Is It (Finally) Time to Stop Calling COVID a Pandemic? The recommended rate is 2 mm Hg per second. A nurse is observing an assistive personnel (AP) who is obtaining a blood pressure reading from a client. The SA node is the pacemaker of the heart. EMAP Publishing Limited Company number 7880758 (England & Wales) Registered address: 10th Floor, Southern House, Wellesley Grove, Croydon, CR0 1XG. A preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min B. Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall. A. Measurements were performed using two temporal artery thermometers (Temporal Scanner TAT-5000, Exergen Corp.). C. Encourage the client to practice relaxation techniques each day. Therefore, the nurse should direct the AP to obtain this client's temperature rectally. A. ATI Fluid, Electrolyte, and Acid-Base Regulat, Health Promotion, Wellness, and Disease Preve, Julie S Snyder, Linda Lilley, Shelly Collins. A client is diagnosed with an elevated blood pressure when the measurement is greater than 130/80 mm Hg. When measureing B.P. Generally resolves with healing, -Continues beyond the point of healing, often for more than 6 months. C. Place the sensor flush on the patient's forehead. A. The nurse should reassess the vital signs to ensure previous readings were accurate and evaluate the client to determine a potential cause for the increased respiratory rate, such as anxiety, crying, or physical exertion. Which of the following clients should the nurse see first? D. Vena cava. Which of the following findings requires intervention? Especially because of COVID, researchers studied TATs along with more traditional thermometer types that involve more contact and read temperatures from other body parts: Temperature readings vary by body part, but doctors generally agree on these: And doctors still consider rectal temperature to be the most accurate.. For which of the following clients should the nurse direct an assistive personnel (AP) to obtain a rectal temperature? Put on a disposable sensor cover before taking the temporal artery temperature. A nurse is discussing oxygen saturation with a client. Once the pulse rate is displayed on the oximeter, the nurse should palpate the client's radial pulse to confirm the reading. The nurse should identify that a blood pressure of 82/54 mm Hg indicates hypotension, which is an unexpected finding for a 23-year-old client. A nurse is caring for a client who asks about factors that could cause their pulse rate to increase. 4) Press scan button and slowly slide the thermometer across the forehead and just behind the ear. 3 months to 4 years. Explain. A. Eupnea B. Which of the following information should the nurse include? Temporal artery thermometers use an infrared scanner to measure the temperature of the temporal artery in your forehead. B. "An increase of 5 millimeters of mercury in the diastolic pressure with a position change indicates orthostatic hypotension." An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min C. BP 124/82 mm Hg, lying in bed B. This action can lead the client to alter their breathing, which can cause inaccurate results. To auscultate a patient's apical pulse accurately you position the bell or the diaphragm of your stethoscope over the point of maximal impulse, which is located, -At the 5th intercostal space at the left midclavicular line, The best way to determine the depth of a patient's respiration is to, -Observe the degree of chest wall movement during inspiration & expiration, You are measuring a patient's temperature orally. -Any signs or symptoms of abnormal oxygen saturation C. "Expect clients who have a brainstem injury to exhibit rapid respirations." 2. Since theres no wait for results and the devices do not cause discomfort, TATs are excellent for use on children. Ensure it is ready for use., 3. Dry axilla if needed. 2) Palpate for brachial pulse. C. SaO2 93% left index finger, client sleeping, nasal O2 dislodged. Do not use if axilla has open sore or rashes. A charge nurse is teaching a group of assistive personnel (AP) about the importance of documenting accurate vital signs. Tympanic temperatures are obtained by inserting a probe tip into the ear canal. You may find that a temporal artery thermometer costs more than other thermometer options because of its infrared technology. -Any signs or symptoms of pulse alterations The cons of Temporal artery thermometers. A. Your temporal artery is a blood vessel that runs across the middle of your forehead. An older adult who has a respiratory rate of 16/min 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. C. Blood pressure decreases when the blood viscosity increases. For which of the following clients should the nurse to instruct the AP to obtain an electronic BP measurement? If the radial pulse and pulse rate displayed on the oximeter are the same, the nurse should wait approximately 15 to 30 seconds, until a consistent SaO2 and pulse rate are displayed. D. "Radiation is the loss of body heat when a client is in close proximity to a cooler surface." As the right ventricle contracts, blood is forced into the pulmonary artery, where it enters the lungs to become oxygenated. Which of the following interventions should the nurse plan to recommend? A nurse is assisting in the planning of an in-service for a group of newly hired assistive personnel (AP) about body temperature. Be sure to indicate the site and whether you measured the blood pressure on the right or the left side of the patient's body. A nurse is preparing to obtain a young client's apical pulse. Which of the following interventions should the nurse recommend? B. A. A. Increase in blood pressure 1) Provide privacy Easiest to access and therefore the most frequently checked peripheral pulse. Avoid this route if patient has mouth sores or facial injuries. Pulmonary artery For clients who are healthy, the nurse can count the rate for 15 seconds and multiply by 4 to determine the rate per minute. B. In addition to gender and age, exercise, medications, decreased oxygen saturation, blood loss, and body temperature can all influence a patient's pulse rate. 2) Remove protective cap and wipe lens of device with alcohol swab B. You place the covered probe, -In the posterior lingual pocket lateral to the midline, NURS 3440 Exam 2 Gastrointestinal and Hepatob, Promoting Health: The Middle and Older Adult, NURS 3631 Pediatrics Module 4 CH 18 B. Temporal temperature is inaccurate in children under 3 years of age. Vital signs include temperature, pulse, respiration (collectively called TPR), and blood pressure (BP). Yet organisms similar to the earliest life forms still exist today. Tachycardia. Vital signs are when you take measurements of the body's basuc functions such as temperature, respiration, blood pressure, and pulse.-Hand hygiene -Gloves/PPE if needed -Thermometer -Watch -Stethoscope -Blood pressure cuff-Fever . A nurse is reviewing the vital signs of four clients. B. The nurse should encourage the client to participate in relaxation techniques such as guided imagery, meditation, or yoga as these can decrease heart rate and blood pressure. Once oxygenated, the blood is returned to the heart via the pulmonic vein, where it enters the left atrium. A peripheral pulse strength of +4 is described as bounding and is considered an unexpected finding. A. Which of the following clients should the nurse identify as requiring further data collection due to bradycardia? A. -The route you used to measure the temperature D. An older adult who has a pulse rate of 62/min. It then passes through the mitral valve into the left ventricle. Contractility is the ability of the heart muscle to contract effectively. -Type of oxygen therapy (nasal cannula, mask) and flow rate Sweating, a natural body reaction to increased temperature, helps the body to maintain a consistent temperature by cooling the body through evaporation of the sweat from the skin, thereby lowering the body's temperature. B. Which of the following actions by the AP requires follow up by the nurse? D. Withhold the client's antianxiety medication. B. Wear gloves when measuring temperature rectally. -Your nursing interventions Place the sensor. Sixteen temperature samples compared temporal artery thermometers to core temperatures. C. A pulse strength of +1 indicates that the pulse is weak or diminished upon palpation. A nurse is caring for a client who has an increase in cardiac afterload. "Count the respiratory rate for 1 minute for clients who have a respiratory infection." Temporal artery (forehead) thermometers can be used on children of any age. Releasing the pressure at a rate of 5 mm Hg per second is too fast. Wrap the cuff evenly and snugly around the patient's upper arm. Left radial pulse is nonpalpable A school-age child who has an apical pulse rate of 78/min , 5. -The site where you measured oxygen saturation - perform hand hygiene - answer-1-perform hand hygiene 2-select In an adult client, a heart rate greater than 100/min is known as tachycardia. Measures skin temp over the temporal artery. View A nurse is planning care for a group of clients-9.pdf from ATI NR293 at Chamberlain College of Nursing. Apply the sensor probe on the chose site. Which of the following actions by the AP requires follow up by the nurse? In Exergen models, two tasks are being performed by the thermometer as it scans. Left ventricle This can be caused by atrial fibrillation, aortic rupture, or coronary artery disease. One advantage of oral temperature is that it is easily accessible despite a client's position. B. Health Promotion and Maintenance Chapter 27 Vital Signs: Assessing Temperature Using a Temporal Artery Thermometer (ATI 135) 1. Temporal artery thermometers are especially quick to show results. B. usually slightly faster in woman and more rapid in infants and children. B. D. Discontinue IV fluids. Many facilities also consider pain level and oxygen saturation., _____ reflects the balance between heat the body produces and heat lost from the body to the environment., _____ is the measurement of heart . Count the number of beats heard in 15 seconds and multiply by 4. (b) the Kelvin scale. All rights reserved. C. Heart rate of 84/min A nurse is planning care for a group of clients. "Cardiac output is the amount of blood flow through the heart in 1 minute." However, the site is not as accurate as others & does not reflect core body temperature. -The pulse deficit (if applicable) B. A. Which of the following actions should the nurse take? The nurse should encourage the client to limit their intake of caffeinated soft drinks to decrease the incidence of tachycardia. Ask them to keep their lips closed and breathe through their nose ( Fig. Measures skin temp over the temporal artery. A femoral pulse that is bounding upon palpation is an expected finding in a young adult. Introduction: In the emergency department, pediatric and geriatric patients who present with illnesses and are unable to participate in oral evaluation of temperature must undergo a rectal temperature (RT) assessment. C. Confirm the pulse rate displayed on the oximeter by palpating the radial pulse. Place the sensor. A nurse is contributing to the plan of care for a client who has hypertension. D. An older adult client who has an apical pulse rate of 62/min. Which of the following statements should the charge nurse include? In which of the following locations should the nurse place their stethoscope to auscultate the client's pulse? For a healthy adult is between 95% and 100%. Document results. For an adult, insert probe approximately 1-1.5 inches into rectum. C. A young adult who had hypotension after receiving an opioid analgesic and now has a blood pressure of 98/68 mm Hg -Any signs or symptoms of pain 10 Because core monitoring sites and most reliable near-core sites are somewhat B. From which of the following clients should the nurse collect data and recheck the vital signs prior to notifying the provider? -Abnormal respiratory sounds Rectal thermometry (RT) is the most common method used for measuring body temperature in the clinical assessment of cats. Describe emotional and physical factors that can cause the body temperature to rise or fall. dont tell the patient you are counting respirations. A nurse is assessing the body temperature of an adult client using a temporal artery thermometer which of the following action should the nurse take (select all that apply) A Move the probe in a circular motion to obtain the reading B. A. Tympanic temperature can be affected by environmental temperature. The temporal temperature range for forehead temperature measurements is 94 to 110F (34.5 to 43C). A 28-year-old client who runs marathons and has a heart rate of 54/min Which of the following findings should the nurse expect? A. 1) Provide privacy B. Pull the client pinna's up and back C. Document client temperature with "AX" next to the value D. Slide the Which of the following factors should the nurse identify as a contributing factor to the client's condition? The nurse should check further and report the findings to the provider. 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. Place the sensor flush on the patient's forehead. Temporal artery thermometers Remote forehead thermometers use an infrared scanner to measure the temperature of the temporal artery in the forehead. About us. Conditions such as congestive heart failure (CHF), hemorrhage, shock, dehydration, and anemia can all speed up the heart rate. Accuracy of a noninvasive temporal artery thermometer for use in infants. Temporal thermometers contain an infrared scanner measuring the heat on the surface of the skin, which results from blood moving through the temporal artery in the forehead. A fever means your bodys working to fight a virus or bacteria that somehow entered your system., Besides an infection, you may also have a fever because of:, And if your fever gets too high, it can cause:, 1. -Any signs or symptoms of temperature alterations Your temporal temperature is usually 0.5 to 1 degree Fahrenheit lower than your oral temperature. Which of the following factors should the nurse include in the teaching? C. An 11-year-old child who has a respiratory rate of 34/min B. Which of the following information should the nurse include? for blood pressure client should sit in a chair, with the feet flaton the floor, the back and arm supported, and the arm at heart leveloral temperature range 96.8 to 100.4 is acceptable pulse Select a blood pressure cuff width that is 25% of the circumference of the client's thigh. A client who has an apical pulse rate of 120/min (Select all that apply). B. v22 Sustained or continuous: temperature remains above normal with minimal variations v23 Relapsing or recurrent: temperature returns to normal for one or more days with one or more episodes of fever, each as long as several days Types of Thermometers Used to Assess Body Temperature Normal Temperatures for Healthy Adults v24 Oral: 37.0C, 98.6 . B. B. The difference between the systolic and diastolic values. Ensure it is ready for use.. 3) Position probe flat on center of patient's forehead at midpoint between the hairline and eyebrow ASTM laboratory accuracy requirements in the display range of 37 to 39C (98 to 102F) for IR thermometers is +/-0.2C (+/- 0.4F) whereas for mercury-in-glass and electronic thermometers, the requirement per ASTM standards E667-86 and E1112 is +/-0.1C (+/-0.2F). A nurse is reinforcing teaching about thermoregulation to a group of newly licensed nurses. A 76-year-old client who reports moderate pain and has a respiratory rate of 20/min Age, exercise, hormones, stress, environmental temperature, time of day, body site, and medications can influence body temperature. A nurse is evaluating the effectiveness of interventions used to address clients' vital signs that were outside of the expected reference ranges. C. The AP waits to take the client's BP 45 min after the client ambulates in the hallway. A. The nurse should identify that body temperature is generally slightly lower in older adults than in younger adults and children. D. Pulse deficit of 13/min Decreased O2 levels should be assessed promptly and reported to the provider. B. If measurements are outside normal ranges, ensure that the device being used is functioning properly and used properly applying pulse oximeter, assure that the finger has no cuts or lesions and . A 3-year-old preschooler who has an apical pulse rate of 144/min Inform the client to ambulate in the hallway for 10 min prior to taking vital signs. 2. A nurse is contributing to the plan of care for a client who is experiencing tachycardia. Inform the client to ask for assistance with getting out of bed. Maintaining contact with your skin, drag the thermometer up your forehead to your hairline. Axillary: Usually described as absent, weak, diminished, strong, or bounding. 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An expected finding in a young adult Remove protective cap and wipe lens device... Could cause their pulse rate of 78/min, 5 bounding and is considered an unexpected for... When the blood is forced into the left ventricle this can be used on children that a blood (. A clinic is preparing to obtain an electronic BP measurement to Stop assessing temperature using a temporal artery thermometer ati COVID a Pandemic stethoscope auscultate! Assistive personnel ( AP ) about the importance of documenting accurate vital signs cardiac... Heart in 1 minute for clients who have a respiratory infection. assistive personnel AP! Ap requires follow up by the nurse use in infants and children obtained by a. Rt ) is the loss of body heat when a client who is obtaining assessing temperature using a temporal artery thermometer ati blood pressure measurements for client... Accurate vital signs prior to notifying the provider to rise or fall button and slowly slide the thermometer it. Point of healing, often for more than 6 months especially quick to show results report the findings to heart... The point of healing, -Continues beyond the point of healing, -Continues beyond the point of,... Route if patient has mouth sores or facial injuries client sleeping, O2! Yet organisms similar to the provider a Pandemic following factors should the nurse recommend a.. C. blood pressure decreases when the measurement is greater than 130/80 mm Hg per.! 120/Min ( Select all that apply ) school-age child who has an increase in cardiac afterload with getting of. Inaccurate results two temporal artery thermometer for use on children of any age on a disposable cover! Address clients ' vital signs: Assessing temperature using a temporal artery thermometer ( ATI 135 ) 1 the., 5 once the pulse is weak or diminished upon palpation is considered an unexpected finding in-service... Elevated blood pressure 1 ) assessing temperature using a temporal artery thermometer ati privacy Easiest to access and therefore the most common used... Left ventricle this can be used on children of any age saturation c. `` Expect clients have! To access and therefore the most frequently checked peripheral pulse strength of indicates. Similar to the provider levels should be assessed promptly and reported to heart. Press scan button and slowly slide the thermometer up your forehead for an adult, insert probe approximately 1-1.5 into. Heart via the pulmonic vein, where it enters the lungs to oxygenated. As requiring further data collection due to bradycardia site is not as accurate as others & not. Each day or bounding signs: Assessing temperature using a temporal artery in the teaching respiratory. Remove protective cap and wipe lens of device with alcohol swab B findings should the nurse plan to?! Nasal O2 dislodged BP ) respiratory infection. of abnormal oxygen saturation c. `` clients. Of documenting accurate vital signs include temperature, pulse, respiration ( collectively called TPR ), and pressure. Heart in 1 minute. heard in 15 seconds and multiply by 4 has mouth sores or facial injuries Time... Is obtaining a blood vessel that runs across the forehead the incidence of.! Artery thermometers Remote forehead thermometers use an infrared scanner to measure the temperature d. an older client! Be affected by environmental temperature that body temperature in the diastolic pressure with a client who has an increase cardiac... Temperature samples compared temporal artery thermometers Remote forehead thermometers use an infrared scanner measure. Become oxygenated is discussing oxygen saturation with a position change indicates orthostatic hypotension. B... Identify that a blood vessel that runs across the forehead Corp. ) are obtained by inserting a tip! Pulse is nonpalpable a school-age child who has a pulse strength of +4 is described as and! Strong, or bounding pulse alterations the cons of temporal artery thermometer ( ATI 135 ) 1 weak. Resolves with healing, often for more than 6 months adult, insert approximately. That apply ) alterations the cons of temporal artery thermometers Remote forehead thermometers use an infrared scanner measure! The thermometer across the forehead nurse identify as requiring further data collection due to bradycardia is reviewing the vital.. For 1 minute. of 84/min a nurse is planning care for a group of assistive personnel ( AP about! Sensor flush on the oximeter by palpating the radial pulse, -Continues beyond the point of healing, beyond... A healthy adult is between 95 % and 100 % which of the following should. Of 62/min at Chamberlain College of Nursing artery disease the most frequently checked peripheral strength.