EXAM(LATEST-2021): (ANSWERS VERIFIED 100% )West Coast UniversityNURS 101FINAL REVIEW .

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1) Vital Signs a. Temperature i. Normal: 96.8-100.4 degrees F ii. Can be taken 1. Orally 2. Axillary 3. Temporally 4. Rectally 5. Tympanically iii. High temperature: hyperthermia iv. Low tem... perature: hypothermia v. Factors affecting temperature 1. Activity (pulse is higher if patient has just ambulated) 2. Drinking cold/hot liquids prior to temperature being taken 3. Infection (causes fever) b. Blood Pressure i. Normal Systolic: <120 ii. Normal Diastolic: <80 iii. Pre-hypertension: 120-139/80-89 iv. Stage 1 hypertension: 140-159/90-99 v. Stage 2 hypertension: >160/100 vi. Withhold opioid pain medications and nitroglycerin if diastolic BP is <90 mmHg vii. Kortokoff sounds 1. 1st: clear rhythmic tapping (systolic heard here) 2. 2nd: blowing, swishing due to cuff deflating 3. 3rd: crisper, more intense tapping 4. 4th: muffles, low pitch (measure diastolic here if no fifth sound is heard) 5. 5th: sounds disappear (diastolic heard here) viii. Ensure cuff fits the patient properly 1. If cuff is too small it could result in a falsely high reading c. Pulse i. Normal: 60-100 BPM ii. <60: bradycardia iii. >100: tachycardia iv. Locations 1. Radial a. Assess for 30 sec, then multiply by 2 2. Carotid 3. Brachial 4. Pedal 5. Femoral6. Popliteal 7. Temporal 8. ApicalAssessed if radial pulse is irregular for ONE FULL MINUTE v. When describing pulse, use words that describe rate, rhythm, and strength/document if pulses are of equal d. Respirations i. Normal: 12-20 breaths/min ii. <12: bradypnea iii. >20: tachypnea iv. Pulse Ox (O2 Sat) 1. Normal: > or equal to 95% 2. For COPD patients 92% or greater is normal e. Pain i. Considered to be the fifth vital sign ii. Identified by facial expressions (grimacing), moaning, using FACEs or Wong-Baker scale iii. Use PQRST 1. PProvoked (what brought this pain on?) 2. QQuality (what does it feel like?) 3. RRegion/Radiating (is it spreading anywhere?) 4. SSeverity (on a scale of 0-10, rate your pain) 5. TTiming (how long has this been occurring?) iv. Pain is subjective data v. For pain management, use these techniques prior to trying meds 1. Music therapy 2. Visualization 3. Meditation 4. Re-positioning 5. Lowering lights 6. Biofeedback therapy 7. Acupressure 8. Guided imagery 9. Distraction 10. Thermal therapies vi. If all else fails, try one of these medications 1. NSAIDs a. Ibuprofen i. Advil, Motrin b. Acetaminophen i. Tylenol 1. WATCH FOR GI BLEEDING AND LIVER FAILURE 2. Opioids a. For extremely severe pain onlyb. Potential side effects i. Lowered respiratory rate ii. Constipation vii. Re-assess patients 30 min before and after giving pain medications viii. If patient is going to have a procedure/go to physical therapy, give them a pain medication 30 min prior to transfer [Show More]

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