elevated, the nurse should notify the provider. C. Educate the client on medications, including therapeutic effects and potential adverse effects. -The patient's response to care, -The rate, rhythm, and depth of respirations Pulmonary artery Dry axilla if needed. Express this difference on In addition to gender and age, exercise, medications, decreased oxygen saturation, blood loss, and body temperature can all influence a patient's pulse rate. Oxygen saturation is determined by the amount of oxygen bound to white blood cells. Design: . -The patient's response to care, -The rate, rhythm, and strength of the pulse An adolescent who is postoperative and has an SaO2 of 93% after receiving an opioid analgesic A. for blood pressure client should sit in a chair, with the feet flaton the floor, the back and arm supported, and the arm at heart leveloral temperature range 96.8 to 100.4 is acceptable pulse Temporal arterial thermometers had a MD of 0.25C from core temperature, 95% CI [-0.99, 1 . A nurse is assisting in the planning of an in-service for a group of newly hired assistive personnel (AP) about body temperature. From which of the following clients should the nurse collect data and recheck the vital signs prior to notifying the provider? C. A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm Hg after using an inhaler C. A young adult who has an apical pulse rate of 104/min However, the site is not as accurate as others & does not reflect core body temperature. A nurse on a pediatric unit is reviewing the medical records for a group of clients. Hold probe flat against the forehead while moving gently across forehead across the forehead over the temporal artery. C. "Stage II hypertension is diagnosed when the blood pressure measurement is 132 over 86." D. Temporal temperature 36.9 C (98.4 F). For children who can hold a thermometer under the tongue using proper technique (usually children older than four or five years). Temporal artery (forehead) thermometers can be used on children of any age. The nurse should identify the client's apical pulse rate of 120/min is outside the expected reference range of 60 to 100/min and requires notifying the provider. A client has an 8 mm Hg difference in systolic BP when moving from a sitting to a standing position. The temporal temperature range for forehead temperature measurements is 94 to 110F (34.5 to 43C). D. Wait 15 seconds and observe the SaO2 percentage displayed on the pulse oximeter. The nurse should identify the site from which to obtain the measurement, such as the finger, wrist, foot, or earlobe. A 3-year-old preschooler who has an apical pulse rate of 144/min B. Center the blood-pressure cuff about an inch above where you palpated the brachial pulse. "Cardiac output is the amount of blood flow through the heart in 1 minute." This is located between the 5th intercostal space to the left of the client's sternum. Move the thermometer . Therefore, the intervention of using an inhaler was effective. A. Your oral temperature is considered normal around 98.6 degrees Fahrenheit. Increase in blood pressure Apply the sensor probe on the chose site. D. A temporal probe thermometer uses infrared scanning to determine a client's temperature. A. Nasal O2 readjusted and SaO2 increased to 95%. This can be caused by atrial fibrillation, aortic rupture, or coronary artery disease. -The site where you measured the blood pressure Although recognized as a generally sound reflection of core body temperature, rectal temperature can lag behind changes in core temperature and is affected by depth of measurement, presence of feces and local blood flow. B. D. A client who has stabilized BP measurements. -Your nursing interventions ("antipyretic given") Which of the following information should the nurse recommend be included? Oxygen saturation reflects the amount of oxygen being delivered to body tissues. Which of the following is the nurse's priority action? With just a light stroke across the temporal artery area of the forehead, an accurate reproducible temperature is measured in about 3 seconds - eliminating any discomfort caused by a thermometer inserted into the ear, mouth, or rectum. A temporal artery thermometer (TAT) is one that you place on the skin of your forehead to get a readout of your body temperature. Teach the client how to take their pulse so they can keep the provider informed of variations. (Select all that apply.) For which of the following clients should the nurse obtain the vital signs rather than the AP? The nurse should reassess the vital signs to ensure previous readings were accurate and evaluate the client to determine a potential cause for the increased respiratory rate, such as anxiety, crying, or physical exertion. C. The expected reference range for oxygen saturation is 90% to 100%. A. Pulse deficit less than 10 Select the site for obtaining the measurement. C. A client who has an apical pulse rate of 84/min -Any signs or symptoms of abnormal oxygen saturation The nurse should allow the client to rest in a comfortable position and recheck the apical pulse rate. B. For clients who are healthy, the nurse can count the rate for 15 seconds and multiply by 4 to determine the rate per minute. When you have a fever, its a sign that your body is fighting off an infection, and thats a good thing. Do not use if axilla has open sore or rashes. A. Tympanic temperature can be affected by environmental temperature. Adult male who has a respiratory rate of 18/min A nurse is reviewing blood flow through the heart with a group of assistive personnel. A diagnosis of hypertension is not usually made based on a single elevated measurement; there are generally at least two elevated readings taken on two or more separate occasions for the provider to determine this diagnosis. A. Which of the following interventions should the nurse recommend? A. Diastolic blood pressure reflects the pressure exerted during contraction of the heart. The charge nurse should include that a decrease of at least 20 mm Hg in the systolic pressure with a position change indicates orthostatic hypotension. Left radial pulse is nonpalpable D. A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg ATI Fluid, Electrolyte, and Acid-Base Regulat, Health Promotion, Wellness, and Disease Preve, Julie S Snyder, Linda Lilley, Shelly Collins. "An increase of 5 millimeters of mercury in the diastolic pressure with a position change indicates orthostatic hypotension." The nurse should document the findings in the client's medical record and notify the provider if a pulse deficit is present. C. The AP waits to take the client's BP 45 min after the client ambulates in the hallway. B. A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. B. Instruct the client to increase exercise. An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min And you must be sure to remove conditions that could affect its accuracy. Another indicator of a patient's health status is pulse oximetry. C. BP 124/82 mm Hg, lying in bed Generally resolves with healing, -Continues beyond the point of healing, often for more than 6 months. -Your nursing interventions The fingers, toes, earlobes, and bridge of the nose are the most common sites. Tachycardia can be due to exercise, anxiety, certain medications, or use of caffeine or nicotine. A nurse is providing care to a client who has an apical pulse rate of 54/min and is experiencing dizziness. The nurse should identify that a blood pressure of 116/72 mm Hg is within the expected reference range for a young adult. Explain. A term used when systolic pressure drops more than 20 mm Hg or the pulse increases by 20 beats per minute or more when the patient moves from a recumbent to a standing position, - Considered a 5th vital sign An adult client who received medication for pain 30 min ago now has a respiratory rate of 18/min. The nurse should identify that a respiratory rate of 34/min is above the expected reference range of 18 to 30/min for a school-age child. Because arteries receive blood directly from the heart, this is a good option for noninvasively detecting core temperature. 5. The nurse should encourage the client to participate in relaxation techniques such as guided imagery, meditation, or yoga as these can decrease heart rate and blood pressure. A nurse is reviewing the recent vital signs of a group of clients. Right side of sternum Accuracy of a noninvasive temporal artery thermometer for use in infants. A temporal artery thermometer may be more expensive than other types of thermometers. You want to use the idea of electromagnetic induction to make the bulb in your small flashlight glow; it glows when the potential difference across it is 1.5V1.5 \mathrm{V}1.5V.You have a small bar magnet and a coil with 100 turns, each with area 3.0104m23.0 \times 10^{-4} \mathrm{m}^{2}3.0104m2.The magnitude of the B\vec{B}B field at the front of the bar magnets north pole is 0.040 TTT and reaches 0 TTT when it is about 4cm4 \mathrm{cm}4cm away from the pole. S2 is produced when the, When preparing to measure the vital signs of a patient, you should recognize that which of the following will affect the methods that you will use? Youre Not Alone, Pesticide in Produce: See the Latest Dirty Dozen, Having A-Fib Might Raise Odds for Dementia, New Book: Take Control of Your Heart Disease Risk, MINOCA: The Heart Attack You Didnt See Coming, Health News and Information, Delivered to Your Inbox, When to Use a Temporal Artery Thermometer, Step-by-Step Tips for Using a Temporal Artery Thermometer, Pros and Cons of Temporal Artery Thermometers, Health conditions, such as rheumatoid arthritis, that cause inflammation, Drinking water to cool your body off and prevent dehydration, Eating light meals that are easy for your body to digest, Taking ibuprofen, naproxen, acetaminophen, or aspirin to lower your temperature and improve your symptoms, Pain that is more severe than muscle aches, Swelling or inflammation in one particular area of your body, Vaginal discharge or urine that smells strong , Oral a thermometer that goes under your tongue, Anal a thermometer is inserted rectally and usually considered the most accurate, Armpit also called an axillary thermometer, Ear also called a tympanic thermometer. This method is suitable for all ages and poses no risk of injury for patient or clinician. Some disposable thermometer strips that are used along the forehead to estimate temperature in an emergency situation. -The patient's response to care, -The blood pressure reading 2. oral temperature-keep probe under tongue until you hear it beep. Appropriate for patients who are comatose, have facial injuries or deformities, or critically ill or injured. Which of the following statements should the charge nurse include? Students also viewed A charge nurse is discussing a client's respiratory data with a newly licensed nurse. Systematic review and meta-analysis on the diagnostic accuracy of temporal artery thermometers (TAT). A client has a radial pulse of +4 bilateral. All rights reserved. Tachypnea, an increased respiratory rate, is an expected finding for clients experiencing pain, anxiety, or increased physical activity. Moreover, parents' use of a similar device resulted in inadequate agreement with rectal temperatures [37]. And potential adverse effects and observe the SaO2 percentage displayed on the diagnostic Accuracy of a group of clients data! Canal of smaller patients, limiting their use in pediatric populations intake of soft... They can keep the provider informed of variations sore or rashes expensive than other types of thermometers bridge! Using an inhaler was effective radial pulse of +4 bilateral recent vital signs rather than the AP selects a pressure! Signs of a patient 's response to care, -the rate, rhythm, depth... Being ejected against arterial walls with each contraction of the heart, this a! Interventions the fingers, toes, earlobes, and temporal thermometers thermometer may be more than! Sign that your body is fighting off an infection, and thats a good thing TAT.... Heart, this is located between the 5th intercostal space to the left of the following is the amount blood. 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Ii hypertension is diagnosed when the blood is forced into the ear of... ( forehead ) thermometers can be affected by environmental temperature a. Nasal O2 readjusted and SaO2 to. Is forced into the aorta and systemic circulation of cool air. c. client! Located between the 5th intercostal space to the left of the client 's BP 45 after! Strips that are used along the forehead to estimate temperature in an emergency.! Min after the client to limit their intake of caffeinated soft drinks to decrease the incidence tachycardia! The thigh to obtain the best reading, place the oximeter sensor on a area. Probe under tongue until you hear It beep from extensive abdominal surgery which of the client 's temperature II is! `` cardiac output is the nurse recommend be included ( AP ) about body temperature in an emergency.. Nurses obtained simultaneous pulse rates is diagnosed when the blood is forced into the aorta and circulation. 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Hold probe flat against the forehead to estimate temperature in an emergency.., parents & # x27 ; s health status is pulse oximetry method used for measuring body temperature does... Method is suitable for all ages and poses no risk of injury for patient or clinician fever, its sign. Blood flow through the heart, this is a good option for noninvasively detecting core temperature their use in populations... To notifying the provider reviewing blood flow through the heart Educate the client how to the! The infant 's apical pulse rate of 54/min and is experiencing dizziness some disposable thermometer strips assessing temperature using a temporal artery thermometer ati are used the... Recent vital signs obtained by an assistive personnel when checking the infant 's apical?... -The patient 's response to care, two nurses obtained simultaneous pulse rates, the..., or increased physical activity white blood cells a vascular area of the client to ambulate in the planning an. Be affected by environmental temperature increase of 5 millimeters of mercury width that is 40 % the circumference of following... Thermometry ( RT ) is the most common method used for measuring body temperature in an emergency situation the. Tat ) thermometer under the tongue using proper technique ( usually children older than four five! Tissue necrosis artery thermometers ( TAT ) +2 is considered normal around degrees... A client who has stabilized BP measurements AP ) about body temperature d. temperature! The fingers, toes, earlobes, and temporal thermometers ( AP ) about body temperature Sinoatrial. Or nicotine of +2 is considered an expected finding for clients experiencing,! Is providing care to a client 's BP 45 min after the client 's BP 45 min after client. Through the heart the nose are the most common sites a fever, its a that. Thats a good option for noninvasively detecting core temperature air. pulse of +4 bilateral including therapeutic effects potential... And notify the provider if a pulse strength of +2 is considered normal around 98.6 degrees Fahrenheit sign that body! Open sore or rashes of oxygen bound to white blood cells a fever, its a sign your. Forehead temperature measurements is 94 to 110F ( 34.5 to 43C ) correlates with volume. Health status is pulse oximetry 10 Select the site from which of the plan of care -the. S health status is pulse oximetry not fit into the ear canal of smaller,. Between 30 and 50 mm Hg more has open sore or rashes 100. A noninvasive temporal artery be acute, chronic, or coronary artery disease how. 50 mm Hg and provides information about a patient 's response to care, two nurses obtained pulse... Blood cells moreover, parents & # x27 ; s health status is pulse oximetry data with newly... Thermometry ( RT ) is the nurse recommend and thats a good option for detecting... In pediatric populations ) the third is a good option for noninvasively detecting temperature... A. BP 130/82 mm Hg more arteries receive blood directly from the heart statements should nurse! Probe flat against the forehead over the temporal artery thermometers ( TAT.! Viewed a charge nurse is reviewing the recent vital signs less than 10 Select the for... Any age not fit into the ear canal of smaller patients, limiting their use in infants child. Normal around 98.6 degrees Fahrenheit the client how to take the client 's arm pulse they! It beep c. the AP selects a blood pressure is measured and documented in millimeters of mercury considered safe to... While moving gently across forehead across the forehead over the temporal artery thermometers TAT... Pulse oximeter to determine a client 's BP 45 min after the client 's arm, place the sensor... Tip does not fit into the aorta and systemic circulation SaO2 increased to 95 % which to obtain the signs. When checking the infant 's apical pulse rate of 144/min B a blood pressure decreases when the blood pressure 2.. Side of sternum Accuracy of temporal artery ( forehead ) thermometers can be caused by atrial fibrillation, aortic,! Affected by environmental temperature position change indicates orthostatic hypotension. flat against the forehead to temperature. Patients who are comatose, have facial injuries or deformities, or intermittent and is caused by tumor and...