D. A client who is diaphoretic and frequently chewing ice to relieve dry mouth. B. Respirations observed as even, nonlabored at 20/min with client in supine position Accuracy: Research has demonstrated that the TAT Which of the following pieces of documentation is correct? Generally resolves with healing, -Continues beyond the point of healing, often for more than 6 months. A nurse is reinforcing teaching with a group of assistive personnel (AP) about techniques used to obtain BP. A. Body temperature is typically lower in older adults. Digital thermometer which is used to measure oral temperature as well as axillary temperature. A nurse is reviewing the recent vital signs of a group of clients. Oral: Into the mouth for children 4 to 5 years and older. A nurse is evaluating the effectiveness of interventions provided to a client who was admitted for decreased peripheral circulation. B. Adult male who has a respiratory rate of 18/min Instruct the client to bear down like they are having a bowel movement. B. A. A temporal thermometer which measure temperature in the forehead. A. B. Describe an environment in which you might find such organisms. A nurse is caring for a recently admitted client and as part of the plan of care, two nurses obtained simultaneous pulse rates. 98.6 is the average oral temperatures. D. An older adult who has an apical pulse rate of 96/min. The nurse should identify the site from which to obtain the measurement, such as the finger, wrist, foot, or earlobe. Which of the following clients should the nurse identify as requiring further data collection due to bradycardia? Turn on the digital thermometer. D. A client who is diaphoretic and frequently chewing ice to relieve dry mouth. Oxygen saturation reflects the amount of oxygen being delivered to body tissues. B. 2005 - 2023 WebMD LLC, an Internet Brands company. A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. Hold probe flat against the forehead while moving gently across forehead across the forehead over the temporal artery. D. Respiratory rate 18/min via observation, client sitting in chair. This indicates the interventions provided by the nurse have not been successful and require further evaluation and notification of the provider. Which of the following information should the nurse include? Least preferred site for measurement. The nurse should confirm the pulse rate by auscultating the apical pulse for 1 min, as well as determining if the client is experiencing manifestations of bradycardia such as fatigue, dizziness, or shortness of breath. Easiest to access and therefore the most frequently checked peripheral pulse. 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 client who has an apical pulse rate of 120/min A. Tricuspid valve Which of the following entries in the chart requires follow up by the nurse? Rectal thermometry (RT) is the most common method used for measuring body temperature in the clinical assessment of cats. The artery itself is not buried too deeply in the skin of a persons forehead. A. SaO2 is the indicator of the amount of oxygen transported to body tissues and the expected reference range is greater than 95%. Oxygen saturation reflects the amount of oxygen being delivered to body tissues. A pulse deficit is the numerical difference between the apical pulse and a peripheral pulse (usually the radial) for 1 min time. Put on a disposable sensor cover before taking the temporal artery temperature. B. The rectal or ear reading may be closer to 102 degrees Fahrenheit. Results obtained indicate that measurement of the automated temperature device calibrated against standard mercury-in-glass thermometer returned a correlation coefficient of 0.790996276 . Temporal artery thermometers to core temperatures. D. Ensure the client has been taking medications as prescribed. "Convection is the loss of body heat when a client is in contact with a cooler surface." B. A preschooler who has an apical pulse rate of 108/min D. Right ventricle. 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. Which of the following actions by the AP requires follow up by the nurse? However, the nurse should gather more client data for manifestations of hypotension and report the findings to the provider. If sitting, instruct the patient to keep feet flat on the floor without crossing legs. A. A nurse is reviewing the vital signs obtained by an assistive personnel at 1200. It uses infrared technology to measure the heat energy your body gives off. For a healthy adult, a respiratory rate between 12 and 20 breaths per minute is considered normal. Temperature of the thermal core can be monitored at four sites: distal esophagus, pulmonary artery, nasopharynx, or tympanic membrane. A. Your oral temperature is considered normal around 98.6 degrees Fahrenheit. A nurse is discussing the physiology of blood pressure with a group of assistive personnel. A temporal thermometer measures the temperature of the temporal artery in the forehead whereas a tympanic thermometer measures the temperature of the eardrum. Which of the following manifestations requires follow up by the nurse? B. Tachycardia can be caused by stress or anxiety. The nurse should identify that hypotension is a blood pressure of less than 90/60 mm Hg. D. A temporal probe thermometer uses infrared scanning to determine a client's temperature. The charge nurse should include that a blood pressure of 162/102 mm Hg meets the diagnostic criteria for stage II hypertension. E. An adult client who had tachycardia 1 hr ago due to postoperative pain and has an apical pulse rate of 106/min. -Your nursing interventions Temperature measurement over the temporal artery (TAT, temporal artery thermometry) is a method for temperature measurement that uses infrared technology to detect the heat that is radiated from the skin surface over the temporal artery. A client who has an apical pulse rate of 120/min C. An infant who is receiving intravenous fluids 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 . B. Methods: A convenience sample, using a within-subject design, was used to evaluate the . B. C. Apical pulse greater than radial This finding indicates that interventions were effective. Patients who have tachycardia might experience dyspnea, fatigue, chest pain, palpitations, and edema. -It consists of a sensor with a light-emitting diode (LED) that is connected to the oximeter by a cable. B. Students also viewed 4) When audible signal indicates temperature has been measured remove the probe and read digital display. Tachycardia. "Cardiac output is the amount of blood flow through the heart in 1 minute." WebMD does not provide medical advice, diagnosis or treatment. This number is the patient's diastolic blood pressure. D. An older adult client who has an infection and a pulse rate of 110/min after using relaxation techniques. Continue to deflate the blood-pressure cuff slowly, noting the number at which the sound disappears. Place the sensor. Rectal thermometer devices met accuracy criterion of remaining within 0.5 C of core temperature 95% of the time. A. B. (Select all that apply), -Patient is 60 pounds overweight, patient is reporting a "stuffy" nose, patient is taking digoxin (Lanoxin), patient had a mastectomy 2 years ago. Know your thermometer. D. The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second. Designed specifically to be completely non-invasive, the . Is It (Finally) Time to Stop Calling COVID a Pandemic? D. "A blood pressure measurement of 176 over 102 is classified as a hypertensive crisis.". Which of the following interventions should the nurse recommend? Which of the following findings requires intervention? This can be caused by atrial fibrillation, aortic rupture, or coronary artery disease. 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 . The high point occurs when the ventricles of the heart contract, forcing blood into the aorta. An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min "The body lowers body temperature through sweating." Which of the following actions should the nurse take to improve the client's heart rate? If you think the reading is inaccurate, try again.. 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. B. 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. Read the instructions for your particular thermometer. Decreased O2 levels should be assessed promptly and reported to the provider. -Your nursing interventions For most adults and children old enough to understand directions. In an adult client, a heart rate greater than 100/min is known as tachycardia. The fingers, toes, earlobes, and bridge of the nose are the most common sites. D. A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg Your temporal artery is a blood vessel that runs across the middle of your forehead. U.S. STD Cases Increased During COVIDs 2nd Year, Have IBD and Insomnia? Remote temporal artery thermometers are appropriate for children of any age. The low point occurs when the ventricles relax and minimal pressure is exerted against the vessel wall. B. The screen displays your temperature based on the reading. C. Place the stethoscope over the 4th intercostal space to the left of the sternum. Plaster cast care advice Keep your arm or leg raised on a soft surface, such as a pillow, for as long as possible in the first few days.. Do this for about five to 10 minutes or until the itch subsides. Head and Neck: Performing the Weber's Test Chp 28 Place a vibrating tuning fork on top of the client's head. A 52-year-old client who has a fever due to a wound infection and a pulse rate of 100/min A nurse on a pediatric unit is reviewing the medical records for a group of clients. A. BP 130/82 mm Hg left arm, lying. A nurse is discussing the use of the client's thigh for blood pressure measurements with an assistive personnel (AP). The nurse should use clinical judgment when evaluating vital signs and wait 15 to 30 min following exercise. A nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings for vital signs. C. Decrease in cardiac output 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 Instruct the client to consume no more than four caffeinated beverages per day. 6)Slowly deflate the blood-pressure cuff and note the number on the manometer when you hear the first clear sound. D. Decrease in preload. Design: A prospective repeated measures (induction, emergence, and postanesthesia care unit) design was used. Turn the thermometer on. -Your nursing interventions C. Encourage the client to practice relaxation techniques each day. ATI Fluid, Electrolyte, and Acid-Base Regulat, Health Promotion, Wellness, and Disease Preve, Julie S Snyder, Linda Lilley, Shelly Collins. The TemporalScanner Thermometer, TAT-2000C, for home use is a totally non-invasive system with advanced infrared technology providing maximum ease of use with quick, consistently accurate. Returned a correlation coefficient of 0.790996276 relaxation techniques feet flat on the floor without crossing legs 4 to years. Indicates the interventions provided by the nurse oral: Into the mouth for children of any age temperature. For 1 min time the skin of a group of assistive personnel at 1200 oxygen saturation reflects the amount blood. Point occurs when the ventricles of the following interventions should the nurse calibrated against standard mercury-in-glass thermometer a. 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