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Thinking About the Procedure Questions and Suggested

Responses for Davis’s Nursing Skills Videos – Measuring Vital
Signs
Davis’s Nursing Skills Video: Taking an Axillary Temperature

1. Why did the nurse use the blue thermometer probe instead of the red one?

Suggested Response:
The red probe is for rectal temperatures only.

2. What did the nurse do to ensure that the thermometer probe was in good contact with the axillary
skin?

Suggested Response:
The nurse unsnapped and removed the gown from the patient's shoulder to provide good access to the
axilla. He also, after placing the thermometer, had the patient hold her arm at her side and fold the
lower arm across the lower chest.

Davis’s Nursing Skills Video: Taking an Oral Temperature

1. How should the patient’s temperature be classified: Hypothermic, Normothermic, or Hypothermic?

Suggested Response:
The patient’s temperature was 98.4, which is normothermic (normal body temperature).

Davis’s Nursing Skills Video: Taking a Rectal Temperature

1. What part of the thermometer was red to indicate for rectal use?

Suggested Response:
The probe holder was red.

Davis’s Nursing Skills Video: Taking a Temporal Artery Temperature

1. How should the patient’s temperature be classified: Hypothermic, Normothermic, or Hypothermic?

Suggested Response:
The patient’s temperature was 98.45, which is normothermic (normal body temperature).

Davis’s Nursing Skills Video: Taking a Tympanic Membrane Temperature

1. How did the nurse put the disposable cover over the thermometer lens?

Suggested Response:
The nurse inserted the lens into the box of covers, pressed down, and attached the cover. The nurse
did not put his hands into the box of covers.

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Davis’s Nursing Skills Video: Assessing Peripheral Pulses

1. What side of the bed was the nurse on when assessing the patient’s carotid pulse?

Suggested Response:
The nurse assessed the carotid pulse on the same side of the bed on which she was located. The nurse
should not reach across the patient to assess the pulse on the opposite side, to prevent compression
on the carotid artery.

2. What two landmarks does the nurse use to locate the carotid artery?

Suggested Response:
The trachea and the sternocleidomastoid muscle.

3. What technique did the nurse in the video use to assess the femoral pulse; and why?

Suggested Response:

The nurse palpated using one hand because she was able to palpate the appropriate depth, and likely
because the patient is in early adulthood and has good femoral circulation. In cases with compromised
peripheral circulation, the nurse would need to use both hands, given the depth of the femoral artery.

4. What two landmarks does the nurse use to locate the femoral artery?

Suggested Response:

The landmarks to locate the femoral artery are the anterior superior iliac spine and the symphis pubis.

5. Assessing the peripheral pulses in some locations may be more difficult due to factors such as smaller
arterial size, large amounts of subcutaneous tissues, vascular changes, etc. For each of the pulses
below, identify where the nurse placed her non-palpating hand to prevent movement while either
locating or palpating the pulse:

A. Dorsalis Pedis

Suggested Response:

Under the toes.

B. Tibial

Suggested Response:

Inner top foot near the great toe.

C. Popliteal

Suggested Response:

On top of the knee.

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Davis’s Nursing Skills Video: Assessing the Apical Pulse

1. How does the nurse position the patient in the video?

Suggested Response:
The patient is in semi-Fowler's position: head of bed elevated about 30 degrees.

2. How is this different from the position described for this procedure in your book?

Suggested Response:
Your book instructs the nurse to position the patient sitting, if possible. This is the easiest position in
which to be able to hear the apical pulse.

3. Can you think of any reasons why the nurse in the video may have positioned her client differently?

Suggested Response:
The supine and sitting positions may be contraindicated for this patient. For example, he may be too
weak to be up in a chair, or perhaps he becomes nauseated or dizzy when the head of the bed is
elevated to 90 degrees. In addition, it may be too difficult to breathe when he is lying flat (supine). All
of that is speculation, of course. The point is that you may have to vary a procedure sometimes, based
on the client's condition.

Davis’s Nursing Skills Video: Assessing for an Apical-Radial Pulse Deficit

1. Use the visual (non-narrated) video. What do you see the nurses do to show respect for the patient's
personhood? What should they do that you cannot see in the video?

Suggested Response:
The nurses should have (and they appear to have) introduced themselves upon approaching the
bedside. They should explain what they are going to do ("I need to take your pulse . . .") and ask
permission before exposing the patient’s chest ("I need to put your gown down, if that's okay"). The
nurse actually exposed only as much of his chest as necessary, also respecting dignity and privacy.

2. What safety measures did they demonstrate?

Suggested Response:
The nurses raised the bed rail and washed their hands with sanitizing gel at the conclusion of the
procedure.

3. At the end of the assessment of the apical-radial pulse, what did the nurses do?

Suggested Response:
They put the patient’s hand back into the gown, put the side rail back up, and left the patient in a
comfortable position before leaving the bedside.

Davis’s Nursing Skills Video: Assessing Respirations

1. Write an example of a nurse’s note describing the patient’s respiratory status. Assume that his rate is
12 breaths per minute (it may be difficult to count in the video) and that he is breathing normally, with
no shortness of breath. What else can you observe?

Suggested Response:

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mm/dd/yyyy 0800 Respiratory rate 12 breaths per minute. Respirations normal depth, regular, and
unlabored. Skin with no cyanosis or pallor. Patient talks without shortness of breath. Linda Sams,
Nursing Student

Davis’s Nursing Skills Video: Measuring Blood Pressure.

1. At the beginning of the procedure, using the manual method (with an aneroid manometer), where was
the measurement arm of the patient?

Suggested Response:
The patient’s measurement arm was slightly bent and resting on the bed.

2. What size cuff did the nurse use?

Suggested Response:
The nurse used the cuff for an adult (27.5 x 36.5 cm).

3. When using the automatic device, how many times did the nurse press on the machine? For what
reasons?

Suggested Response:
We saw the nurse touch the machine twice: once to turn it on and once to start the measurement.

Copyright © 2020 F.A. Davis Company