Study Guide for Fundamentals of Nursing The Art and Science of Nursing Care

2.See table below.

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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

3. 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.


4. 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.


5. 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

6. 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


7. 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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