ATI Vital Signs

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When auscultating a patient’s apical pulse, you listen until you hear the S1 and S2 heart sounds clearly and regularly. S2 is produced when the…

Semilunar Valves close -The second heart sound, S2, is generated by the closure of the semilunar valves (the aortic and pulmonic valve) and signals the start of diastole. S2 is the "dub" heard in the normal "lub-dub" sound.

You are preparing to use a tympanic thermometer. Which of the following steps has the highest priority in the accurate use of this piece of equipment for measuring body…

Gently pulling the pinna back and upward -A tympanic thermometer is probably not the best choice when the patient’s ears show signs of infection, inflammation, or trauma because of the risk of further damage, pain, or contamination. But the device would still register temperature accurately.

You are assessing the vital signs of a newly admitted patient. To establish an accurate baseline of the patient’s respiration you

Observe the patient’s chest movements while appearing to assess his pulse -You are mostly likely to observe the true respiratory pattern (rate, rhythm, and depth) when the patient is unaware that he is being assessed. When patients know their respiration is being observed, it is common for them to alter their respiratory pattern either voluntarily or involuntarily.

When assessing a patient’s respiration, it is recommended that the patient…

Have the head of the bed elevated 45 to 60 degrees -This is a comfortable position for most patients and it allows full ventilatory movement. Also, any type of discomfort can increase respiratory rate.

To auscultate a patient’s apical pulse accurately, you position the bell or the diaphragm on your stethoscope over the point of maximal impusel, which is located…

at the fifth intercostal space at the left midclavicular line -To locate the point of maximal impulse, first located the angle of Louis – bony prominence just below the suprasternal notch. Slide you fingers down each side of the angle of Louis to locate the second intercostal space. Gently move your fingers down the left side of the sternum to the fifth intercostal space and laterally to the left midclavicular line. You have found the PMI.

The best way to determine the depth of a patient’s respiration is to…

observe the degree of chest wall movements during inspiration and expiration -You determine the depth of respiration subjectively by evaluating how much chest wall movement you can observe. The movement is generated by the movement of the diaphragm and intercostal muscles as the patient breathes. With shallow respiration, for example, you will observe very little movement. Deep respiration involves full expansions for the lungs which is usually quite visible

When taking a adults patient’s temperature rectally, it is important to…

insert the probe about an inch and a half into the patient’s anus -An insertion depth of 1.5 inches (3.5 cm) ensures sufficient exposure of the probe to the blood vessels in the rectal wall. Positioning the probe against the blood vessels enables to measure heat maximally and accurately.

The most important factor in measuring blood pressure accurately is..

using a cuff of the appropriate size for the patient

You are assessing a patient’s vital signs. the patient has a temp. of 102 degrees F. Which of the following do you expect to find?

An elevated pulse rate -A fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate.

When taking a patient’s BP why is it important to notice the pressure on the manometer when you hear the fourth Korotkoff sound or phase?

You might not hear a fifth Korotkoff sound -Most clinicians consider the fifth Korotkoff sound, which is actually the disappearance of sound, an adult patient’s diastolic pressure. However, with some patient’s, there is no distinct fifth sound. You hear sounds all the way to 0 mm Hg. For these patients, you would record the fourth Korotkoff sound as the diastolic blood pressure. The initial sound, or first Korotkoff sound, is a clear, rhythmic tapping sound that coincides with the patient’s systolic blood pressure. The pressure on the manometer when you hear the first sound is the top number of the blood pressure. The third Korotkoff sound is the loudest. It is the phase during which blood flows freely through an increasingly open artery. As a result, the sounds are crisper and more intense.

You have assessed a 45 yr old patient’s vital signs. Which of the following assessment values requires immediate attention?

A respiratory rate of 30/min An oral temp. of 100 F indicates a fever but this degree of elevation in body temp is rarely a situation that requires immediate attention While a blood pressure of 148/88 mm Hg is above the normal range for an average adult, it does not require immediate action. A respiratory rate of 30/min is above the normal range and indicates a respiratory problem that requires immediate attention. An adult breathing at that rate might be experiencing shortness of breath or dyspnea and, without intervention, this could become a life-threatening situation. A radial pulse of 45 beats/30 seconds translates to 90/min for documentation purposes. While you should assess a pulse this rapid for a full minute, 90/min is still within the normal range for an adult, is not a serious finding, and does not require immediate action.

You are measuring a patient’s temp. orally. You place the covered probe

in the posterior linguinal pocket lateral to the midline -The heat produced by superficial blood vessels in the right and left posterior sublingual pocket is what generates an accurate oral temperature reading. Inserting the probe sideways into the back of the area under the tongue on the left or the right will access this area.

Symptoms to consider when checking blood pressure…

It is likely that a patient who is 60 pounds overweight would have a large than average upper arm circumference. If so, you would have to use a large blood pressure cuff (instead of a regular sized cuff) to assure an accurate blood pressure reading. ns -Nausea, while uncomfortable and possibly a symptom of gastrointesitonal pathology, has no direct effect on how you would assess vital signs A patient who has nasal congestion might resort to mouth breathing which would alter a temp measurement obtained orally. This condition would also require that you assess the patient’s respiration for a full 60 seconds -While the recent ingestion of foods of extreme temperatures (hot or cold) can affect the accuracy of a temperature measured orally, the lack of food has no direct baring on how you would check the patient’s vital signs The presence of a cardiovascular problem that warrants pharmacological digoxin therapy would require that you assess the patient’s apical pulse for a full 60 seconds. Lymphatic drainage might be altered in the affected arm post mastectomy. The application of pressure from the assessment of blood pressure could result in a painful condition called lymphedema.

The difference between a patient’s systolic and diastolic blood pressure is called

pulse pressure; if the patient’s blood pressure is 130/85 mm Hg, the pulse pressure is 45/min. Pulse pressure can be a predictor of heart problems, especially in older adults. For example, an elevated pulse pressure usually reflects stiffness and reduced elasticity of the aorta, most often due to hypertension or atherosclerosis. The auscultatory gap is a phenomenon that is most common with patients who have hypertension. It is a temporary disappearance of sound, usually between the first and second Korotkoff sounds. If you do not inflate the blood-pressure cuff enough to hear the systolic pressure as you begin to deflate it, an auscultatory gap could lead to an underestimation of systolic pressure or an overestimation of diastolic pressure. Diurnal variation is the difference between blood pressure measurements taken at different times of the day. It varies widely from patient to patient, but generally, readings are lowest in the early morning and peak in the late afternoon or early evening. The pulse deficit is the difference between a patient’s radial and apical pulse rates. Pulse deficits often reflect abnormal heart rhythms.

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