Afebrile
Without a fever
Apical-radial pulse
Taking the apical and radial pulses at the same time.
Blood pressure
The amount of force exerted against the walls of an artery by the blood.
Body temperature
The amount of heat in the body that is a balance between the amount of heat produced and the amount lost by the body.
Bradycardia
A slow heart rate; less than 60 beats per minute
Diastole
The period of heart muscle relaxation; the heart is at rest.
Diastolic pressure
The pressure in the arteries when the heart is at rest.
Febrile
With a fever.
Fever
Elevated body temperature
Hypertension
When the systolic pressure is 140 mm Hg or higher or the diastolic pressure is 90 mm Hg or higher.
Hypotension
When the systolic pressure is below 90 mm Hg or the diastolic pressure is below 60 mm Hg.
Pulse
The beat of the heart felt at an artery as a wave of blood passes through the artery.
Pulse deficit
The difference between the apical and radial pulse rates.
Pulse rate
The number of heartbeats or pulses in one minute.
Respiration
Breathing air into and out of the lungs.
Sphygmomanometer
A cuff and measuring device used to measure blood pressure.
Stethescope
An instrument used to listen to the sounds produced by the heart, lungs, and other body organs.
Systole
The period of heart muscle contraction; the heart is pumping blood.
Systolic pressure
The pressure in the arteries when the heart contracts.
Tachycardia
A rapid heart rate more than 100 beats per minute
Thermometer
A device used to measure temperature.
Vital signs
Temperature, pulse, respirations, and blood pressure; and pain in some agencies.
BP
Blood Pressure
C
Centigrade
DUS
Doppler Ultrasound Stethescope
F
Fahrenheit
Hg
Mercury
ID
Identification
IV
Intravenous
mm
millimeter
mm Hg
millimeter of mercury
TPR
Temperature, pulse, and respirations
Which should report at once?
A rectal temperature of 101.6� F
A rectal temperature is taken when the person
Is unconscious
Which site is used to take an infant's temperature?
Rectal site
When using an electronic thermometer
Cover the probe with a probe cover
Which is usually used to take an adult's pulse?
The radial pulse
For an adult, which pulse do you report at once?
An irregular pulse at 124 beats per minute
You count a regular pulse for 30 seconds. Which is true?
If you count 44 beats, you record a pulse rate of 88
Which statement about the apical-radial pulse is true?
The apical pulse can be greater than the radial pulse.
In an adult, normal respirations are
12 to 20 per minute
Respirations are usually counted
After taking the pulse
Which blood pressure is normal for an adult?
112/78 mm Hg
When measuring BP
Apply the cuff to the bare upper arm
The systolic blood pressure is the point
Where the first sound is heard
When taking a BP, the sound disappears at the 1st short line above 70. You record the
Diastolic pressure as 72
You are not sure you heard an accurate BP measurement. You should
Measure the BP again after 60 seconds
This means with a fever
Febrile
This a rapid heart rate that is over 100 beats per minute
Tachycardia
This is taking the apical and radial pulse at the same time.
Apical-radial pulse
An instrument used to listen to the sounds produced by the hear, lungs, and other body organs is a
Stethescope
When the systolic blood pressure is below 90 mm Hg and the diastolic pressure is below 60 mm Hg it is called
Hypotension
This is the number of heartbeats or pulses felt in 1 minute
Pulse rate
The amount of heat in the body that is a balance between the amount of heat produced and amount lost by the body is the
Body temperature
This is the period of heart muscle contraction
Systole
This is when the blood pressure measurements remain above a systolic pressure of 140 mm Hg or a diastolic pressure of 90 mm Hg.
Hypertension
The cuff and measuring device used to measure blood pressure is a
Sphygmomanometer
The beat of the heart felt at an artery as a wave of blood passes through the artery is the
Pulse
Without a fever is
Afebrile
Temperature, pulse, respirations, and blood pressure are
Vital signs
This is a slow heart rate; the rate is less than 60 beats per minute
Bradycardia
The amount of force it takes to pump blood out of the heart into the arterial circulation is the
Systolic pressure
The period of heart muscle relaxation is
Diastole
The difference between the apical and radial pulse rates is the
Pulse deficit
This is the amount of force exerted against the walls of an artery by the blood
Blood pressure
Breathing air into and out of the lungs is
Respiration
This is the pressure in the arteries when the heart is at rest
Diastolic pressure
Elevated body temperature is
Fever
This is a device used to measure temperature
Thermometer
Persons in nursing centers usually have vital signs measured
Weekly
Unless otherwise ordered, take vital signs when the person
Is lying or sitting
Body temperature is lower in the
Morning
If you are taking vital signs on a person with dementia, it may be better if
You take the pulse and respirations at one time, and the temperature and blood pressure at another time
What should you do if a person asks for the vital sign measurements?
You can tell the person the measurements if center policy allows
If you take a rectal temperature, the normal range of the temperature would be
98.6�F to 100.6�F
If you are taking the temperature of an older person, you would expect the temperature to be
Lower than the normal range
A glass rectal thermometer has
A stubby tip color-coded in red
To read a glass thermometer you should hold it at the
Stem and bring it to eye level to read it
If you are preparing to take an oral temperature, ask the person not to
Eat, drink, smoke, or chew gum for at least 15 to 20 minutes.
An electronic thermometer is inserted into the rectum
1/2 inch
When taking a temperature for persons who are confused and resist care, the best choice would be to
Use a tympanic or temporal artery thermometer
Which pulse is most commonly used?
Radial
This pulse is taken during cardiopulmonary resuscitation (CPR).
Carotid
When using a stethoscopem you can help to prevent infection by
Wiping the ear-pieces and diaphragm with antiseptic wipes before and after use.
When a pulse rate is 120 beats per minute, you
Report that the person has tachycardia
The pulse rate is the number of heartbeats or pulses felt in
1 minute
You need to feel the pulse to determine the
Force
When taking the radial pulse, place
Two or three fingers on the thumb side of the wrist over the radial artery
You may count the radial pulse for 30 seconds and multiply by 2 if
The pulse is regular
The apical pulse is taken
For a full minute
An apical pulse of 72 is recorded as
72Ap
An apical-radial pulse is taken by
Having one staff member take the apical pulse and a second staff member take the radial pulse at the same time.
A pedal pulse is found
Over a foot bone
When counting respirations, the best way is to
Keep your fingers or stethoscope over the pulse site so the person thinks you are still counting the pulse.
Each respiration involves
1 inhalation and 1 exhalation
The blood pressure may be higher in older persons because
Blood pressure increases with age
The blood pressure may not be taken
On an arm that has a dialysis access site
You will find out the size of blood pressure cuff needed
By asking the nurse
When taking the blood pressure, you place the stethoscope diaphragm
Over the brachial artery at the inner aspect of the elbow.
When getting ready to take the blood pressure, position the person's arm
Level with the heart
The blood pressure cuff is inflated how much beyond the point where you last felt the radial pulse?
30 mm Hg
Blood Pressure
BP
Centigrade
C
Doppler Ultrasound Stethescope
DUS
Fahrenhite
F
Mercury
Hg
Identification
ID
Intravenous
IV
millimeters
mm
millimeter of Mercury
mm Hg
Temperature, Pulse, Respirations
TPR
Vital signs are taken when the person takes drugs that affect
the respiratory or circulatory systems
When vital signs are taken, report to the nurse at once if
1. Any vital sign that is changed from a prior
measurement.
2. An abnormal vital sign.
Sites for measuring temperature are the
1. Oral
2. Rectal
3. Axillary
4. Tympanic
5. Temporal
Which site has the highest normal range for temperature?
Rectal
Which site has the lowest baseline temperature
Axillary
If a glass thermometer breaks you should
Tell the nurse because it may contain mercury which is a hazardous chemical.
When you read a Fahrenheit thermometer, the short lines mean
0.2 or 2 tenths
How long does a glass thermometer remain in place orally?
2-3 minutes
How long does a glass thermometer remain in place rectally?
2 minutes
How long does a glass thermometer remain in place axillary
5-10 minutes
When taking an oral temperature, place the bulb end of the thermometer
Under the tongue and to one side
When taking an axillary temperature, the axilla must be
dry
Tympanic membrane and temporal artery thermometers are used for confused persons because they are
Fast and comfortable
When using an electronic thermometer, what does the color of the probe mean?
Blue - oral and axillary thermometers
Red - rectal thermometers
When you take a rectal temperature, you do this to the tip of the thermometer or the end of the covered probe before inserting it into the rectum
Lubricate
When taking a tympanic membrane temperature on an adult, pull up and back on the ear to
straighten the ear canal
The adult pulse rate is between
60 and 100
List words to describe a forceful pulse
strong, full, or bounding
List words to describe a hard-to-feel pulse
weak, thready, or feeble
If the pulse is irregular, count the pulse for
1 minute
When you take a pulse what observations should be reported and recorded?
1. Pulse site
2. Pulse rate
3. Pulse deficit
4. If regular or irregular
5. Pulse force
Do not use your thumb to take a pulse because
the thumb has a pulse and you could mistake the pulse in your thumb for the person's pulse.
When taking apical pulse, each lub-dub sound is counted as
1 beat
The apical pulse rate is never less than the
radial pulse rate
The nurse may mark the skin with an X where the
dorsalis pedis pulse is found
A healthy adult has how many respirations per minute?
12 - 20
What observations should be reported and recorded when counting respirations?
1. Respiratory rate
2. Equality and depth of respirations
3. pain or difficulty breathing
4. respiratory noises
5. abnormal respiratory pattern
6. regular or irregular respirations
One respiration is counted for each
rise and fall of the chest
Respirations are counted for
30 seconds or 1 minute if they are irregular
Blood pressure is controlled by
1. The force of heart contractions
2. The amount of blood pumped with each
heartbeat
3. How easily the blood flows through the blood
vessels
Report blood pressures that are
1. Systolic over 120 mm Hg or under 90 mm Hg
2. Diastolic over 80 mm Hg or under 60 mm Hg
Let the person rest for how long before taking the blood pressure
10 - 20 minutes
When you are taking a blood pressure, the person should be
Sitting or lying
Sometimes the doctor orders blood pressure in what position?
Standing
When listening to the blood pressure, the first sound you hear is the
Systolic pressure
When listening to the blood pressure, the point where the sound disappears is the
Diastolic pressure
Measurements of the vital signs is important because they help the nurse
Plan for and evaluate the person's care.
When it comes to vital signs, you are responsible for
1. Knowing vital sign ranges
2. Reporting abnormal ranges
You allow the person to have this when you use the arm for blood pressure or pulse that the person prefers.
Independence
If you cannot feel a pulse or hear a blood pressure, you should never
Make up a measurement
Name the eight pulse sites
1. Temporal
2. Carotid
3. Apical
4. Brachial
5. Radial
6. Femoral
7. Popliteal
8. Dorsalis Pedis
Which pulse is used during CPR?
Carotid
Which pulse is most commonly taken?
Radial
Which pulse is used when placing the stethoscope to take the blood pressure?
Brachial
Which pulse is found with a stethoscope?
Apical