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261 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Normal temperature for adults in Celsius. |
35.8-37.5 Celsius |
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Normal pulse/heart rate for an adult. |
60-100 bpm |
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Normal respirations for an adult. |
12-20 per minute |
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Why should you not let your patient know you are counting respirations? |
The patient may hold their breath or change their breathing patterns. |
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Normal blood pressure for an adult. |
120/80 |
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Why do elderly people normally have a lower body temperature? |
As we age, we lose subcutaneous tissue. |
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Blood pressure level that is considered hypertension in adults. |
Anything equal to or greater than 140/90. |
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When will someone be determined as having hypertension/high blood pressure? |
After multiple visits to the doctor. |
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Normal temperature for an infant in Celsius. |
37.1-38.1 Celsius |
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Normal pulse/heart rate for an infant. |
80-160 bpm |
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Normal respirations for an infant. |
20-40 per minute |
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Normal blood pressure for an infant. |
85/37 |
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Factors in temperature increase. |
Physical Exertion Fever Dehydration Smoking Hot Beverages Hot Weather |
6 |
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Factors in decrease of temperature. |
Hypothermia Decrease in subcutaneous tissue with age. Consuming cold beverages or ice. |
3 |
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Factors in radial/apical pulse increase. |
Physical Activity Fever/Stress Medications Pain Disease |
5 |
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Factors in radial/apical pulse decrease. |
Athleticism Medications Disease |
3 |
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Factors in increase of respirations. |
Increased Fluid Trauma Exertion Pain Infections |
5 |
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Factors in decreased respirations. |
Increased intracranial pressure in the brain Opioid abuse/misuse |
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Factors in increased blood pressure. |
Hypertension Stress Over Exertion Pain Emotions |
5 |
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Factors in decreased blood pressure. |
Medications Disease Hemorrhage |
3 |
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The most accurate pulse in the body. |
Apical pulse. |
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Where is the radial pulse located. |
The wrist. |
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Where is the brachial pulse found? |
At the bend of the arm. |
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Where is the apical pulse found? |
Mid clavicular line at the fifth intercostal space. |
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The most accurate temperature in the body. |
Rectal |
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What does pyrexia mean? |
Fever |
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Important defense mechanism |
Pyrexia (fever) |
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With fever |
Febrile |
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Without fever |
Afebrile |
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Hyperthermia Fever |
High Fever |
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Severe reaction to certain drugs used for anesthesia. |
Malignant Hyperthermia |
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Faint Dizzy Headache Profuse Sweating Irritability Weak, Rapid Pulse Shallow Breathing Pale, Cool, Clammy Skin Nausea or Vomiting Muscle Cramps…. Are all symptoms of what? |
Heat Exhaustion |
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Absence of Sweating Pulsating Headache Hot, Red, Dry Skin High Body Temp, above 103 Nausea or Vomiting Strong, Rapid Pulse Confusions Convulsions May lose consciousness… Are all symptoms of what? |
Heat Stroke |
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Is the following treatment for heat exhaustion or heat stroke? 1) Have victim lie down in a cool shaded area or air conditioned area. 2) Drink water if victim is conscious. 3) Use caution when victim stands up. Apply cold compressions. |
Heat Exhaustion |
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Is the following treatment for heat exhaustion or heat stroke? 1) Dial 911. 2) Take actions to cool victim by any means. Place victim in a cool area, wrap in wet towel, sponge with cools water. |
Heat Stroke |
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One of the main ways to tell the difference between heat exhaustion and heat stroke. |
There is an absence of sweating with a heat stroke and the presence of profuse sweating with heat exhaustion. |
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If your body temperature rises to 104 or higher, you can possible have a _______________. |
Heat Stroke |
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What is the two step method of taking blood pressure? |
Estimate systolic Take BP |
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A significant and sudden drop in body temperature. |
Hypothermia |
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Injury to the body tissues caused by exposure to cold temperatures, typically affecting the nose, fingers, and toes. |
Frostbite |
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Slow breathing. |
Bradypnea |
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Fast breathing |
Tachypnea |
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Fast and over exaggerated breathing. |
Hypernpea |
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Without breathing. |
Apnea |
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Same as hyperpnea |
Hyperventilation |
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Same as bradypnea and could be related to opioid overdose |
Hypoventilation |
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Irregular periods of breathing and then absence of breathing. |
Cheyne-Stokes Respirations |
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Deep snoring respirations that may be associated with ketoacidosis. |
Kussmaul’s Respiration |
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Abnormal patterns of breathing that include shallow inspirations, then regular or irregular periods of apnea. |
Biot’s Respirations |
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On a capillary refill, a normal finding would be less than how many seconds? |
3 |
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A normal capillary refill would indicate what? |
Normal Circulation |
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The process of performing deliberate, purposeful, observations in a systematic manner. |
Inspection |
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Use of the sense of touch to assess skin temperature, turgor, texture, and moisture as well as vibrations within the body. |
Palpation |
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The act of striking one object against another to produce sound. |
Percussion |
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The act of listening with a stethoscope to sounds produced within the body. |
Auscultation |
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Abnormal findings of a capillary refill. |
Absent, weak, or thread pulses. |
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Abnormal findings of a capillary refill. |
Absent, weak, or thread pulses. |
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An abnormal finding of a capillary refill could indicate what? |
Hypertension Circulatory Overload Poor Peripheral Perfusion Poor Cardiac Output |
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What is peripheral profusion? |
Blood flow to the extremities. |
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A form of low blood pressure that happens when standing up from sitting or lying down. |
Orthostatic Hypotension |
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What will happen if you take blood pressure with a cuff that is too small? |
The blood pressure may read to high. |
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What will happen if you take blood pressure with a cuff that is too large? |
The blood pressure may read to low. |
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Why should you not take a blood pressure over a sleeve? |
You can get a false reading that is high. |
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Where should the arrow on a blood pressure cuff align? |
brachial artery |
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What are the max number of times you should take a blood pressure in an arm? |
Twice |
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What are some things to consider when deciding where to take someone’s blood pressure? |
- Don’t take over dialysis grafts, shunts, or IV sites. - ask for arm preference - do not take on a side where a patient has had a mastectomy |
3 |
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A blood pressure reading that is greater than 139/89 after multiple visits to the doctor, a person may be considered to have what? |
Hypertension |
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An important part of the body’s defense mechanisms against infection. |
Fever |
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An intervention for fever: Nursing must increase patient _____ and prevent ______. |
Comfort Complications |
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Per a provider’s order, what may we appropriately administer in prescribed doses to decrease fever in our patients? |
Acetaminophen Ibuprofen |
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This medication is not recommended for anyone less than 19 years old because of an increased risk for Reye’s Syndrome. |
Aspirin |
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An unknown metabolic condition that may precipitate liver failure in those who take aspirin at a young age. |
Reye’s Syndrome |
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Two types of ibuprofen. |
Motrin and Advil |
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Interventions for Low Blood Pressure |
Increased Fluid Volume Blood Products Adjusted BP Meds Assessment for sepsis or infections |
4 |
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Interventions for high blood pressure. |
Diet and Exercise Rest Blood Pressure Medicine Decrease stress and emotional problems in life |
+ Add 4a hint |
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Increased pulse interventions. |
Decrease physical exertion Take meds Decrease stress, anxiety, or overwhelming emotions |
3 |
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Decreased pulse interventions. |
May need meds to increase pulse Have a thorough work up to determine causes of low pulse rate. |
2 |
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Interventions for increases respiratory rate. |
Rest Medical tx for conditions such as asthma Relaxation techniques like yoga or meditation |
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Interventions for increased respiratory rate. |
Rest Medical treatment for conditions such as asthma Relaxation techniques like yoga or meditation |
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Interventions for decreased respiratory rate. |
Fix drug OD problems from opioids(Narcan) May need tx for intracranial issues like tumors |
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What is ADPIE? |
Assess (gather information and review) Diagnose (identify the problem through a nursing diagnosis) Plan (set your goals to solve the problem) Implement (reach goals through nursing action) Evaluate (determine outcome of goals and what, if anything needs changed) |
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In the nursing process, what do you do in the assess stage? |
Gather information from the client and review it with the client. |
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Can an LPN assess a patient? Explain your answer. |
No, an LPN cannot asses a patient. They can only collect data. Assessment is an RN skill. |
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In the nursing process, what do you do in the diagnose stage. |
You identify the problem through a nursing diagnosis. |
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In the nursing process, what do you do in the planing stage? |
You set goals to solve the problems. |
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In the nursing process, what do you do in the implement stage? |
Reach the goals through nursing actions. |
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In the nursing process, what do you do in the evaluate stage? |
You determine the outcome of the goals what, if anything needs to change. |
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What type of communication should you use when completing an interview with a client? |
Therapeutic |
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Two things you should develop with the patient at the beginning of an interview. |
Rapport Trusting Relationship |
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When does discharge planning for a patient start? |
Upon admissions |
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Techniques to use when interviewing patients. |
Develop rapport Give purpose for interview Determine what the patient would like to be called Assess their comfort with room Reduce environmental noises If needed, obtain interpretive services Use active listening Use open ended questions Use close ended questions |
9 |
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Parts of assessing appearance and behavior. |
Gender/race/age Level of Consciousness (LOC) Color of skin/speech Signs of distress (pallor, labored breathing, guarding, anxiety) Body build, stature, height & weight Posture/gait/body movements & ROM/symmetry of body parts/gross abnormalities Hygiene, grooming, body odor/dress Facial features, expressions, &mannerisms, affect, mood Signs of abuse, neglect, substance abuse Nutritional status Assess vital signs |
11 |
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When we identify our patients, we do not use this? |
DOB |
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What should we use to identify our patient? |
Gender Race Age |
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Demographic information includes: |
Name Address Contact Info DOB Age Gender Race and Ethnicity Marital Status Occupation Employment Status Insurance Emergency Contact Info Family & others living at home Advance directives |
11 |
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A brief statement in the patient’s own words as to why they are seeking care. |
Chief Concern |
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History of Present Illness: PQRST |
P: Provokes Q: Quality R: Radiate S: Severity T: Time |
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Explain P in the PQRST of History of Illness. |
P stands for PROVOKE. Ask the patient what caused or causes the pain. |
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Explain P in the PQRST of History of Illness. |
P stands for PROVOKE. Ask the patient what caused or causes the pain. |
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Explain Q in the PQRST of History of Illness. |
Q stands for quality. Is the pain dull, sharp, constant, sporadic, etc… |
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Explain R in the PQRST of History of Illness. |
R stands for RADIATE. Does the pain stay in one spot/area or moves. |
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Explain S in the PQRST of History of Illness. |
S stands for SEVERITY. On a scale of 0 - 10, what’s the pain level. |
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Explain T in the PQRST of History of Illness. |
T stands for a TIME. When did the pain start. |
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What is family history? |
The health history of your blood relatives. |
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Explain psychosocial history |
having to do with the mental, emotional, social, and spiritual health |
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Explain health promotion behaviors. |
Exercise, herbal remedies |
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What should we practice in an examination when it comes to infection control? |
Standard precautions |
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What should the environment be like when examining a patient and what should we make sure we have prior to starting? |
- have adequate lighting - quiet, comfortable - privacy: visualize only one section of the body at a time - equipment needed to complete the assessment |
3 |
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List the techniques of physical assessment. |
Inspect Palpation Percussion Auscultation |
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Auscultation |
Listening to sounds to determine norms and abnorms. |
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A technique where you use the fingertips to tap the body over body tissues to produce vibrations and sound waves. |
Percussion |
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The five things we look for when assessing skin. |
Color Moisture Temperature Texture Turgor |
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When assessing the skin and looking at color, what does pigmented mean? |
brown, black, gray, red or pink spots or patches |
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When assessing the skin and looking at color, what does cyanotic mean? |
The patient’s skin is blue. |
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When assessing the skin and looking at color, what does cyanotic mean? |
The patient’s skin is blue. |
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If a patient’s skin is blue, what could this indicate? |
Difficulty breathing, over exerted |
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When assessing the skin and looking at color, what does jaundiced mean? |
The patient is yellow and is indication that something is wrong with the liver. |
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When assessing the skin and looking at color, what does pallor mean? |
The patient is pale. |
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When assessing the skin and looking at color, what does erythema mean? |
The patient is red. |
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When assessing the skin and looking at moisture, what are we looking for? |
Is it wet or dry. |
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When assessing the skin and looking at temperature, what are we looking for? |
Is the skin warm, hot, cold. |
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When assessing the skin and looking at temperature, what are we looking for? |
Is the skin warm, hot, cold. |
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When assessing the skin and looking at texture, what are we looking for? |
Is the skin smooth, dry, or cracked. |
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When assessing the skin and looking at temperature, what are we looking for? |
Is the skin warm, hot, cold. |
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When assessing the skin and looking at texture, what are we looking for? |
Is the skin smooth, dry, or cracked. |
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When assessing the skin and looking at turgor, what are we looking for? |
We are looking to see if the skin “tents.” |
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Level of edema that is 2mm depression, barely detectable, and immediately rebounds. |
1+ |
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Describe edema level 1+ when assessing the skin. |
2mm depression, barely detectable. Immediate rebound. |
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Level of edema that has a 4mm deep pit and takes a few seconds to rebound. |
2+ |
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Describe level 2+ of edema when assessing the skin. |
4mm deep pit and takes a few seconds to rebound. |
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Level of edema that is 6mm deep pit and takes 10-12 seconds to rebound. |
3+ |
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Describe level 3+ of edema when assessing the skin. |
6mm deep pit and takes 10-12 seconds to rebound. |
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Level of edema that is 8mm and takes more than 20 seconds to rebound. |
4+ |
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Describe level 4+ of edema when assessing the skin. |
8mm, very deep pit that takes more than 20 seconds to rebound. |
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After a skin assessment, if someone is a 3+ or 4+ of edema, what does that mean? |
There is fluid retention and swelling. |
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What data should we collect from the hair or head when completing an assessment? |
Roundness of the crown Color of the hair Distribution of the hair Quantity of the hair Thickness or thinness of the hair Texture of the hair Lubrication of the hair Any presence of lice or bugs in scalp |
8 |
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What should we be able to determine after looking at the patient’s nails during an assessment? |
- the general health of a person - nutritional status - level of care |
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Cranial nerve 1 and major function. |
Olfactory and Smell |
1 function |
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Cranial nerve 2 and major function. |
Optic and Vision |
1 function |
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Cranial nerve 3 and major functions. |
Oculomotor Eyelid and eyeball movement |
1 function |
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Cranial nerve 4 and major functions. |
Trochlear Innervates superior oblique Turns eye downward and laterally |
2 functions |
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Cranial nerve 5 and major functions. |
Trigeminal Chewing Face & mouth - touch/pain |
2 functions |
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Cranial nerve 6 and major function. |
Abducens Turns eyes laterally |
1 function |
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Cranial nerve 7 and major functions |
Facial Controls most facial expressions Secretion of tears & saliva Taste |
3 functions |
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Cranial nerve 8 and major functions |
Vestibulocochlear Hearing equilibrium sensation |
2 functions |
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Cranial nerve 9 and major functions |
Glossopharyngeal Taste senses carotid blood pressure |
2 functions |
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Cranial nerve 10 and major functions |
Vagus Senses aortic blood pressure Slows heart rate Stimulates digestive organs Taste |
4 functions |
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Cranial nerve 11 and major functions. |
Spinal Accessory Controls trapezius & sternocleidomastoid (neck movements) Controls swallowing movements |
2 functions |
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Cranial nerve 12 and major functions |
Hypoglossal Controls tongue movements |
1 function |
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What three cranial nerves control eye movements? The cardinal signs of gazes. |
3, 4, & 6 |
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What cranial nerve slows down the heart rate? Give an example of how to do this. |
Cranial nerve 10, the vagus nerve. You could cough or strain as if you are trying have a bowel movement. |
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What is cranial nerve 1 and how do you check it? |
Cranial nerve 1 is the olfactory nerve with the major function of smell. You can check it by allowing the patient to test their smell using something such as cinnamon. |
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What is cranial nerve 2 and how would you test it? |
optic nerve that aids vision Have patient read eye chart |
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What is cranial nerve 5 and how would you check it? |
Cranial nerve 5 is the trigeminal nerve. You can have them bite down while you look at their tmj joint. |
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What is cranial nerve 5 and how would you check it? |
Cranial nerve 5 is the trigeminal nerve. You can have them bite down while you look at their tmj joint.
Because the trigeminal nerve also senses facial/mouth touch and pain, you can use a cotton ball to rub the patient’s forehead, then ask them describe what they are feeling. |
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What is cranial nerve 5 and how would you check it? |
Cranial nerve 5 is the trigeminal nerve. You can have them bite down while you look at their tmj joint. Because the trigeminal nerve also senses facial/mouth touch and pain, you can use a cotton ball to rub the patient’s forehead, then ask them describe what they are feeling. |
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What is cranial nerve 7 and how would you check it? |
Cranial nerve 7 is facial. You can ask the patient to smile, make a sad face. You can have the patient taste something such as sugar and have them let you know what they tasted. |
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What is cranial nerve 8 and how do you test it? |
Cranial nerve 8 is vestibulocochlear. You can complete a Weber and Rinne test. |
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What is cranial nerve 9 and how would you test it? |
Cranial nerve 9 is the glossopharyngeal nerve. You would test it by having the patient open their mouth and say “ahh” and the tonsils should open like a curtain. |
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What is cranial nerve 10 and how would you test it? |
Cranial nerve 10 is the vagus nerve. You would test it by putting a toothbrush on their tongue or something on the back of their throat, and then look for a gag reflex. |
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What is cranial nerve 11 and how would you test it? |
Cranial nerve 11 is the spinal accessory nerve. It can be tested by having the patient shrug their shoulders or have them shrug up as you push down. |
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What is cranial nerve 12 and how would you test it? |
Cranial nerve 12 is the hypoglossal nerve. You can have the patient stick out their tongue and move it around in different directions. |
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Used to test the body’s sense of position (proprioception) and to investigate the loss of motor coordination and balance issues related to the function of your dorsal columns. |
Romberg’s Test |
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What is proprioception? |
Your body’s sense of position. |
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Loss of motor coordination. |
Ataxia |
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How would you check cranial nerve 2, the optic nerve? |
Use of a snellen chart, standing 20 feet away. |
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Three common eye & vision problems to check for when assessing a patient. |
- extraocular movements - Nystagmus (involuntary eye movement) - visual fields (how far the eye can see without moving) |
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What size is most pupils between? |
3 and 5 |
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What size is most pupils between? |
3 and 5 |
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What instrument would you use to check someone’s external eye structure? |
A pen light. |
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Pupils can tell us what about our patients? |
Possible drug use. |
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Where do you place the tuning fork using the Weber’s test? |
In the middle of your forehead. |
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What is a normal Weber’s test result? |
When the patient can hear the sound from the tuning fork equally, in both ears. |
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Where do you place the tuning fork in the Rinne’s test? |
Behind the ear at the mastoid bone. |
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What is a normal Rinne’s test result? |
When you can move the tuning fork from the back of the ear to the side and still hear its sound. |
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What are some differences between the Weber and Rinne’s test. |
The Weber tests both ears at once; the Rinne’s test one at a time.
The tuning fork is placed in the middle of the forehead for the Weber’s test and behind the ear at the mastoid bone for the Rinne’s test. |
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What should we be checking in the mouth when assessing a patient? |
Color Texture Hydration Contour Lesions Buccal mucosa Gums Teeth Floor of mouth Hard and soft palate Pharynx |
11 |
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Respiratory Patterns: Vesicular: __________ Quiet: __________ Polyphonic Wheeze: __________ Bronchial: __________ Fine Crackles: __________ Coarse Crackles: __________ |
Normal Consolidation, collapse, or effusion Asthma, COPD Consolidation, Fibrosis Pulmonary Fibrosis LRTI, Bronhiectasis, Effusion |
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Heart Sounds: Lub & Dub Explain them. |
Lub is S1 and is the first sound we here caused by the closure of mitral and tricuspid valve. Dub is S2 and is the second sound you hear caused by the closure of the aortic and pulmonic valve. |
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What are the steps in examining the abdomen? |
Inspection (look) Auscultation (listen) Percussion Palpation (feel) |
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If you do not hear bowel sound when examine the abdomen, how long should you listen for sounds? |
Five minutes in each quadrant. |
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Normal temperature for adults in Fahrenheit. |
96.4 - 99.5 |
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Normal temperature for an infant in Fahrenheit. |
98.7 - 100.5 |
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Characteristics that influence temperature. |
Age Exercise Hormone Levels Circadian Rhythm Stress Environment Nutrition Skin, fat, & subcutaneous tissue amount |
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Temperature Alterations |
Pyrexia (fever) Febrile/Afebrile Fever of unknown origin Hyperthermia Malignant hyperthermia Heatstroke (104°F or higher) Heat exhaustion Hypothermia Frostbite |
9 |
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Treatment for heat exhaustion. |
1) Have victim lie down in a cool shaded area or air conditioned area. 2) Drink water if victim is conscious. 3) Use caution when victim stands up. Apply cold compressions. |
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Symptoms of heat exhaustion: |
Faint Dizzy Headache Profuse Sweating Irritability Weak Rapid Pulse Shallow Breathing Pale, Cool, Clammy Skin Nausea or Vomiting Muscle Cramps |
11 |
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Symptoms of heat stroke: |
Absence of sweating Pulsating headache Hot, red, dry skin High body temp - above 103 Nausea/Vomiting Strong/Rapid Pulse Confusion May loose consciousness |
8 |
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Treatment for heat stroke. |
1) Dial 911. 2) Take actions to cool victim by any means. Place victim in a cool area, wrap in wet towel, sponge with cools water. |
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Interventions for fever. |
Nursing must increase patient comfort and prevent complications. Administer appropriate and prescribed doses of acetaminophen or ibuprofen PER provider orders. |
2 |
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What would an abnormal capillary refill indicate? |
Decreased cardiac output. |
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Unless otherwise specified by the provider, all BP meds are held for a systolic reading less than _______. |
90 |
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A systolic reading of less than 90 is considered _______. |
Hypotension |
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When someone’s systolic reading drops 20-30 points, they are experiencing __________. |
Hypotension |
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When interviewing a client, begin with the _________ of the interview, gather __________, summarize __________ at the end. |
purpose information findings |
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When gathering client information, we must consider two things. What are they? |
Source of history & reliability of the historian. |
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A brief statement in the patient’s own words of why he/she is seeking care. |
Chief concern |
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What level of education degree does percussion begin? |
BSN |
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Using different parts of the hand to detect different characteristics. |
Palpation |
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Chart used to test visual acuity |
Snellen Chart |
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Three common eye & vision problems. |
Extraocular movements Nystagmus Visual fields |
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What is PERRLA and what does each letter stand for? |
An abbreviation used to document the findings of pupillary examination. Pupils- Equal and Round React to Light Accommodation |
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When checking the skin for turgor, if it “tents,” this could be an indication of what? If it doesn’t tent, it is an indication of what? |
That the patient could possibly be dehydrated. If the skin goes right back into place, we know that is good skin turgor. |
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Three key factors in successfully inspecting & palpating the heart. |
Patient must be relaxed and comfortable. Inspect and palpate simultaneously. Check the PMI for the best heart rate. |
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Three key factors in successfully inspecting & palpating the heart. |
Patient must be relaxed and comfortable. Inspect and palpate simultaneously. Check the PMI (apex/fifth intercostal space, left of the midclavicular line)for the best heart rate. |
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What is PMI? |
Point of Maximal Impulse/Intesity |
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Where is the best place to check for a heart rate and where is it located? |
Apex Fifth intercostal space, left of the midclavicular line. |
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When listening to the heart, what three things should we listen for? |
Dysrhythmia Extra heart sounds Murmurs |
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When inspecting the musculoskeletal, we should generally inspect these two things and look for these age related changes. |
Gait Postural |
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If a patient is in bed, be sure to inspect the _____ and _____ looking at the _____ and assess for _____. |
legs feet color assess |
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In what order do you perform auscultation/palpation on the abdomen? |
RL RU LU LL |
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Used to determine the level of consciousness. |
Glasgow coma scale |
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The Glasgow coma scale assesses three things. What are they? |
Eye opening Motor response Verbal response |
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When you are done when your assessment: __________ findings, report __________ to _________. Leave patient __________. |
document abnormals, providers Comfortable |
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After your assessment, if findings are serious, how should they be handled? |
Consult the provider before informing the patient. |
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A screening to see if the patient is alert and oriented to person, place, and time. |
Mini-Mental State Examination (MMSE) |
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Steps in collecting a specimen. |
1. Introduce yourself. 2. Wash hands and glove. 3. Collect urine sample per protocol. 4. Place in container. 5. Label with patient label. 6. Initial, date, & time label. 7. Put in biohazard bag, seal, and send to lab per protocols. |
7 steps |
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The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next? • Ask another student nurse to check it for him. • Use the Bell side of the stethoscope to listen. • Use the Doppler ultrasound device. • Connect the client to the oxygen saturation monitoring device. |
• Use the Doppler ultrasound device. |
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When assessing a client's radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next? • Obtain a bedside electrocardiogram • Auscultate the apical pulse for 60 seconds • Compare with previously documented findings • Report the findings to the health care provider |
• Auscultate the apical pulse for 60 seconds |
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Which site results in measuring a client's core body temperature? • Axillary • Oral • Rectal • Tympanic |
Rectal |
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A nurse needs to measure the blood pressure of a client with an electronic manometer. Which of the following advantages does an electronic manometer provide over an aneroid manometer or mercury manometer? • Ability to read gauge from any direction. • Need for readjustment is eliminated. • No stethoscope is required. • Inexpensive depending on quality. |
• No stethoscope is required. |
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The nurse discovers during assessment that the client has an altered temperature. Select one caustive factor for each type of heat loss. Radiation ____________ Conduction __________ Evaporation _________ Convection __________ |
infrared heat waves the air itself through sweating exposure to a fan |
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A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure? |
Over the client’s thigh |
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Which outcome best reflects achievement of the goal, "The client will demonstrate c steps in taking his own pulse rate"? • firm palpation of bilateral carotid artery for one minute • light palpation of the femoral pulse below the inguinal area • firm placement of thumb on the inner wrist of the opposite arm • palpation of the radial pulse on the thumb side of the inner aspect of the wrist. |
• palpation of the radial pulse on the thumb side of the inner aspect of the wrist. |
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The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with: |
increased temperature. |
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A client who has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong? |
She should place her three fingers just below the wrist on the outside of the arm with the palm up. |
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A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client? • "Dizziness is caused by very low blood pressure when you lie down." • "Dizziness can occur when baroreceptors overreact to the changes in BP." • "Dizziness can occur due to changes in the hospital environment." • "Dizziness when you change position can occur when fluid volume in the body is decreased." |
"Dizziness when you change position can occur when fluid volume in the body is decreased." |
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The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct? • Grasp the client's inner wrist with the nondominant thumb positioned over the radial artery. • Compress the radial artery until no pulsation is felt, then gently remove the fingertips until the pulsation returns. • Encircle the client's antecubital fossa with both hands and lightly compress the brachial artery with the first fingers of both hands. • Lightly compress the client's radial artery using the first, second, and third fingers. |
• Lightly compress the client's radial artery using the first, second, and third fingers. |
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The nurse is preparing to administer a medication that the client takes to treat a cardiac arrythmia. Which site should the nurse use to assess pulse in this client? |
Apical |
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A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods? |
listen with the stethoscope at the fifth intercostal space left mid-clavicular line |
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A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record? |
There is an auscultatory gap. |
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The home care nurse is assessing a 37-year-old client's vital signs at rest. Which finding requires nursing intervention? • respirations 18 breaths/min • temporal temperature 100.8° F (38.2° C) • blood pressure 116/80 mm Hg • pulse rate 70 beats/min |
Temporal temperature 100.8°F (38.2°C) |
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The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth? |
Deep in the posterior sublingual pocket. |
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When administering beta blocker medications, the health care provider adds an order to hold medication when the client is bradycardic. Which statement explains this order? • The client's respiratory rate is less than 18 breaths per minute. • The client's pulse rate is below 60 beats per minute. • The client's systolic blood pressure is less than 100 mm Hg. • The client is unable to stay upright when blood pressure is checked. |
• The client's pulse rate is below 60 beats per minute. |
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An older adult client monitors their blood pressure at home. Lately the client has been experiencing dizziness and nausea, followed by a headache when arising from lying down for a nap. The client was worried it was their blood pressure and began measuring their blood pressure arising from their nap. The client found that their blood pressure would drop shortly after getting. The client followed up with their health care provider and was diagnosed with orthostatic hypotension. What is the most important concern the nurse will include in the teaching plan? • acute confusion related to hypotension • sedentary lifestyle related to frequent afternoon naps • falls risk related to inadequate physiologic response to postural (positional) changes • lack of knowledge related to the inability to take an accurate blood pressue at home |
• falls risk related to inadequate physiologic response to postural (positional) changes |
acute confusion related to hypotension |
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The nurse is caring for a client who has smoked for more than 20 years and is now experiencing labored respirations. The nurse documents the client is experiencing: |
Dyspnea |
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Which pulse site is generally used in emergency situations? |
Carotid |
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A nurse is assessing a client's blood pressure manually. The nurse should identify the client's systolic blood pressure (SP) when which event occurs? |
The first faint, but clear, sound appears. |
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A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse? • Pulse is felt with difficulty and disappears with slight pressure. • Pulse is felt easily, and moderate pressure causes it to disappear. • Pulse is strong and remains strong despite moderate pressure. • Pulse is strong, and light pressure causes it to disappear. |
• Pulse is felt with difficulty and disappears with slight pressure. |
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A 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client? • To call her health care provider • Not to worry and to take double the dose of BP medication • To take the recommended daily dose of medication and call the health care provider if the average of her BPM readings increase/decrease by 10, or if she has any other concerns. • To take the medication that she missed and retake her BP |
To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns. |
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An ultrasonic Doppler is used for: |
auscultating a pulse that is difficult to palpate. |
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The nurse is assessing the client's blood pressure (BP) and heart rate (HR) for orthostatic hypotension. In which step should this nurse intervene because of potential danger? • Client sitting at edge of bed, feet dangling for 3 minutes; asymptomatic • After 3 minutes of sitting, BP 100/50; HR 90. • Client in supine position for 3 minutes and BP 120/70; HR 70; asymptomatic. • Client stands at bedside, becomes pale, diaphoretic. |
• Client stands at bedside, becomes pale, diaphoretic. |
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A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse? |
The radial pulse is difficult to obtain. |
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A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will: |
Decrease the apical pulse |
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After taking vital signs of an older adult, the nurse writes down findings as T = 98.9/37.2 oral, P = 104, R = 18, BP = 120/82. Based on the collected data, which step would the nurse take next? |
Take the pulse again to assess for tachycardia. |
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While recording the pulse of an infant at 160 beats/min, the parent asks if it is normal for the infant's pulse rate to be so high. Which statement by the nurse best answers the parent's question? • "Every infant's heart rate is different, so you will need to discuss that with the health care provider." • "A heart rate of 160 beats/min is normal for a healthy infant." • "A heart rate of 160 beats/min is a little too fast for an infant, so I will take it again in 5 minutes." • "A heart rate of 160 beats/min is actually slow for an infant, so I will ask the health care provider to reassess." |
• "A heart rate of 160 beats/min is normal for a healthy infant." |
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The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart? |
Listen for heart sounds. |
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The home care nurse is assessing a 37-year-old client's vital signs at rest. Which finding requires nursing intervention? • blood pressure 116/80 mm Hg • temporal temperature 100.8° F (38.2° C) • respirations 18 breaths/min • pulse rate 70 beats/min |
• temporal temperature 100.8° F (38.2° C) |
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A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation? |
• Auscultate the lung sounds and count respirations. |
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The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate? |
The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant’s apical pulse. |
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Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding? • "I know these spots are called senile lentigines and they are likely cancer." "All of these spots are called seborrheic keratoses and they should be taken off." "These brown spots are senile lentigines and are common when you get older." • "Older people often have splotchy skin due to seborrheic keratoses." |
• "These brown spots are senile lentigines and are common when you get older." |
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The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment? |
The client is dehydrated. |
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Upon assessment of an older adult, the nurse notes the client's skin to have a yellow color. The nurse interprets this finding as a result of which health condition? |
Hepatitis |
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Which respiratory sound indicates an upper airway obstruction? |
Strider |
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The nurse should use the bell of the stethoscope during auscultation of: |
A client’s heart murmur. |
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A nurse is assisting with assessment of the internal eye structures of clients in an ophthalmologist's office. What would the nurse document as a normal finding? |
A reddish retina |
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Which component(s) is included in the integumentary system? Select all that apply. |
Hair Skin Nails |
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A nurse has explained her intention to conduct a Weber test and a Rinne test. Which pieces of equipment will the nurse require? |
Tuning Fork |
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A 56-year-old client has a medium skin tone and a diagnosis of heart failure. The nurse's morning lung assessment of the client reveals crackles in the mid to lower lungs and respiratory rate of 32 breaths/min. The nurse notices that the client is restless and their skin has an ashen appearance. Which nursing action is the priority intervention? |
Measure the pulse oximetry. |
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The nurse is asking admission interview questions and the client has explained the reason for seeking care. What is the most appropriate way to document the response? • Client describes shortness of breath and increased sputum production. • Client reports breathlessness and productive cough. • Client reports respiratory distress and frequent spitting. • Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." |
Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." |
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A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic? Select all that apply. • Irregular edges • Single color • Symmetrical shape • Larger than 1/4 inch in diameter • Change in ale mole |
Irregular edges Larger than 1/4 inch in diameter Change in the mole |
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