Editing Fundamentals of Nursing – RN Flashcards (section)

== Vital signs ==

;What are the adult reference ranges for the standard vital signs?
:Temperature about 36.5 to 37.5 degrees Celsius (97.7 to 99.5 degrees Fahrenheit) orally, pulse 60 to 100 beats per minute, respirations 12 to 20 breaths per minute, blood pressure below 120 over 80 millimeters of mercury for normal, and oxygen saturation about 95 to 100 percent on room air.

;What defines a positive orthostatic vital sign finding?
:A drop of at least 20 millimeters of mercury systolic or at least 10 millimeters of mercury diastolic within three minutes of standing, or symptoms such as dizziness or visual change. Measure supine, then sitting, then standing, allowing one to three minutes between positions.

;How does cuff size and technique affect blood pressure accuracy?
:The bladder width should be about 40 percent of arm circumference and the length about 80 percent. A cuff that is too narrow, applied over clothing, or used with the arm below heart level gives a falsely high reading. A cuff that is too wide gives a falsely low reading.

;When must the nurse hold digoxin, and how is the pulse assessed?
:Assess the apical pulse at the fifth intercostal space, left midclavicular line, for one full minute. Hold the dose and notify the provider if the adult apical rate is below 60 beats per minute, because further bradycardia may signal toxicity.

;When is pulse oximetry unreliable?
:With poor perfusion, hypothermia, vasoconstriction, hypotension, motion, dark nail polish, and carbon monoxide poisoning, in which the reading may be falsely normal because the oximeter cannot distinguish carboxyhemoglobin from oxyhemoglobin.