Align the sensor with the middle of your forehead for the most accurate reading.. Which of the following clients should the nurse identify as requiring further data collection due to bradycardia? With hypotension the client will have systolic BP less than 90 mm Hg or a diastolic BP less than 60 mm Hg. 2005 - 2023 WebMD LLC, an Internet Brands company. For example, if you have a two-year-old and use a temporal artery thermometer, you may get a reading of 101 degrees Fahrenheit. Which of the following actions should the nurse take to improve the client's heart rate? C. A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm Hg after using an inhaler B. Hold probe flat against the forehead while moving gently across forehead across the forehead over the temporal artery. Encourage the client to reduce intake of caffeinated soft drinks. Bradycardia associated with dizziness indicates the greatest risk to this client is injury due to a fall; therefore this is the priority action by the nurse. C. Sinoatrial (SA) node A. B. A nurse is evaluating the effectiveness of interventions used to address clients' vital signs that were outside of the expected reference ranges. A client who has an apical pulse rate of 120/min The nurse should identify that hypotension is a blood pressure of less than 90/60 mm Hg. A nurse is caring for a client who has a heart rate of 118/min. A school-age child The point at which you no longer feel the pulse is the estimated systolic pressure. Measuring Temperature with Tympanic thermometer. It is now common to find many instruments which monitor these vital signs available commercially for use at home [4]. 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. 2. D. "Cardiac output is the resistance of the ventricles to pump blood through the heart.". A nurse is discussing the physiology of blood pressure with a group of assistive personnel. -The patient's response to care, -The patient's oxygen saturation Ask them to keep their lips closed and breathe through their nose ( Fig. - perform hand hygiene - answer-1-perform hand hygiene 2-select Which of the following statements should the nurse include? C. Peripheral pulse +2 bilateral Temporal artery thermometers use an infrared scanner to measure the temperature of the temporal artery in your forehead. Which of the following actions should the nurse take when checking the infant's apical pulse? A. Atrioventricular (AV) node -Any signs or symptoms of pulse alterations A. Which of the following entries in the chart requires follow up by the nurse? Identify the order of the steps the nurse should include. Therefore, the nurse should direct the AP to obtain this client's temperature rectally. To determine precise tidal volume, a spirometer is needed, Estimate tidal volume by observing the expansion and symmetry of chest-wall movement during inspiration and expiration, The force that blood exerts against the vessel wall. Which of the following clients' vital signs indicate that interventions were effective? An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min Read the temperature. C. A 52-year-old client who has an SaO2 of 92% A. A nurse is evaluating the effectiveness of interventions used for clients who had alterations in vital signs. 98.6 is the average oral temperatures. The temporal artery reading is obtained by scanning the thermometer across the patient's forehead. Which of the following statements should the nurse include? U.S. STD Cases Increased During COVIDs 2nd Year, Have IBD and Insomnia? 5) Discard disposable cover and document results. A nurse is planning care for a group of clients. A. Usually, the thermometer will make a . 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.. C. Blood pressure decreases when the blood viscosity increases. A nurse is reinforcing teaching with a group of newly licensed nurses about vital sign measurements. Left radial pulse is nonpalpable The AP uses a cuff width that is 40% of the circumference of the client's arm. 1 When ambient temperature changes or animals undergo . When measureing B.P. About us. This finding requires intervention by the nurse. Therefore, the intervention of using an inhaler was effective. Express this difference on A. Increase in blood pressure We performed a retrospective analysis of over 1.8 million emergency department electronic health records to identify assess the performance of TAT measurement using patients with near-contemporaneous temperature measurements taken . An adult client who received medication for pain 30 min ago now has a respiratory rate of 18/min. The nurse should instruct the AP to obtain blood pressure measurements in the thigh when a client has severe edema in the arms or a shunt in place for dialysis. The nurse should document the findings in the client's medical record and notify the provider if a pulse deficit is present. "Conduction is the loss of body heat when sweat dries from a client's skin." Systematic review and meta-analysis on the diagnostic accuracy of temporal artery thermometers (TAT). -Type of oxygen therapy (nasal cannula, mask) and flow rate Tachycardia can be caused by stress or anxiety. 4) Press scan button and slowly slide the thermometer across the forehead and just behind the ear. The average normal oral temperature is 98.6 F (37 C). Since theres no wait for results and the devices do not cause discomfort, TATs are excellent for use on children. Which of the following findings indicate the intervention was effective? The temporal artery thermometer (TAT) is an infrared device designed for non-invasive assessment of body temperature by scanning the temporal artery. For an adult, insert probe approximately 1-1.5 inches into rectum. B. A charge nurse is discussing a client's respiratory data with a newly licensed nurse. SEC-502-RS-Dispositions Self-Assessment Survey T3 (1) Techniques DE Separation ET Analyse EN Biochimi 1 . A nurse is reviewing the vital signs of four clients. B. Accuracy: Research has demonstrated that the TAT C. Educate the client on medications, including therapeutic effects and potential adverse effects. D. A school-age child who has a respiratory rate of 14/min. A low SaO2 indicates the body's tissues and cells are not receiving enough oxygen and can be related to several causes including hypothermia, decreased cardiac output, or lung disease. C. Place the stethoscope over the 4th intercostal space to the left of the sternum. An adolescent who has a respiratory rate of 20/min A nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings for vital signs. Which of the following is the nurse's priority action? D. Midclavicular line below right clavicle. But body temperature is different for infants and adults. A pulse deficit is the numerical difference between the apical pulse and a peripheral pulse (usually the radial) for 1 min time. Results obtained indicate that measurement of the automated temperature device calibrated against standard mercury-in-glass thermometer returned a correlation coefficient of 0.790996276 . As we discussed earlier is a snapshot graph of a wave at t=0st=0 \mathrm{~s}t=0s. Draw the history graph for this wave at x=6mx=6 \mathrm{~m}x=6m, for t=0st=0 \mathrm{~s}t=0s to 6s6 \mathrm{~s}6s. Cuff width= 20% greater than the diameter of the limb at its midpoint or 40% of circumference. -It consists of a sensor with a light-emitting diode (LED) that is connected to the oximeter by a cable. The average difference between the rectal and the temporal artery measurement was 0.3C. A nurse is caring for a recently admitted client and as part of the plan of care, two nurses obtained simultaneous pulse rates. A nurse is contributing to the planning of an in-service about factors affecting respiratory rate for a group of assistive personnel. This type of thermometer is non-invasive and may even be applied while a patient is sleeping. A. Apply the sensor probe on the chose site. -Any signs or symptoms of temperature alterations A. Anxiety can cause a decrease in respiratory rate. Turn on the digital thermometer. A nurse is caring for a client who has an increase in cardiac output. One advantage of oral temperature is that it is easily accessible despite a client's position. Instruct the client to increase exercise. Health Promotion and Maintenance Chapter 27 Vital Signs: Assessing Temperature Using a Temporal Artery Thermometer (ATI 135) 1. Oral temperatures should not be obtained in clients who have consumed foods or liquids or smoked tobacco products within the previous 30 min. The nurse should auscultate the apical pulse over the apex of the heart, which is located in the 4th intercostal space to the left of the sternum in infants and children less than 7 years of age. 6)Slowly deflate the blood-pressure cuff and note the number on the manometer when you hear the first clear sound. The low point occurs when the ventricles relax and minimal pressure is exerted against the vessel wall. The nurse should encourage the client to limit their intake of caffeinated soft drinks to decrease the incidence of tachycardia. It can also be caused by an abnormality in the electrical system of the heart. -Any signs or symptoms of pain A nurse is reviewing blood flow through the heart with a group of assistive personnel. As the ventricle contracts, the blood is forced into the aorta and systemic circulation. EHM:Physics, physiology and serendipity of temporal artery thermometry., Harvard Medical School: Treating fever in adults. , Journal of General Internal Medicine: Performance of Temporal Artery Temperature Measurement in Ruling Out Fever: Implications for COVID-19 Screening., Kaiser Permanente: Fever Temperatures: Accuracy and Comparison., Mayo Clinic: Thermometers: Understand the options., Seattle Childrens: Fever - How to Take the Temperature.. A. Moreover, parents' use of a similar device resulted in inadequate agreement with rectal temperatures [37]. (Select all that apply.) Place the sensor. If it remains elevated, the nurse should notify the provider. A 17-year-old who has a respiratory rate of 16/min Which of the following manifestations requires follow up by the nurse? Which of the following findings should the nurse report to the RN? The SA node is the pacemaker of the heart. Quality, NURS 3631 Pediatrics Module 4 CH 14 Health Pr, Kathryn A Booth, Leesa Whicker, Terri D Wyman, Lecture 4 Funds A: Part 1 Pentose Phosphate P. Obtain a manual blood pressure reading from the client. A nurse is contributing to the plan of care for a client who has a temperature of 39.1 C (102.4 F). Ask the client whether they can hear the sound best in the right ear, left ear, or both ears equally. A nurse is reviewing the vital signs for a group of clients obtained by an assistive personnel. Inform the client to ask for assistance with getting out of bed. 1) Provide privacy B. Toddler who has a respiratory rate of 44/min A pulse strength of +4 indicates that the pulse is of normal strength upon palpation. A. A. Eupnea -The site where you measured the blood pressure D. Reinforce client teaching regarding medications to control blood pressure. Direct sunlight, cold temperatures or a sweaty forehead can affect temperature readings. D. Encourage the client to take a warm shower. A. A client who has a BP lower than the expected reference range A pulse strength of +2 is considered an expected finding. The client's diaphoresis will make it difficult to obtain an accurate temperature via the tympanic membrane or temporal artery. Which of the following information should the nurse recommend be included about measuring body temperature? B. A diagnosis of hypertension is not usually made based on a single elevated measurement; there are generally at least two elevated readings taken on two or more separate occasions for the provider to determine this diagnosis. Head and Neck: Performing the Weber's Test Chp 28 Place a vibrating tuning fork on top of the client's head. For clients who are healthy, the nurse can count the rate for 15 seconds and multiply by 4 to determine the rate per minute. D. A temporal probe thermometer uses infrared scanning to determine a client's temperature. C. Confirm the pulse rate displayed on the oximeter by palpating the radial pulse. A. 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