A nurse is observing an assistive personnel (AP) obtain vital signs from an adult client. C. An infant who is receiving intravenous fluids 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. Be sure you know how to store and maintain it., 2. Expected finding is the client hears sound equally in both ears (negative weber test) 9. , 5. C. Confirm the pulse rate displayed on the oximeter by palpating the radial pulse. 5. B. 4. B. Which of the following statements should the charge nurse include? You are assessing a patient's vital signs. C. Place the sensor flush on the patient's forehead. B. Toddler who has a respiratory rate of 44/min The expected reference range for respiratory rate in toddlers is 24 to 40/min, so this client will need to be assessed by the nurse, as they are exhibiting tachypnea. A nurse is caring for a recently admitted client and as part of the plan of care, two nurses obtained simultaneous pulse rates. -Your nursing interventions A nurse is reviewing the vital signs for a group of clients to determine the effectiveness of interventions. -Your nursing interventions Is It (Finally) Time to Stop Calling COVID a Pandemic? 1)Patient should be in supine position. 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. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart? The fingers, toes, earlobes, and bridge of the nose are the most common sites. A charge nurse is evaluating a newly licensed nurse's documentation of vital signs for several clients. The client's auscultated apical pulse was 106/min and the palpated radial pulse was 93/min. "The body lowers body temperature through sweating." Continue to deflate the blood-pressure cuff slowly, noting the number at which the sound disappears. Place the sensor. 1) Provide Privacy Tachycardia. A. The child is exhibiting bradypnea, which requires further data collection by the nurse. Which of the following factors should the nurse identify as a contributing factor to the client's condition? D. A client who was recently admitted and reports chest pain. For most adults and children old enough to understand directions. Accuracy: Research has demonstrated that the TAT So you may have to do a little math. B. Ask the client to open their mouth before inserting the thermometer into one of their posterior sublingual pockets at the base of the tongue, not in front of it ( Fig. D. An older adult client who has an infection and a pulse rate of 110/min after using relaxation techniques. 2) Remove protective cap and wipe lens of device with alcohol swab A 17-year-old who has a respiratory rate of 16/min Oral temperatures should not be obtained in clients who have consumed foods or liquids or smoked tobacco products within the previous 30 min. An older adult who has a respiratory rate of 16/min A nurse is providing care to a client who has an apical pulse rate of 54/min and is experiencing dizziness. In an adult client, a heart rate greater than 100/min is known as tachycardia. oral temperature-keep probe under tongue until you hear it beep. The AP provides support for the client's arm while taking the BP. B. Client reports experiencing postoperative pain as 7 on a scale of 0 to 10. C. Encourage the client to take a short walk. Move the thermometer . Cons. C. Hold the client's thyroid medication. -Any signs or symptoms of pulse alterations A temporal artery thermometer (TAT) is one that you place on the skin of your forehead to get a readout of your body temperature. The 'gold' standard is to compare the TAT to the Pulmonary Artery Catheter thermometer (PAT), which measures core temperature. Oxygen saturation reflects the amount of oxygen being delivered to body tissues. But body temperature is different for infants and adults. A. Which of the following information should the nurse include? 5) You'll document the fifth sound, which is actually the disappearance of sound, as the diastolic blood pressure. B. For which of the following clients should the nurse to instruct the AP to obtain an electronic BP measurement? The nurse should identify the site from which to obtain the measurement, such as the finger, wrist, foot, or earlobe. The pressure is measured with a sphygmomanometer. 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 . For example, radiative heat loss can occur when a client sits near a window when it is cold outside. It causes less discomfort than a rectal thermometer and is less disturbing to a newborn. A 28-year-old client who runs marathons and has a heart rate of 54/min For an infant, this temperature is more of a concern than it may be for an adult.. D. A client who has stabilized BP measurements A. BP 130/82 mm Hg left arm, lying. A nurse is caring for a client who has a heart rate of 120/min. 8-year-old male: respiratory rate 34/min, SaO2 97%. B. Palpate the femoral pulse when obtaining blood pressure in the thigh. A nurse is caring for a client who has a heart rate of 118/min. D. Encourage the client to engage in pattern paced breathing by panting. D. A pedal pulse that is weak upon palpation is an expected finding in an older adult. Use all the steps.) 5) Discard disposable cover and document results. This study asks if a temporal artery temperature (TAT) measure can supplant the RT measure. A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. B. B. The temporal artery reading is obtained by scanning the thermometer across the patient's forehead. Digital multiuse thermometers read body temperature when the sensor located at the tip of the thermometer . D. Temporal temperature 36.9 C (98.4 F). Temporal Temperature Measurement Method 1) Provide privacy 2) Remove protective cap and wipe lens of device with alcohol swab 5)Listening to the brachial pulse with your stethoscope, inflate the blood-pressure cuff to 30 mm Hg above the patient's estimated systolic pressure. The nurse should identify that hypotension is a blood pressure of less than 90/60 mm Hg. Taking the Child's Temperature . Which of the following clients should the nurse identify as exhibiting tachycardia? A. Wait 30 seconds. B. Dyspnea The nurse should identify that cardiac output is the amount of blood pumped by the ventricles through the heart within 1 min. C. Right atrium Which of the following clients is experiencing an alteration in their respiratory rate that requires intervention? "The first step in checking for orthostatic hypotension is obtaining a client's blood pressure while they are standing." Arch Pediatr Adolesc . Testimonials; FAQ; Windows. For which of the following clients should the nurse obtain the vital signs rather than the AP? Cmo aprobar el examen ATI de salud mental? An adolescent who has a respiratory rate of 20/min It measures the temperature of the blood flowing through the temporal artery, on the forehead. Adult male who has a respiratory rate of 18/min The charge nurse should include that the nurse should count the respiratory rate for 1 min for clients who have a respiratory infection. Measures skin temp over the temporal artery. A. Design: A prospective repeated measures (induction, emergence, and postanesthesia care unit) design was used. Blood pressure can be obtained electronically using a machine that has a blood pressure cuff attached. 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 . A nurse is reviewing blood flow through the heart with a group of assistive personnel. B. 3 months to 4 years. 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. Usually described as absent, weak, diminished, strong, or bounding. Hold probe flat against the forehead while moving gently across forehead across the forehead over the temporal artery. Move the thermometer. A nurse is evaluating the effectiveness of interventions provided to a client who was admitted for decreased peripheral circulation. A client who has a blood pressure of 100/74 mm Hg Remote temporal artery thermometers are appropriate for children of any age. B. A. Ask them to keep their lips closed and breathe through their nose ( Fig. A toddler who has diarrhea -Any signs or symptoms of temperature alterations Which of the following statements should the nurse include? C. Expect blood pressure in the thigh to be 10 to 15 mm Hg less than in the arm. A charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. usually .9 degrees lower than oral temperature. 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. Decrease in contractility You typically need to wait for 20-30 seconds. An older adult client who has pneumonia and a respiratory rate of 26/min after a position change B. (b) the Kelvin scale. B. 3. Which of the following statements should the nurse include? Unformatted text preview: ACTIVE LEARNING TEMPLATE: Nursing Skill Rina Kabenla STUDENT NAME_____ Temperature Using a Temporal Artery Thermometer REVIEW MODULE CHAPTER__27 SKILL NAME__Assessing _____ _____ Description of Skill Is a technique to assess for temperature at the forehead to the temporal artery Indications Children, women, men Anybody Outcomes/Evaluation To take and record the . 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