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ATS – REVIEW VITAL SIGNS AND DOCUMENTATION. Temperature is the measurement of the balance between heat produced and heat lost. True False. :20. Oral temperature is the most accurate method for taking temperature. TRUE FALSE. :20. Starvation leads to an increase body temperature. TRUE
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Temperature is the measurement of the balance between heat produced and heat lost • True • False :20
Oral temperature is the most accurate method for taking temperature • TRUE • FALSE :20
Starvation leads to an increase body temperature • TRUE • FALSE :20
How long should a glass oral thermometer be soaked in disinfectant before use? • 15 minutes • 30 minutes • 45 minutes • overnight :20
The brachial pulse site is used for • Pulse check with CPR • Pulse check for vital signs • Pulse site to check a blood pressure • Brachial pulse sites should never be used :20
Which of these would describe pulse RHYTHM? • Strong or weak • Fast or slow • Regular or irregular • All of the above :20
Tachycardia is defined as • Heart rate greater than 100 beats per minute in adults • Heart rate less than 60 beats per minute in adults • Absence of a pulse • Pulse pressure greater than 100 :20
Which of these are considered the four main vital signs? • TPR, Pulse oxcimetry • TPR, BP • BP, pupil reaction, TPR • TPR, BP, pupil reaction, oxcimetry :20
A patient with difficult, labored respirations could be described as having • Cheyne Stokes respiration • Apnea • Dyspnea • Stertorous :20
A patient with periods of apnea and periods of dyspnea could be described as having • Cheyne Stokes respiration • Apnea • Dyspnea • Stertorous :20
Graphic representations of things such as vital signs and height and weight are • Useful because they provide a visual diagram of variations that are important • Useful because it allows comparison to baseline and normal or acceptable values • All of the above • Neither A, B, or C are true :20
What causes heart sounds? • The contraction of heart muscle • The relaxation of heart muscle • The closing of valves in the heart • Movement of blood through atria and ventricles :20
Hypertension: • Reflects constant pressure on the walls of arteries • Reflects constant pressure on the mitral valve • Reflects a problem with ventricular contraction • Reflects constant relaxation on the walls of the veins :20
What is the usual effect of shock on the body? • Higher blood pressure • Lower blood pressure • Lower heart rate • Fever above 103 :20
Pyrexia is: • Another term for fever • The same as hyperthermia • Only used to describe a fever greater than 103 degrees F • Never a finding of concern :20
Your patient has difficulty breathing with a high pitch whistling sound during expiration. This is: • Cheyne-Stokes respiration • Normal respiration • Wheezing • Rales :20
The best way to document a patient’s symptoms is • Writing direct quotes and putting the entry in quotation marks • Interpreting what you think the patient is trying to say • Use standard abbreviations to note their symptoms in a shortened form • Write the statement using appropriate medical terminology :20
How should a healthcare professional determine which abbreviations to use? • Use a resource such as Tabor’s Medical Dictionary for any term • Use personal abbreviations that are clear • Follow facility policies • Use any JCAHO approved abbreviation :20
A coworker calls from home and says they forgot to sign their name on the patient medication record and asks you to sign for them. You should • Sign your name and put their name beside your name • Sign their name • Sign your name only • Refuse to sign either name :20
Source oriented medical record keeping does which? • Organizes by chronological order • Organizes charting by specialty (example: tabs under which doctors chart progress notes, separate tab for orders) • Organizes by type of body system affected • Organizes by type of health problem :20
Who can chart on a patient medical record? • Only doctors • Only nurses • A and B only • Any health care professional who provides a direct service to the patient :20
What is one purpose of charting? • Helps ensure compliance with regulatory agencies • Prevents lawsuits • Prevents costly procedures • Allows the patient to see what has gone on :20
Normal temperature ranges: • Depending upon thermometer: 97.6 to 99.6, 98.6 to 100.6, 96.6 to 98.6, 98.6 to 100.6 F • Are always 95.8 to 101 F regardless of type of thermometer used • Are the same for all types of thermometers • Are never charted on the medical record :20
Heart rate • Normal ranges 60 to 100 beats per minute in adult • Normal ranges 40 to 60 beats per minute in all age groups • Are higher for athletes at rest • Are lower for infants and children :20
Adult Normal systolic blood pressure • 100 to 120 mm Hg • 140 to 160 mm Hg • Less than 90 • Greater than 180 :20
Adult Normal diastolic blood pressure • Greater than 120 mm Hg • 60 to 80 mm Hg • 12 to 20 mm Hg • Any of the above would be normal readings :20
What items must be included in charting? • Date • Time • Signature • All of the above :20
When charting, what factors are important in writing? • Legible • Easy to Read • Clear • All of the above :20
What types of things involving patient care must be immediately reported to supervisors? • Abnormal Findings • Abnormal Results • Questions/Concerns about unclear orders • All of the above :20