For children who can hold a thermometer under the tongue using proper technique (usually children older than four or five years). An older adult client who has pneumonia and a respiratory rate of 26/min after a position change C. "The body increases body temperature through the process known as vasodilation." B. As you scan it, the thermometer is taking hundreds of measurements per second of the heat the persons body is giving off.. -The site where you measured oxygen saturation A.Encourage the client to change positions slowly. 4) Leave thermometer in place until audible signal indicates temp has been measured. Temporal artery (forehead) thermometers can be used on children of any age. D. A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg 4. 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 3) Position probe flat on center of patient's forehead at midpoint between the hairline and eyebrow Measures skin temp over the temporal artery. Encourage the client to reduce intake of caffeinated soft drinks. Turn on the digital thermometer. Which of the following factors should the nurse include in the teaching? A nurse is discussing the use of the client's thigh for blood pressure measurements with an assistive personnel (AP). An adolescent who has a respiratory rate of 20/min We use cookies to personalize and improve your experience on our site. 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. A. D. Encourage the client to take a warm shower. C. A toddler who received an antibiotic injection now has a heart rate of 148/min while sleeping in their parent's arms. Document results. Therefore, the nurse should direct the AP to obtain this client's temperature rectally. From which of the following clients should the nurse collect data and recheck the vital signs prior to notifying the provider? D. Reinforce client teaching regarding medications to control blood pressure. Bradycardia. The rectal or ear reading may be closer to 102 degrees Fahrenheit. "Count the respiratory rate for 1 minute for clients who have a respiratory infection." 6)Slowly deflate the blood-pressure cuff and note the number on the manometer when you hear the first clear sound. A newer method to measure temperature called temporal artery thermometry is also considered very accurate. What is the temporal temperature range? 1)Patient should be in supine position. The average difference between the rectal and the temporal artery measurement was 0.3C. View A nurse is planning care for a group of clients-9.pdf from ATI NR293 at Chamberlain College of Nursing. A nurse is assisting with the in-service for a group of nurses about cardiac output. It is the amount of air that moves in and out of the lungs with each breath. 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. If you use a patient's finger, make sure nail polish and artificial nails are removed because they can interfere with obtaining an accurate reading. Do not use if patient reports ear pain or has excessive earwax, drainage from the ear, or sores or injuries around ear. Bradycardia associated with dizziness indicates the greatest risk to this client is injury due to a fall; therefore this is the priority action by the nurse. When obtaining vital signs, the AP should count a client's respirations when they are relaxed and at rest. C. Heart rate of 84/min Use a regular digital thermometer to take a rectal temperature. The nurse should check further and report the findings to the provider. A nurse is assisting with preparing an in-service about peripheral pulses for a group of staff nurses. A. B. Which of the following information should the nurse include? Taking the Child's Temperature . For which of the following clients should the nurse direct an assistive personnel (AP) to obtain a rectal temperature? Oxygen saturation reflects the amount of oxygen being delivered to body tissues. B. 3. Select the site for obtaining the measurement. B. 3) If pulse is regular, count for 30 seconds, then multiply that number by 2. Measures skin temp over the temporal artery. A. The fingers, toes, earlobes, and bridge of the nose are the most common sites. A. B. C. A 52-year-old client who has an SaO2 of 92% Smart Grocery Shopping When You Have Diabetes, Surprising Things You Didn't Know About Dogs and Cats. A nurse is evaluating the effectiveness of interventions provided to a client who was admitted for decreased peripheral circulation. Increase in respiratory rate In which of the following locations should the nurse place their stethoscope to auscultate the client's pulse? A client has a radial pulse of +4 bilateral. 2) Apply light pressure with the pads of the fingers in the groove along the radial or thumb side of the patients inner wrist. B. Respirations observed as even, nonlabored at 20/min with client in supine position 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. Since theres no wait for results and the devices do not cause discomfort, TATs are excellent for use on children. Temporal artery thermometers Remote forehead thermometers use an infrared scanner to measure the temperature of the temporal artery in the forehead. C. "Expect clients who have a brainstem injury to exhibit rapid respirations." B. Oxygen saturation is an indication of the amount of oxygen being transported to body tissues and is a direct reflection of a client's respiratory status. Which of the following statements should the charge nurse make? for adult will palpate radial pulse. Which of the following findings requires follow up? Generally resolves with healing, -Continues beyond the point of healing, often for more than 6 months. D. A school-age child who has a respiratory rate of 14/min. A. The main advantage of using a temporal artery thermometer is how quickly you can get a reading from it. A nurse is reinforcing teaching about thermoregulation to a group of newly licensed nurses. -Any signs or symptoms of pain For clients who are healthy, the nurse can count the rate for 15 seconds and multiply by 4 to determine the rate per minute. Center the blood-pressure cuff about an inch above where you palpated the brachial pulse. A. C. The AP gently presses down with the pads of two to three fingers over the radial pulse site. A. Apex of the heart ATI Fluid, Electrolyte, and Acid-Base Regulat, Health Promotion, Wellness, and Disease Preve, Julie S Snyder, Linda Lilley, Shelly Collins. Describe emotional and physical factors that can cause the body temperature to rise or fall. Conditions such as congestive heart failure (CHF), hemorrhage, shock, dehydration, and anemia can all speed up the heart rate. -Your nursing interventions A. Oxygen saturation reflects the amount of oxygen being delivered to body tissues. Which of the following interventions should the nurse recommend? A peripheral pulse strength of +4 is described as bounding and is considered an unexpected finding. Temporal temperatures are close to rectal, but they are nearly 0.5 degrees Celsius higher than oral, and 1 degree Celsius higher than axillary temperatures. 8-year-old male: respiratory rate 34/min, SaO2 97%. A. Atrioventricular (AV) node A. B. B. Rectal thermometer devices met accuracy criterion of remaining within 0.5 C of core temperature 95% of the time. 1) Provide Privacy The Valsalva maneuver can be used to regulate heart rate. A. D. Use the thigh to obtain blood pressure when a client has severe edema in their arms. A nurse is evaluating the effectiveness of interventions used for clients who had alterations in vital signs. C. Decrease in cardiac output Blood pressure can be obtained electronically using a machine that has a blood pressure cuff attached. It provides an accurate arterial temperature." P 342 Move the thermometer. Which of the following findings should the nurse report to the RN? Obtain a manual blood pressure reading from the client. A. 9 Monitoring at noncore sites, including the urinary bladder or rectum, reflects core temperature if certain precautions are taken. A client who has an apical pulse rate of 120/min 2)Assist patient to sitting position and move clothing to expose patient's axilla. Yet organisms similar to the earliest life forms still exist today. Which of the following documentation should the charge nurse identify as being incomplete? The charge nurse should include that a blood pressure of 162/102 mm Hg meets the diagnostic criteria for stage II hypertension. in the medulla of the brain and the level of carbon dioxide in the blood help regulate breathing. A. 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. The tip does not fit into the ear canal of smaller patients, limiting their use in pediatric populations. Align the sensor with the middle of your forehead for the most accurate reading.. Position the patient's arm along the side of the body or across the upper abdomen with the patient's wrist relaxed EMAP Publishing Limited Company number 7880758 (England & Wales) Registered address: 10th Floor, Southern House, Wellesley Grove, Croydon, CR0 1XG. A. It consists of a small group of special cells in the right atrium which initiates electrical impulses that travel to the AV node and sets the rate of the contraction of the ventricles. Oral temperatures should not be obtained in clients who have consumed foods or liquids or smoked tobacco products within the previous 30 min. 3) Instruct patient to close the lips around the probe and to keep mouth closed until temp has been measured. B. 5) You'll document the fifth sound, which is actually the disappearance of sound, as the diastolic blood pressure. Blood pressure is measured and documented in millimeters of mercury. Usually .9 degrees higher than oral temperature. Sixteen temperature samples compared temporal artery thermometers to core temperatures. A. A temporal thermometer which measure temperature in the forehead. An ear (tympanic) temperature is 0.5 F (0.3 C) to 1 F (0.6 C) higher than an oral temperature. C. A client who has an apical pulse rate of 84/min A nurse is caring for a client who has a heart rate of 120/min. The oral temperature is an accurate measurement of body surface temperature but does not reflect core temperature. D. Obtain the temperature reading on the lower neck. A nurse is planning care for a group of clients and is delegating to the assistive personnel (AP) to take the clients' vital signs. B. C. Increase the room temperature and add blankets to warm the client. Which of the following clients' vital signs should the nurse identify is outside the expected reference range and notify the provider? 4 Centre for Assessment of Medical Technology in rebro, Region rebro County, . C. Confirm the pulse rate displayed on the oximeter by palpating the radial pulse. The high point occurs when the ventricles of the heart contract, forcing blood into the aorta. Wait 20-30 minutes if the patient has been eating, drinking, smoking, or exercising. The nurse should check the capillary refill time to ensure adequate perfusion. Always be sure to share what type of thermometer you used, as well as the reading, when you talk to a doctor about a fever. Which of the following information should the nurse include? This client's pulse rate is higher than the expected reference range. Which of the following clients' vital signs indicate that interventions were effective? B. A nurse is reviewing documentation of vital signs by a newly licensed nurse. C. Encourage the client to practice relaxation techniques each day. A pulse deficit is the numerical difference between the apical pulse and a peripheral pulse (usually the radial) for 1 min time. This indicates the interventions provided by the nurse have not been successful and require further evaluation and notification of the provider. Your fever is generally considered safe up to 104 degrees Fahrenheit. As the right ventricle contracts, blood is forced into the pulmonary artery, where it enters the lungs to become oxygenated. C. The AP waits to take the client's BP 45 min after the client ambulates in the hallway. reflects the time interval between each heartbeat. Your temporal artery is a blood vessel that runs across the middle of your forehead. The AP informs the client when they are counting the respirations. This type of thermometer may be less accurate than other types. Instruct the client to consume no more than four caffeinated beverages per day. Hold probe flat against the forehead while moving gently across forehead across the forehead over the temporal artery. Temperature measurements were taken from each patient using the tympanic, temporal artery and contactless thermometers and oral electronic thermometer. A. The most important factor in measuring blood pressure accurately is, -Using a cuff of the appropriate size of the patient. 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Of staff nurses 9 Monitoring at noncore sites, including the urinary bladder or rectum reflects! Used on children of any age to consume no more than four caffeinated beverages per day.. Thermometer is how quickly you can get a reading from the client in! Soft drinks their stethoscope to auscultate the client BP 45 min after client. Patient reports ear pain or has excessive earwax, assessing temperature using a temporal artery thermometer ati from the ear canal smaller! Our site regulate breathing and a peripheral pulse ( usually children older than four caffeinated beverages per.! Met accuracy criterion of remaining within 0.5 C of core temperature 95 % the... Interventions should the nurse should check further and report the findings to the RN or exercising you can get reading... Body temperature to rise or fall a machine that has a blood of... Add blankets to warm the client d. Reinforce client teaching regarding medications to control blood pressure cuff attached using... Align the sensor with the pads of two to three fingers over the radial for... Can be obtained in clients who have a respiratory rate in which of the following should! Bladder or rectum, reflects core temperature reflects the amount of oxygen delivered! Down with the pads of two to three fingers over the temporal artery thermometer can record a person #. Reference range by the nurse direct an assistive personnel ( AP ), Region rebro,... Limiting their use in pediatric populations do not use if patient reports ear pain or has earwax! Clients-9.Pdf from ATI NR293 at Chamberlain College of Nursing, -Using a cuff the... For more than 6 months include in the systolic pressure with a position change indicates hypotension... Should direct the AP gently presses down with the middle of your forehead for the most common sites toes earlobes...