Chapter 10: Basic Nursing Skills

Question 1

what to check for when rounding

Answer 1

bathroom needs
pain levels
comfort/potential reposition
if pt needs help reaching something
properly functioning medical equipment

Question 2

how often do you measure vitals

Answer 2

q4h

Question 3

what are included in vitals

Answer 3

HR
RR
BP
O2 Sat
temp
pain

Question 4

baseline oral temp range

Answer 4

97.6 - 99.6

Question 5

baseline rectal temp range

Answer 5

98.6 - 100.6

Question 6

baseline axillary temp range

Answer 6

96.6 - 98.6

Question 7

baseline tympanic temp range

Answer 7

96.6 - 99.7

Question 8

baseline temporal temp range

Answer 8

97.2 - 100.1

Question 9

Adult baseline RR

Answer 9

12-20 rpm

Question 10

adult baseline HR

Answer 10

60-100 bpm

Question 11

normal BP

Answer 11

90-119

60-79

Question 12

hypotensive BP

Answer 12

less than 90

less than 60

Question 13

elevated BP

Answer 13

120-129

less than 80

Question 14

stage 1 hypertension BP

Answer 14

130-139

80-89

Question 15

stage 2 hypertension BP

Answer 15

higher than 140

higher than 90

Question 16

hypertensive crisis BP

Answer 16

higher than 180

higher than 120

either need to occur

Question 17

what color are rectal thermometers

Answer 17

red

Question 18

what is the most accurate temp location

Answer 18

rectal

Question 19

what is the least accurate temp location

Answer 19

axillary

Question 20

diaphoresis

Answer 20

excessive sweating
sign of fear, pain, heart attack

Question 21

cyanosis

Answer 21

blue/gray color of the skin
sign of decreased O2

Question 22

pallor

Answer 22

pale skin
sign of poor circulation

Question 23

flushing

Answer 23

skin appears red/darker than normal
sign of fever, pain, or environment too hot

Question 24

what ages do you use the brachial pulse site for

Answer 24

under 6 y/o

Question 25

normal HR range for small children

Answer 25

100-120 bpm

Question 26

normal Hr range for newborns

Answer 26

120-180 bpm

Question 27

causes of tachycardia

Answer 27

fever, dehydration, heart failure

Question 28

causes of bradycardia

Answer 28

infection

Question 29

apical pulse

Answer 29

pulse in the heart; below the nipple

Question 30

auscultation

Answer 30

listening to the body

Question 31

normal RR for infants

Answer 31

30-40 rpm

Question 32

apnea

Answer 32

absense of breathing

Question 33

dyspnea

Answer 33

difficulty breathing

Question 34

eupnea

Answer 34

normal respirations

Question 35

orthopnea

Answer 35

SOB when lying down that’s relieved by sitting up

Question 36

tachypnea

Answer 36

rapid respirations

Question 37

bradypnea

Answer 37

slow respirations

Question 38

cheyne-stokes

Answer 38

alternating periods of slow, irregular respirations and rapid, shallow respirations, along w/ short periods of apnea

Question 39

normal O2 stat

Answer 39

95-100%

Question 40

convert lbs to kg

Answer 40

2.2 lbs = 1 kg

Question 41

convert in to cm

Answer 41

2.54 in = 1 cm

Question 42

hydrocephalus

Answer 42

abnormal accumulation of fluid in the head

Question 43

how to measure head circumference

Answer 43

measure from above eyebrow and around the widest part of the back of the head

Question 44

calculate BMI

Answer 44

weight

height^2

Question 45

NPO how long before surgery

Answer 45

2-8 hr

Question 46

goal of postoperative care

Answer 46

prevent infections, promote healing, return pt to a State of health

Question 47

immediate concerns postoperative

Answer 47

breathing problems, mental status, pain, and wound healing

Question 48

potential complications of surgery

Answer 48

urinary retention, infections, constipation, BP variances, blood clots

Question 49

rights of med administration

Answer 49

right pt
med
time
route
dose
documentation