2.See table below.
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:
ANSWER KEY 365
Type of Thermometer Brief Description Contraindication Normal Reading
A. GLASS
oral Calibrated in degrees Unconscious, irrational, 98.6F
Centigrade or Fahrenheit seizure-prone, infants, 37.0C
oral disease
rectal Calibrated in degrees Newborns, diseases of 99.5F
Centigrade or Fahrenheit rectum, certain heart 37.5C
diseases
B. ELECTRONIC Two nonbreakable probes, Site dependent
disposable probe covers
C. TYMPANIC MEMBRANE Infrared sensors off Infants to 3 months 99.5F
membrane Tympanic membrane 37.5C
damage
D. TEMPERATURE SENSITIVE Forehead or abdomen; Newborns 94.0F
PATCH changes color at different 34.4C
temperatures
E. AUTOMATED MONITORING Measure body temperature, Site dependent
DEVICE pulse, and blood pressure
automatically
- a.The middle three fingers may be used to palpate
all peripheral pulse sites.
b.A stethoscope may be used to auscultate the api-
cal pulse.
c. Doppler ultrasound may be used to assess pulses
that are difficult to palpate or auscultate. - a.Pumping action of the heart: When the amount
of blood pumped into the arteries increases,
the pressure of blood against arterial walls also
increases.
b.Blood volume: When blood volume is low, blood
pressure is also low because there is less fluid
within the arteries.
c. Viscosity of blood: The more viscous the blood,
the higher the blood pressure.
d.Elasticity of vessel walls: The elasticity of the
walls, in addition to the resistance of the arteri-
oles, helps to maintain normal blood pressure. - a.Impaired Gas Exchange: Excess or deficit in oxy-
genation and/or carbon dioxide elimination at
the alveolar–capillary membrane
b.Ineffective Airway Clearance: Inability to clear
secretions or obstructions from the respiratory
tract to maintain a clear airway
c. Ineffective Breathing Pattern: Inspiration and/
or expiration that does not provide adequate
ventilation
d.Inability to Sustain Spontaneous Ventilation:
A state in which the response pattern of
decreased energy reserves results in an individ-
ual’s inability to maintain breathing adequate
to support life
- a.Altered Tissue Perfusion: A decrease in oxygen,
resulting in the failure to nourish the tissues at
the capillary level
b.Risk for Fluid Volume Imbalance: A risk for a
decrease, increase, or rapid shift from one to the
other of intravascular, interstitial, or intracellular
fluid
c. Fluid Volume Excess: The state in which an
individual experiences increased isotonic fluid
retention
d.Fluid Volume Deficit: The state in which an indi-
vidual experiences decreased intravascular, inter-
stitial, or intracellular fluid
e.Decreased Cardiac Output: A state in which the
blood pumped by the heart is inadequate to
meet the metabolic demands of the body - a.Stethoscope: Used to auscultate and assess body
sounds, including the apical pulse and blood
pressure. The acoustical stethoscope has an
amplifying mechanism connected to earpieces
by tubing.
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