# Vital Signs

 Which of the following patients would require follow-up? A) A child with a respiratory rate of 24 breaths per minute.Feedback: INCORRECT The normal respiratory rate for a newborn is 30 to 60 breaths per minute. The normal respiratory rate of a child is 20 to 30 breaths per minute.The normal respiratory rate for a teenager is 16 to 19 breaths per minute. The normal respiratory rate for an adult is 12 to 20 breaths per minute. A rate of 10 would require follow-up. B) An adolescent with a respiratory rate of 16 breaths per minute. Feedback: INCORRECT The normal respiratory rate for a newborn is 30 to 60 breaths per minute. The normal respiratory rate of a child is 20 to 30 breaths per minute.The normal respiratory rate for a teenager is 16 to 19 breaths per minute. The normal respiratory rate for an adult is 12 to 20 breaths per minute. A rate of 10 would require follow-up C) An adult with a respiratory rate of 10 breaths per minute. Feedback: CORRECT The normal respiratory rate for a newborn is 30 to 60 breaths per minute. The normal respiratory rate of a child is 20 to 30 breaths per minute.The normal respiratory rate for a teenager is 16 to 19 breaths per minute. The normal respiratory rate for an adult is 12 to 20 breaths per minute. A rate of 10 would require follow-up. D) A newborn with a respiratory rate of 50 breaths per minute. Feedback: INCORRECT The normal respiratory rate for a newborn is 30 to 60 breaths per minute. The normal respiratory rate of a child is 20 to 30 breaths per minute.The normal respiratory rate for a teenager is 16 to 19 breaths per minute. The normal respiratory rate for an adult is 12 to 20 breaths per minute. A rate of 10 would require follow-up. Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? A) Temp 96.8° F, P-60, R-18, BP 160/90, O2 sat 93%.  B) Temp 97.0° F, P-60, R-16, BP 116/78, O2 sat 95%.   C) Temp 98.6 °F, P-56, R-20, BP 120/80, O2 sat 91%. D) Temp 98.0 °F, P-76, R-22, BP 110/70, O2 sat 88%. Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? A) Temp 96.8° F, P-60, R-18, BP 160/90, O2 sat 93%. Feedback: INCORRECT Normal values for an older adult are: average body temperature approximately 36° C (96.8° F), heart rate 60 to 100 beats per minute, respiratory rate 12 to 20 breaths per minute, average BP less than 120 over 80, and pulse oximetry 90% to 100%. A BP greater than 140 over 90 may be an indication of hypertension. B) Temp 97.0° F, P-60, R-16, BP 116/78, O2 sat 95%. Feedback: CORRECT Normal values for an older adult are: average body temperature approximately 36° C (96.8° F), heart rate 60 to 100 beats per minute, respiratory rate 12 to 20 breaths per minute, average BP less than 120 over 80, and pulse oximetry 90% to 100%. A BP greater than 140 over 90 may be an indication of hypertension. C) Temp 98.6 °F, P-56, R-20, BP 120/80, O2 sat 91%. Feedback: INCORRECT Normal values for an older adult are: average body temperature approximately 36° C (96.8° F), heart rate 60 to 100 beats per minute, respiratory rate 12 to 20 breaths per minute, average BP less than 120 over 80, and pulse oximetry 90% to 100%. A BP greater than 140 over 90 may be an indication of hypertension. D) Temp 98.0 °F, P-76, R-22, BP 110/70, O2 sat 88%. Feedback: INCORRECT Normal values for an older adult are: average body temperature approximately 36° C (96.8° F), heart rate 60 to 100 beats per minute, respiratory rate 12 to 20 breaths per minute, average BP less than 120 over 80, and pulse oximetry 90% to 100%. A BP greater than 140 over 90 may be an indication of hypertension. A 56-year-old female patient has been admitted with a diagnosis of pneumonia. Which information should be provided to the NAP delegated to take her temperature? (Select all that apply.) A) The patient's age. B) The type of temperature required. C) The patient's diagnosis. D) The frequency for taking or monitoring the temperature. E) What changes to report immediately to you, the physician, or their delegate. It is more important that the temperature be done on time by the correct route, with the correct equipment, and that identified changes be reported as requested.Correct Answer(s): B, D, E Which of the following situations may affect a patient's vital signs? (Select all that apply.) A) Time of day. B) Occupation. C) Moving from lying to standing position. D) Pain rated as a 7 on 1-10 pain scale. E) Isolation precautions. A, C, DFactors that may alter vital signs include time of day, stress (emotional and physical), temperature alterations/weather conditions, exercise/activity, emotions, medication, postural changes, acute pain, smoking, disease/injury status, noise, food/liquid consumption, and odors. The person's occupation and isolation precautions do not alter vital signs. If a person's job requires an activity that increases exertion or stress, the activity affects vital signs, not the occupation. You are supposed to take your patient's vital signs preoperatively and record them on the patient's record as part of the patient's preparation for surgery. Why is it necessary to take vital signs preoperatively? (Select all that apply.) A) To see if the patient is "feeling funny." B) To provide a set of vital signs to use for comparison during and after surgery. C) To make sure the patient is not experiencing any complications such as a high fever that may contraindicate surgery or require intervention at this time. D) To provide the patient with reassurance that he or she is being cared for by a competent staff.   B & CThe patient who is going to surgery is going to experience a change in condition and an invasive procedure. Vital signs are necessary so that the operative team has a baseline for comparison as well as to rule out any complications before the beginning of the surgical event. Providing reassurance to the patient can be done verbally. Who would you expect to have the lowest body temperature? D) A 16-year-old who ran 1 mile. Feedback: INCORRECT The 80-year-old would have a lower starting temperature and therefore, would most likely have the lowest body temperature although it may take longer to return to baseline after exercise.To be febrile means to have a fever. The toddler would fail to have the lowest body temperature. A 16-year-old will have a higher starting body temperature, and exercise will increase the body temperature further. A child will have a higher starting temperature and exercise will increase the body temperature further. B) An 80-year-old who walked half a mile. Feedback: CORRECT The 80-year-old would have a lower starting temperature and therefore, would most likely have the lowest body temperature although it may take longer to return to baseline after exercise.To be febrile means to have a fever. The toddler would fail to have the lowest body temperature. A 16-year-old will have a higher starting body temperature, and exercise will increase the body temperature further. A child will have a higher starting temperature and exercise will increase the body temperature further. C) A toddler who is febrile. Feedback: INCORRECT The 80-year-old would have a lower starting temperature and therefore, would most likely have the lowest body temperature although it may take longer to return to baseline after exercise.To be febrile means to have a fever. The toddler would fail to have the lowest body temperature. A 16-year-old will have a higher starting body temperature, and exercise will increase the body temperature further. A child will have a higher starting temperature and exercise will increase the body temperature further. D) A child playing softball. Feedback: INCORRECT The 80-year-old would have a lower starting temperature and therefore, would most likely have the lowest body temperature although it may take longer to return to baseline after exercise.To be febrile means to have a fever. The toddler would fail to have the lowest body temperature. A 16-year-old will have a higher starting body temperature, and exercise will increase the body temperature further. A child will have a higher starting temperature and exercise will increase the body temperature further. The NAP is preparing to measure a patient's vital signs. The patient reports having eaten a bowl of warm soup. The NAP asks the RN what he should do. What is the best response? A) "Ask the patient not to eat, drink, or smoke for 15 minutes and then assess the patient's oral temperature." B) "Since the soup was not hot, go ahead and take the patient's temperature." C) "Change to the red thermometer probe and take the patient's temperature rectally." D) "Take the patient's temperature using the axillary route and when you record the reading, add 1°F." A) "Ask the patient not to eat, drink, or smoke for 15 minutes and then assess the patient's oral temperature." Feedback: CORRECT The temperature of food or liquid could impair the accuracy of the reading. The NAP should ask the patient not to eat, drink, or smoke for 15 minutes and then assess the oral temperature. Taking a rectal temperature can be needlessly embarrassing and uncomfortable for the patient. Although the axillary route could be used, it is less accurate than the oral route. Furthermore, when recording an axillary temperature reading, the site is documented, but the reading itself is unchanged. B) "Since the soup was not hot, go ahead and take the patient's temperature." Feedback: INCORRECT The temperature of food or liquid could impair the accuracy of the reading. The NAP should ask the patient not to eat, drink, or smoke for 15 minutes and then assess the oral temperature. Taking a rectal temperature can be needlessly embarrassing and uncomfortable for the patient. Although the axillary route could be used, it is less accurate than the oral route. Furthermore, when recording an axillary temperature reading, the site is documented, but the reading itself is unchanged. C) "Change to the red thermometer probe and take the patient's temperature rectally." Feedback: INCORRECT The temperature of food or liquid could impair the accuracy of the reading. The NAP should ask the patient not to eat, drink, or smoke for 15 minutes and then assess the oral temperature. Taking a rectal temperature can be needlessly embarrassing and uncomfortable for the patient. Although the axillary route could be used, it is less accurate than the oral route. Furthermore, when recording an axillary temperature reading, the site is documented, but the reading itself is unchanged. D) "Take the patient's temperature using the axillary route and when you record the reading, add 1°F." Feedback: INCORRECT The temperature of food or liquid could impair the accuracy of the reading. The NAP should ask the patient not to eat, drink, or smoke for 15 minutes and then assess the oral temperature. Taking a rectal temperature can be needlessly embarrassing and uncomfortable for the patient. Although the axillary route could be used, it is less accurate than the oral route. Furthermore, when recording an axillary temperature reading, the site is documented, but the reading itself is unchanged. For which patient would a tympanic thermometer be the preferred thermometer to use? A) A marathon runner who developed weakness during the race. B) A newborn in the intensive care unit who requires continuous temperature monitoring. C) A child who had tubes surgically placed in the ears. D) A tachypneic patient who is receiving oxygen by nasal cannula. A) A marathon runner who developed weakness during the race. Feedback: INCORRECT An advantage to the tympanic thermometer is that it can be used for tachypneic patients. The tympanic thermometer is contraindicated in patients who have had surgery of the ear or tympanic membrane and does not accurately measure core temperature after exercise. A continuous measurement cannot be obtained with the tympanic thermometer. B) A newborn in the intensive care unit who requires continuous temperature monitoring. Feedback: INCORRECT An advantage to the tympanic thermometer is that it can be used for tachypneic patients. The tympanic thermometer is contraindicated in patients who have had surgery of the ear or tympanic membrane and does not accurately measure core temperature after exercise. A continuous measurement cannot be obtained with the tympanic thermometer. C) A child who had tubes surgically placed in the ears. Feedback: INCORRECT An advantage to the tympanic thermometer is that it can be used for tachypneic patients. The tympanic thermometer is contraindicated in patients who have had surgery of the ear or tympanic membrane and does not accurately measure core temperature after exercise. A continuous measurement cannot be obtained with the tympanic thermometer. D) A tachypneic patient who is receiving oxygen by nasal cannula. Feedback: CORRECT An advantage to the tympanic thermometer is that it can be used for tachypneic patients. The tympanic thermometer is contraindicated in patients who have had surgery of the ear or tympanic membrane and does not accurately measure core temperature after exercise. A continuous measurement cannot be obtained with the tympanic thermometer. Which of the following patients would you expect to have to monitor their temperature more frequently? (Select all that apply.) A) A patient receiving a blood transfusion for chronic anemia. B) An elderly patient who needs assistance with feeding and dressing. C) A 43-year-old female who has undergone a hysterectomy. D) A child who is small for his age. E) A 19-year-old with a white blood count of 15,000. A, C, EAn elderly person who needs assistance with activities of daily living is not necessarily at risk for an alteration in temperature. Being small for age or small in stature does not place a patient at risk for temperature alteration. The NAP reports that the patient's temperature is 39° C. Which of the following are appropriate nursing actions? (Select all that apply.) A) Place the patient's feet in a tub of cool water with ice. B) Apply a hyperthermia blanket as ordered. C) Remove the patient's blankets. D) Limit the patient's fluid intake. E) Administer an antipyretic to the patient as ordered. C & EAlthough the task of temperature assessment may be delegated, it is the nurse's responsibility to determine the accuracy of the measurement and to assess for further indication of infection. Fluids should be increased to 3 L daily (unless contraindicated). The nurse should administer an antipyretic as ordered and reassess the temperature in 30 minutes and every 4 hours until the temperature has stabilized within normal limits. A cool wet wash cloth may be provided, but the patient should not be excessively chilled, such as with ice. Cooling the temperature in the room will aid in reducing the temperature, and reducing the amount of external covering will promote heat loss. A hyperthermia blanket is used to raise body temperature. Which of the following actions, if made by the NAP, would require intervention and further instruction by the nurse? (Select all that apply.) A) The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after applying a probe cover. B) The NAP wipes the single-use chemical dot thermometer and places it back in the patient's drawer for future use. C) The NAP waits until a tone sounds to read the tympanic thermometer. D) The NAP uses a blue-tipped electronic probe for assessing a patient's axillary temperature. E) The NAP pulls the pinna up, back, and out in an adult when inserting the tympanic thermometer. A & BThe electronic thermometers are differentiated by the probe cover tips: blue for oral or axillary, red for rectal. Even though a probe cover is applied, a red-tipped probe should not be placed into a patient's mouth. The single-use chemical dot thermometer is plastic and can only be used once. All electronic thermometers (oral, axillary, rectal) and the tympanic thermometer have a tone that sounds when the measurement is complete. Pull the pinna up, back, and out in an adult when inserting the tympanic thermometer. Identify the factors that may have an effect on an 82-year-old patient's temperature: (Select all that apply.) A) Drinking a cold glass of water. B) Participation in strenuous physical therapy exercises. C) Infection. D) Room temperature. E) Patient's body weight.   A, B, C, DThe average body temperature of older adults is lower (96.8 °F). Cold water and a cool room temperature would lower temperature. A warm room would raise temperature. Exercise and an infection would raise temperature. If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? D) 37° C to 39° C Feedback: INCORRECT The normal temperature range for an adult is 96.8° F to 100.4° F or 36° C to 38° C. The normal temperature range for a newborn is 95.9° F to 99.5° F. B) 96.8° F to 100.4° F Feedback: CORRECT The normal temperature range for an adult is 96.8° F to 100.4° F or 36° C to 38° C. The normal temperature range for a newborn is 95.9° F to 99.5° F. C) 96.8° F to 98.6° F Feedback: INCORRECT The normal temperature range for an adult is 96.8° F to 100.4° F or 36° C to 38° C. The normal temperature range for a newborn is 95.9° F to 99.5° F. D) 35° C to 36° C Feedback: INCORRECT The normal temperature range for an adult is 96.8° F to 100.4° F or 36° C to 38° C. The normal temperature range for a newborn is 95.9° F to 99.5° F.   Your newborn patient's temperature has been rising rapidly and the baby has been crying. Which of the following thermometers would be the best to use in measuring this patient's temperature? A) Temporal artery   B) Tympanic C) Chemical dot    D) Rectal electronic A) Temporal artery Feedback: CORRECT The temporal artery thermometer reflects rapid change in core temperature and can be used on newborns. The tympanic membrane sensor is unable to accurately measure core temperature changes during and after exercise. Chemical dot thermometers are inappropriate for use when there is a sudden and/or variable rise in temperature.It would be unnecessary to use a rectal thermometer and could cause bowel perforation if inserted too far on a newborn. B) Tympanic Feedback: INCORRECT The temporal artery thermometer reflects rapid change in core temperature and can be used on newborns. The tympanic membrane sensor is unable to accurately measure core temperature changes during and after exercise. Chemical dot thermometers are inappropriate for use when there is a sudden and/or variable rise in temperature.It would be unnecessary to use a rectal thermometer and could cause bowel perforation if inserted too far on a newborn. C) Chemical dot Feedback: INCORRECT The temporal artery thermometer reflects rapid change in core temperature and can be used on newborns. The tympanic membrane sensor is unable to accurately measure core temperature changes during and after exercise. Chemical dot thermometers are inappropriate for use when there is a sudden and/or variable rise in temperature.It would be unnecessary to use a rectal thermometer and could cause bowel perforation if inserted too far on a newborn. D) Rectal electronic Feedback: INCORRECT The temporal artery thermometer reflects rapid change in core temperature and can be used on newborns. The tympanic membrane sensor is unable to accurately measure core temperature changes during and after exercise. Chemical dot thermometers are inappropriate for use when there is a sudden and/or variable rise in temperature.It would be unnecessary to use a rectal thermometer and could cause bowel perforation if inserted too far on a newborn.  Which of the following would be appropriate to delegate the task of pulse assessment? (Select all that apply.)A) An apical pulse of a patient who is going to receive digoxin (Lanoxin). B) A radial pulse on a patient with a 1200 mL fluid restriction. C) A radial pulse of a patient in the emergency room with chest pain. D) A femoral pulse following a lower leg amputation. E) The temporal pulse of a child.   Feedback: CORRECT The skill of pulse measurement can be delegated to NAP unless the patient is considered unstable or you are evaluating a response to a treatment or medication. The pulse of a patient on a fluid restriction may be delegated to NAP, as well as the temporal pulse of a child, provided the NAP knows how to locate this pulse site. A) An apical pulse of a patient who is going to receive digoxin (Lanoxin). B) A radial pulse on a patient with a 1200 mL fluid restriction. C) A radial pulse of a patient in the emergency room with chest pain. D) A femoral pulse following a lower leg amputation. E) The temporal pulse of a child.   Feedback: CORRECT The skill of pulse measurement can be delegated to NAP unless the patient is considered unstable or you are evaluating a response to a treatment or medication. The pulse of a patient on a fluid restriction may be delegated to NAP, as well as the temporal pulse of a child, provided the NAP knows how to locate this pulse site. Which of the following patients would you suspect would be at risk for having an alteration in peripheral pulse? (Select all that apply.) A) a 76-year-old with diabetes who is otherwise healthy. B) A patient who was just informed of a diagnosis of cancer. C) A patient with peripheral vascular disease. D) A patient who is receiving bolus IV fluids. E) A patient with Alzheimer's disease.   B, C & DCertain conditions place patients at risk for pulse alterations. This may include a person with heart disease, a patient who is experiencing anxiety, and a patient who received a sudden infusion of IV fluids. Uncomplicated diabetes and Alzheimer's disease fail to directly relate to pulse alteration. Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, you should consider: A) Checking the carotid pulse.   B) Using a stethoscope and assessing the quality of the apical pulse as well as the rate.   C) Counting the pulse again for 30 seconds and multiplying the results by two.   D) Checking the radial pulse on the opposite side. A) Checking the carotid pulse. Feedback: INCORRECT You should assess the quality and rate of the apical pulse. The rate should be counted over a full minute to ensure greater accuracy. B) Using a stethoscope and assessing the quality of the apical pulse as well as the rate. Feedback: CORRECT You should assess the quality and rate of the apical pulse. The rate should be counted over a full minute to ensure greater accuracy. C) Counting the pulse again for 30 seconds and multiplying the results by two. Feedback: INCORRECT You should assess the quality and rate of the apical pulse. The rate should be counted over a full minute to ensure greater accuracy. D) Checking the radial pulse on the opposite side. Feedback: INCORRECT You should assess the quality and rate of the apical pulse. The rate should be counted over a full minute to ensure greater accuracy.   What is the normal pulse range for an adult? A) 120 to 160 beats per minute.   B) 90 to 140 beats per minute.   C) 60 to 100 beats per minute.   D) 50 to 80 beats per minute. A) 120 to 160 beats per minute. Feedback: INCORRECT The normal pulse range for an adult is 60 to 100 beats per minute. The the pulse rate of a newborn is 120 to 160 beats per minute. The pulse rate of a 2-year-old is 90 to 140 beats per minute. B) 90 to 140 beats per minute. Feedback: INCORRECT The normal pulse range for an adult is 60 to 100 beats per minute. The the pulse rate of a newborn is 120 to 160 beats per minute. The pulse rate of a 2-year-old is 90 to 140 beats per minute. C) 60 to 100 beats per minute. Feedback: CORRECT The normal pulse range for an adult is 60 to 100 beats per minute. The the pulse rate of a newborn is 120 to 160 beats per minute. The pulse rate of a 2-year-old is 90 to 140 beats per minute. D) 50 to 80 beats per minute. Feedback: INCORRECT The normal pulse range for an adult is 60 to 100 beats per minute. The the pulse rate of a newborn is 120 to 160 beats per minute. The pulse rate of a 2-year-old is 90 to 140 beats per minute.   When should you take vital signs? •On a routine schedule according to a health care provider's order or institution's standards of practice•Before, during, and after surgery and/or an invasive diagnostic procedure.•Before and after the administration of medications or application of therapies that affect cardiovascular, respiratory, and temperature-control functions.•Before, during, and after a transfusion of blood products.•Before, during, and after nursing interventions influencing a vital sign (e.g., before and after a patient previously on bed rest ambulates, before and after the patient performs range-of-motion exercises).•When the patient reports specific symptoms of physical distress (e.g., feeling "funny" or "different").•When the patient's general physical condition changes (e.g., loss of consciousness or increased severity of pain).•Whenever you suspect that there is reason to believe that the condition of the patient is changing—what nurses call an "increased index of suspicion." What vital signs can you to delegate to a UAP? All of them. Pulse, BP, Temp, Oxygen Sat., respiration. What guidelines must you follow when delegating vitals to NAP?  •Inform the NAP which vital signs are required and patient situation specifics. Instruct the NAP about any unique vital sign techniques such as lying or sitting BP measurements and restrictions in a patient's positioning. •Clearly indicate what must be reported back to you, such as out-of-range vital signs.•Inform the NAP of the frequency for taking and reporting vital signs.•Instruct the NAP about any specific safety measures to consider before taking the vital signs (for example, how to obtain measurement when a patient is confused or restless).•Clarify that the NAP knows the patient's normal values•Instruct the NAP about patient-related factors that falsely raise or lower vital signs.The nurse caring for the patient is responsible for vital signs measurement. You can delegate measurement of selected vital signs (i.e. stable patients) to NAP. However, nurses must analyze vital signs to interpret their significance and make decisions about appropriate interventions. What are the acceptable temp ranges for adults? TemperatureRange: 36° to 38° C (96.8° to 100.4° F) What is the average oral/tympanic temp of adults? Averageoral/tympanic: 37° C (98.6° F) What is the avg rectal temp of adults? Averagerectal: 37.5° C ( 99.5° F) What is the avg axillary temp of adults? Average axillary: 36.5° C ( 97.7° F) Where on the body can you take a client's temperature? OralRectalAxillaeTympanic What is the pulse range in adults? 60-100 beats per min How do you find a client's pulse? Palpate the radial artery for 30 seconds and times that # by 2...Or...count for 15 seconds and times that # by 4 Resp. range for adults? 12-20 breaths per min How do you find out amount of respirations per min. DO NOT TELL PT THAT YOU WILL BE CHECKING HIS/HER RESPIRATIONS, THIS WILL ALTER YOUR READING.Instead, pretend that you are taking the pulse and monitor the respirations. Each inhale/exhale count as 1.Monitor for 30 seconds and times by 2, or count for 15 seconds and times by 4 Blood Pressure range for adults? <120/80 mmHg What is pulse pressure? Represents the force that your heart generates when it contracts How do you find out what the pulse pressure is? Systolic-Diastolic=Pulse pressure What is the range for oxygen saturation in adults? 90-100% What is the heart rate range (pulse range) for infants (6 months)? 120-160 bpm What is the HR range for a toddler ~ 2 years old? 90-140 bpm What is the HR range for a preschooler? 80-110 What is the HR range for a school-age child? 75-100 What is the HR range for an adolescent 60-90 bpm What is the respiratory range for newborns? 30-40 What is the resp range for an infant (6 months)? 20-40 What is the resp range for a toddler (~ 2 years old)? 25-32 What is the resp range for an adolescent? 16-19 What is the average optimal blood pressure for a newborn (3000g/6.6 lbs) 40 (mean) What is the avg optimal bp for a 1 month old 85/54 What is the avg optimal bp for a 1 year old? 95/65 What is the avg optimal bp for a 6 year old? 105/65 What is the avg optimal bp for a 10-13 y/o? 110/65 What is the avg optimal bp for a 14-17 y/o? 120/75 How would children/adolescents get diagnosed with hypertension? Repeated measurement of a blood pressure that is in the 95th percentile or greater adjusted for age, height and gender. What is the acceptable oxygen saturation range for client's with chronic disease conditions like COPD? 85-89% Authorcsagastume1 ID167239 Card SetVital Signs DescriptionVitals Updated2012-08-24T06:18:14Z Show Answers