A nurse is evaluating the effectiveness of interventions provided to a client who was admitted for decreased peripheral circulation. Note the number at which the pulse reappears. A nurse is assisting with preparing an in-service about peripheral pulses for a group of staff nurses. Rectal thermometer devices met accuracy criterion of remaining within 0.5 C of core temperature 95% of the time. 5. This finding indicates that interventions were effective. Expected finding is the client hears sound equally in both ears (negative weber test) 9. D. SaO2 of 96%. Conditions such as decreased thyroid activity, hyperkalemia, an irregular cardiac rhythm, and increased intracranial pressure can all slow the heart rate. Tachycardia can be caused by stress or anxiety. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart? Which of the following factors should the nurse include in their response? Direct sunlight, cold temperatures or a sweaty forehead can affect temperature readings. Read the instructions for your particular thermometer. A nurse is reviewing the vital signs for a group of clients to determine the effectiveness of interventions. C. An older adult client has a tympanic temperature of 35.9 C (96.6 F). D. Oral temperature is easily accessible despite a client's position. An older adult client who has pneumonia and a respiratory rate of 26/min after a position change Temperature measurements were taken from each patient using the tympanic, temporal artery and contactless thermometers and oral electronic thermometer. D. A 78-year-old client who has a temperature of 35.9C (96.6F). Temporal thermometers contain an infrared scanner measuring the heat on the surface of the skin, which results from blood moving through the temporal artery in the forehead. B. This finding requires intervention by the nurse. Align the sensor with the middle of your forehead for the most accurate reading.. Purpose: To evaluate the agreement of temporal artery temperature (Tat) with esophageal temperature (Tes) and oral temperature (Tor), and explore potential factors associated with the level of agreement between the thermometry methods in different clinical settings. Which of the following actions should the nurse take to improve the client's heart rate? -Your nursing interventions This method is suitable for all ages and poses no risk of injury for patient or clinician. Obtain a manual blood pressure reading from the client. A rectal temperature is 0.5 F (0.3 C) to 1 F (0.6 C) higher than an oral temperature. B. A charge nurse is evaluating a newly licensed nurse's documentation of vital signs for several clients. C. BP 124/82 mm Hg, lying in bed C. Place the sensor flush on the patient's forehead. A. Is It (Finally) Time to Stop Calling COVID a Pandemic? B. The temporal artery reading is obtained by scanning the thermometer across the patient's forehead. The nurse should allow the client to rest in a comfortable position and recheck the apical pulse rate. A. Pulse deficit of 0 A nurse is observing an assistive personnel (AP) who is obtaining a blood pressure reading from a client. b. . We performed a retrospective analysis of over 1.8 million emergency department electronic health records to identify assess the performance of TAT measurement using patients with near-contemporaneous temperature measurements taken . 1) Provide privacy A 3-year-old preschooler who has an apical pulse rate of 144/min Right side of sternum A. 4 Centre for Assessment of Medical Technology in rebro, Region rebro County, . Measuring body temperature | Nursing Times. A charge nurse is discussing the physiology of the heart with a newly licensed nurse. The AP pulls the pinna up and back when obtaining a tympanic temperature. exchange of oxygen and carbon dioxide between atmosphere and the cells of the body. The nurse should identify that a pulse strength of +1 indicates that the pulse is weak or diminished upon palpation. Know your thermometer. D. A temporal probe thermometer uses infrared scanning to determine a client's temperature. -The site where you measured oxygen saturation Mobility and Immobility: Evaluating a Client's Use of a Walker (CP card #107) -DO NOT use walker to stand up -Flex elbows 20-30 degrees -advance walker approximately 12 inches, advance affected leg (LEFT), then move unaffected leg (RIGHT) Students also viewed Chapter 6. pg.162-164 Monitoring Intake and O 45 terms Andrea_Messer NUR 115 exam 1 -You might not hear a 5th Korotkoff sound, You are assessing the vital signs of a newly admitted patient. Next, the nurse should apply the sensor probe to the selected site and instruct the client not to move. What is the temporal temperature range? Blood pressure is measured in millimeters of mercury (mm Hg) and is expressed as a fraction. D. Withhold the client's antianxiety medication. Which of the following findings indicate the intervention was effective? A charge nurse is discussing a client's respiratory data with a newly licensed nurse. Methods: A convenience sample, using a within-subject design, was used to evaluate the . A nurse is caring for a client who has an increase in cardiac afterload. B. Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall. Which of the following information should the nurse recommend be included? Vital signs include temperature, pulse, respiration (collectively called TPR), and blood pressure (BP). This method is reserved for clients in stable condition with BP measurements within the expected reference range. 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.. When obtaining vital signs, the AP should count a client's respirations when they are relaxed and at rest. 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. Accuracy of a noninvasive temporal artery thermometer for use in infants. C. Place the stethoscope over the 4th intercostal space to the left of the sternum. 60-100 BPM. Select the site for obtaining the measurement. -Your nursing interventions -Any signs or symptoms of temperature alterations -Pulse oximetry is a quick and noninvasive way to measure a patient's oxygen saturation. D. A client who has a blood pressure of 162/102 mm Hg has stage II hypertension. Which of the following findings indicate an intervention was effective? correlates with the volume of blood being ejected against arterial walls with each contraction of the heart. A. A nurse is discussing oxygen saturation with a client. "Cardiac output is the amount of blood flow through the heart in 1 minute." -The patient's response to care, -The rate, rhythm, and depth of respirations It involves observing the rate, depth, and rhythm of chest-wall movement during inspiration and expiration. B. Sixteen temperature samples compared temporal artery thermometers to core temperatures. 3)Inflate the blood-pressure cuff with your dominant hand while you use the fingertips of your nondominant hand to palpate the brachial pulse. But body temperature is different for infants and adults. D. The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second. D. An older adult who has an apical pulse rate of 96/min. The fingers, toes, earlobes, and bridge of the nose are the most common sites. SaO2 is the indicator of the amount of oxygen transported to body tissues and the expected reference range is greater than 95%. Another indicator of a patient's health status is pulse oximetry. Left radial pulse is nonpalpable Sites reflecting core temperatures are more reliable indicators of body temperature because surface temperature varies depending on blood flow to the skin and the amount of heat lost to the external environment. U.S. STD Cases Increased During COVIDs 2nd Year, Have IBD and Insomnia? A school-age child who received two units of packed red blood cells now has a BP of 76/54 mm Hg. B. Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall. C. Hold the client's thyroid medication. Temporal Temperature Measurement Method 1) Provide privacy 2) Remove protective cap and wipe lens of device with alcohol swab -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. The 'gold' standard is to compare the TAT to the Pulmonary Artery Catheter thermometer (PAT), which measures core temperature. A young adult client who has a radial pulse rate of 56/min A preschooler who has an apical pulse rate of 108/min B. B. The pros: A remote temporal artery thermometer can record a person's temperature quickly and are easily tolerated. You place the covered probe, -In the posterior lingual pocket lateral to the midline, NURS 3440 Exam 2 Gastrointestinal and Hepatob, Promoting Health: The Middle and Older Adult, NURS 3631 Pediatrics Module 4 CH 18 Which of the following actions should the nurse take when checking the infant's apical pulse? oral temperature-keep probe under tongue until you hear it beep. - Inject the medication. To establish an accurate baseline of the patient's respiration, you, -Observe the PTs chest movements while appearing to assess his pulse. A. C. Apical pulse greater than radial A temporal artery thermometer may be more expensive than other types of thermometers. B. Respirations observed as even, nonlabored at 20/min with client in supine position -The patient's response to care, -The location, intensity, quality, duration, and pattern of the pain For example, if you have a two-year-old and use a temporal artery thermometer, you may get a reading of 101 degrees Fahrenheit. Which of the following manifestations requires follow up by the nurse? A nurse is preparing to obtain a young client's apical pulse. -The patient's response to care, -The blood pressure reading A nurse is contributing to the plan of care for a client who is experiencing tachycardia. the be of and to a in that for have it on i with not as you this by or at do from we an will they but all he your if can their one more which use about other make his what there would who my say so when time new our get some work may out year also people good no go up these than take any see its how them only like into know need should just most first such her me find many give way information . D. Ensure the client has been taking medications as prescribed. B. A newer method to measure temperature called temporal artery thermometry is also considered very accurate. 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 client's diaphoresis will make it difficult to obtain an accurate temperature via the tympanic membrane or temporal artery. A. 1) Provide privacy D. An older adult client who received an antipyretic medication 1 hr ago now has a temperature of 38.7 C (101.6 F). A nurse is reviewing the recent vital signs of a group of clients. Which of the following steps has the highest priority in the use of this piece of equipment for measuring body temperature? Keep your mouth closed and keep the thermometer in place for about 40 seconds. C. SaO2 93% left index finger, client sleeping, nasal O2 dislodged. C. Right atrium Use a regular digital thermometer to take a rectal temperature. Windows, Doors & Conservatories. Which of the following clients' vital signs should the nurse identify is outside the expected reference range and notify the provider? Monitoring of the five important vital signsheart rate, blood pressure, respiratory rate, oxygen saturation, and temperature [1,2,3]allow accurate diagnosis and treatment of pathological conditions. data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAKAAAAB4CAYAAAB1ovlvAAAAAXNSR0IArs4c6QAAAw5JREFUeF7t181pWwEUhNFnF+MK1IjXrsJtWVu7HbsNa6VAICGb/EwYPCCOtrrci8774KG76 . Measuring Temperature with a Temporal Thermometer. The nurse should instruct the AP to obtain blood pressure measurements in the thigh when a client has severe edema in the arms or a shunt in place for dialysis. 2. Notify the charge nurse of the client's blood pressure reading. Measuring Temperature with Tympanic thermometer. The cons: Oral: Into the mouth for children 4 to 5 years and older. a. increases the flow of auxin down the shoot, c. produces a plant that will grow taller, d. produces a plant that will grow fuller. -Any signs or symptoms of pulse alterations D. Encourage the client to take a warm shower. While the notation of the client ambulating in the hall can be a factor in the tachycardia, the nurse does not indicate they will re-evaluate the pulse rate after the client has rested. A. 7)Remove the blood-pressure cuff, perform hand hygiene, and document your findings. Slide straight across forehead, to thetemporal area not down the side of the face. Which of the following actions should the nurse take next? D. Discontinue IV fluids. The nurse should identify that cardiac output is the amount of blood pumped by the ventricles through the heart within 1 min. Instruct the client to increase exercise. C. A young adult who has an apical pulse rate of 104/min (Select all that apply), -Patient is 60 pounds overweight, patient is reporting a "stuffy" nose, patient is taking digoxin (Lanoxin), patient had a mastectomy 2 years ago. B. You may find that a temporal artery thermometer costs more than other thermometer options because of its infrared technology. A temporal artery thermometer (TAT) is one that you place on the skin of your forehead to get a readout of your body temperature. Bradycardia. B. A 17-year-old who has a respiratory rate of 16/min 3b ). It provides an accurate arterial temperature." P 342 C. "A decrease of 20 millimeters of mercury in the systolic pressure with a position change indicates orthostatic hypotension." 4. D. "A blood pressure measurement of 176 over 102 is classified as a hypertensive crisis.". D. The AP selects a blood pressure cuff width that is 40% the circumference of the client's arm. 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