Chapter 15 Vital Signs, Oxygen, Chest Tubes, and Lines

The collection of vital signs data is quick and noninvasive. The usual vital signs measured include

• respiration, pulse, cardiac output, and uric acid levels.

• electrolytes, blood gases, urinalysis values.

• temperature, blood pressure, blood gases, and bowel sounds.

• 
  temperature, pulse, respiration, and blood pressure.

Answer explanation

Collectively, the vital signs are body temperature, pulse rate, blood pressure, and respiratory rate. In addition, assessment of the patient’s mental alertness (sensorium) is often reported along with the vital signs.

Minute ventilation consists of

• the smallest amount of inspiration needed to sustain life.

• good respiratory rate and respiratory depth.

• the number of respirations per minute.

• total tidal volume.

Answer explanation

Minute ventilation, sometimes referred to as adequate ventilation, is predicated on good respiratory rate and respiratory depth. The depth of breath determines tidal volume and adequate tidal volume and respiratory rate is necessary to ensure sufficient minute ventilation.

All of the following are related except

• rectal.

• inguinal.

• tympanic.

• oral.

Answer explanation

Five routes can be used to measure and extrapolate core body temperature: (1) oral, (2) axillary, (3) tympanic, (4) temporal, and (5) rectal. There is no body temperature measurement that is inguinal.

All of the following are true of body temperature measurement except

• 
  all temperatures should be the same, regardless of where the temperature is measured.

• an oral temperature reading higher than 99.5° F indicates a fever.

• rectal and TA measurement are typically 1° higher than oral readings

• temporal artery (TA) measurements can be measured in 3 seconds non-invasively.

Answer explanation

Body temperature readings may be measured in either degrees Fahrenheit (°F) or degrees Celsius (°C) and vary depending on where they are measured. Oral temperature readings in healthy adults and children are within the narrow range of 97.7° F to 99.5° F (36.5° C to 37.5° C). Tympanic measurements range from 95.9° F to 99.5° F (35.5° C to 37.5° C). Axillary temperatures register slightly lower, and rectal and TA temperatures register approximately 1° F higher than oral readings

The peak blood pressure reading, when measuring blood pressures, is

• blood pressure resulting from right ventricular contraction.

• the same as the ventricular ejection fraction or quotient.

• diastolic pressure.

• systolic pressure.

Answer explanation

During a contraction of the heart, blood is ejected from the ventricles into the arterial blood vessels, creating an increase in pressure. The peak pressure present during contraction of the heart is known as the systolic pressure.

A reliable device to measure oxygen saturation levels of arterial blood is a

• pulse oximeter.

• stethoscope.

• 
  spirometer.

• 
  sphygmomanometer.

Answer explanation

A pulse oximeter is a noninvasive device used to provide ongoing assessment of the hemoglobin oxygen saturation of arterial blood as well as the patient’s pulse rate. Normal pulse oximeter (SpO₂) values for a healthy person are 95% to 100%.

A patient who has a temporal artery temperature of 100° F is

• hypothermic.

• 
  febrile.

• 
  hyperthermic.

• normal.

Answer explanation

The TA lies superficial in the temporal region of the skull. A noninvasive swipe of the thermometer along the forehead and across the temporal region provides immediate, accurate measures closely correlating to core body temperature. Today, TA thermometry is popular. A TA reading of 100° F is considered normal (Table 15.1).

All of the following apply to respiratory measurements except

• the respiratory rate of newborns averages 12 to 20 breaths/min.

• a single respiration cycle consists of an inspiration and an expiration.

• adult respiration quality refers to rhythm, depth, and degree of effort.

• respiratory rates in children are more accurately measured for at least one minute

Answer explanation

Respiratory rates are measured as the number of breaths per minute; normal range at rest is 12 to 20 breaths/min. Newborns’ respiratory rates average 30 to 60 breaths/min.

The term bradypnea is used to describe

• a decrease in respiratory rate.

• the depth of respiration.

• 
  absence of breathing.

• difficulty in breathing.

Answer explanation

Bradypnea is the term used to describe a decrease in the respiratory rate. Bradypnea occurs much less frequently than tachypnea and results from depression of the respiratory center of the brain, which is common with drug overdoses, head trauma, and hypothermia.

The objective of oxygen therapy is to

• increase diaphragmatic movement to decrease tidal volume.

• increase the CO₂ concentration going to the patient.

• produce a condition of hypoxemia.

• increase the O₂ concentration going to the patient

Answer explanation

The primary clinical indications for oxygen administration are to correct hypoxemia. This is achieved by increasing oxygen levels in the blood. The overall goal of oxygen therapy is to maintain adequate tissue oxygenation while minimizing cardiopulmonary work.