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Fundamentals of Nursing > Clinical > Flashcards

Clinical Flashcards

1
Q

Normal BP for adults

A

120/80

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2
Q

Normal bp for newborn

A

70/45

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3
Q

normal respirations adults

A

12-20

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4
Q

normal newborn respirations

A

30-50

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5
Q

normal pulse adults

A

60-100

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6
Q

normal pulse newborn

A

100-170

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7
Q

normal temp for adults

A

98.6

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8
Q

normal temp for newborn

A

96.0-99.5

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9
Q

normla temp for elderly

A

96.8

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10
Q

How can acute pain affect vital signs?

A

Increase pulse, respiratory depth and rate, and BP

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11
Q

What can pain do to Cardiac output?

A

Increases it and vasoconstriction occurs

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12
Q

What are the 4 ways to take temp?

A

Orally
Rectally
Tympanic
Axillary

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13
Q

What do you need to remember to ask when taking oral temp?

A

Have you had anything cold or hot to drink in the last 15-30 min?

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14
Q

In cardiovascular patients, which way would you NOT take their temp?

A

Rectally

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15
Q

Which type of temp is the least accurate?

A

Axillary

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16
Q

What are the 5 areas to assess heart sounds?

A

APE To Man: Aortic, Pulmonic, Erb’s Point, Tricuspid, Mitral

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17
Q

What is the S1?

A 
Lub
Beginning of systally
AV valves close (mitral and tricuspid)
measurement of max pressure against arterial walls
Reflection of cardiac output
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18
Q

Where is S1 heard the loudest?

A

Mitral (apex of heart)

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19
Q

What is the S2?

A 
Dub
End of systally/beginning of distally
Relax and filling (measurement of pressure remaining in the arteries during relaxation phase)
Pulmonic and Aortic valves close
Reflection of PVR
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20
Q

What is Bradycardia?

A

Less than 60 bpm

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21
Q

What is Tachycardia?

A

More than 100 bpm

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22
Q

When assessing heard sounds or pulses, what are you listening for?

A

Quality
Rate
Rhythm - regular or irregular (dysrhythmia)
Volume - weak, thready, strong, bounding

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23
Q

When assessing new patient, where should you listen to heart sounds and take pulse?

A

Heart sounds: all 5 areas

Pulse: all peripheral pulses

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24
Q

What are the 9 sites for assessing pulse?

A 
Temporal
Carotid
Apical
Brachial
Radial
Ulnar
Femoral
Posterior tibial
Dorsalis pedis
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25
Q

What is BP a measure of?

A

Pressure in the arteries

26
Q

What factors affect BP?

A

Cardiac Output -inc = inc
Blood volume - inc. = Inc
Viscosity - inc = inc
PVR (peripheral vascular resistance) -

27
Q

What is systally?

A

max pressure against arterial walls

Reflection of cardiac output

28
Q

What is diastally?

A

pressure remaining in arteries during relaxation

Reflection of PVR

29
Q

What happens if the cuff is too big?

A

BP will be too low

30
Q

What happens if the cuff is too wide?

A

BP will be too low

31
Q

What happens if the cuff is too small?

A

BP will be too high

32
Q

When assessing weight, what do you need to remember?

A

Weigh the same time, in the same place, same clothes and document.

33
Q

What patients do you need to weigh daily?

A

Renal and Cardiac patients

34
Q

What is cardiac output?

A

volume of blood pumped by the heart in 1 min.

35
Q

What is stroke volume?

A

volume of blood that enters the aorta with each ventricular contraction

36
Q

What does hemorrhage do to stroke volume?

A

Decreases it

37
Q

What does IV fluids to do stroke volume?

A

Increases it

38
Q

What is viscosity?

A

thickness of blood

Greater the thickness the harder the heart has to work

39
Q

What is PVR? Peripheral Vascular Resistance

A

size and distensibility of the arteries

Plaque

40
Q

What is orthostatic hypotension?

A

postural hypotension
Refers to a sudden drop of 25 mm Hg in systolic pressure and 10 mm Hg in diastolic when a client moves from a lying to a sitting or sitting to a standing position

41
Q

How do we assess for orthostatic hypotension?

A

After 5 min of laying flat
After 1 min of sitting
After 1 min of standing
After 2 min of standing

42
Q

What are the volume assessments for pulse?

A

0=absent
1+ is weak or thready
2+ is normal
3+ is bounding

43
Q

What is euprea?

A

normal respirations 12-20

44
Q

What is bradypnea?

A

below 10 respirations

45
Q

What is tachypnea?

A

Above 24 respirations

46
Q

What is hypoventilation?

A

shallow respirations

47
Q

What is hyperventilation?

A

deep respirations

48
Q

What is dyspnea?

A

difficulty breathing, shortness of breath

49
Q

Where do you assess lung sounds?

A

10 front/12 back

Inspect/palpate/percuss/auscultation

50
Q

What are the 3 types of lung sounds?

A

Vesicular
Bronchovesicular
Bronchial

51
Q

What are vesicular lung sounds?

A

soft, breezy, low pitch
inspiration > expiration
heard on lung periphery

52
Q

what are bronchovesicular lung sounds?

A

Medium pitch
Inspiration = expiration
Heard posterior b/ scapula

53
Q

What are Bronchial lung sounds?

A

Loud, high pitch
Expiration > inspiration
Heard at trachea

54
Q

What are some abnormalities of lung sounds?

A

Crackles - heard on inspiration
Rhonchi - heard on expiration, trachea, musical
Wheezes - heard on expiration, snoring
Pleural friction rub - creaking
Stridor- heard on inspiration, crowing sound

55
Q

What order do you assess abdominal?

A

Inspection, Auscultation, percussion, palpation

56
Q

What order do you assess quadrants?

A

start lower right, upper R, upper L, lower L

57
Q

How long do you assess for bowel sounds?

A

Listen at least 5 minutes if not hearing sounds

should hear high pitched gurgling every 5-15 sec

58
Q

What is the Sims’ position and when do we use it?

A

on side with upper leg flexed

Used for rectal exam

59
Q

What is Prone position?

A

Laying on stomach
musculoskeletal observation
intolerable for patient with respiratory difficulty

60
Q

What is Dorsal Recumbent?

A

Knees flexed

Promotes abdominal relaxation

61
Q

What is supine?

A

Laying on back, most relaxed

easy access to abdomen

62
Q

When should sitting be used?

A

For full expansion of lungs

Fundamentals of Nursing (3 decks)

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