Clinical skills

Question 1

Factors to assess when taking tympanic temp:

Answer 1

Otitis media, impacted cerumen, inflammation, recent ear surgery

Question 2

Factors that can affect pulse rate and rhythm:

Answer 2

Medical history, disease process, age, exercise, and medications

Question 3

How to rate strength of pulse:

Answer 3

Bounding, full or strong, barely palpable or diminished;; or absent

Question 4

For a regular pulse-

Answer 4

Count rate for 30 secs and multiply by 2

Question 5

For irregular pulse-

Answer 5

Count rate for 60 secs

Question 6

Normal pulse rate:

Answer 6

60-100 BPM

Question 7

How to locate PMI/apical impulse:

Answer 7

Over the apex of the heart in the 5th intercostal space at the left midclavicular line

Question 8

Color of probe when taking rectal temp:

Answer 8

Red

Question 9

Placement of tympanic thermometer probe:

Answer 9

Gently tug the pinna backward, up, and out before inserting the probe.

Question 10

How to tale temporal artery temperature:

Answer 10

Place the sensor flush on the patient’s forehead.

Question 11

What is the nurse’s priority action if a patient’s radial pulse has an irregular rhythm?

Answer 11

Assess pt for pulse deficit

Question 12

Inadequate oxygenation to the body will cause the radial pulse to become:

Answer 12

Tachycardic

Question 13

Which action would take priority if a patient’s apical pulse has an irregular rhythm?

Answer 13

Reassess pulse for 1 full min

Question 14

Factors that cause pulse deficit:

Answer 14

Irregular heart rate, dyspnea, fatigue, chest pain, orthopnea, palpitations

Question 15

How to find a pulse deficit:

Answer 15

Subtract the radial rate from the apical rate. If the difference is more than 2 BPM, a pulse deficit exists.

Question 16

F/u care for a pt with a pulse deficit:

Answer 16

Signs or sxs of decreased cardiac output, such as edema, cyanosis or pallor of the skin, and dizziness or syncope.

Question 17

Factors that can affect respiratory rate:

Answer 17

Exercise, anxiety, acute pain, smoking, and medications

Question 18

Normal respiratory rate:

Answer 18

12-20 breaths per minute

Question 19

What to note as you count respiratory rate:

Answer 19

The depth of the respiration as shallow, normal, or deep by observing chest wall movement.

Question 20

F/u care after checking respiratory rate:

Answer 20

Compare respirations with the pt’s previous baseline, usual rate, depth, and rhythm. Correlate the pt’s respiratory rate, depth, and rhythm with pulse ox and arterial blood gas measurements.

Question 21

Which action can the nurse take to keep a patient from consciously controlling his or her breathing during an assessment?

Answer 21

Assess respiration after measuring the pulse.

Question 22

The nurse plans to assess a patient’s respiratory rate; however, the patient has just returned from ambulating to the bathroom. What should the nurse do to minimize the effect of exercise on the patient’s respiratory rate?

Answer 22

Encourage the patient to rest for 10 minutes before assessing respiration.

Question 23

During the assessment of a patient’s respiratory rate, when the second hand reaches the 15-second mark, the respiratory count is 8. What should the nurse do at this time?

Answer 23

Continue to count the patient’s breaths for a full 60 seconds.

Question 24

Where should the BP cuff lie on the arm?

Answer 24

2-3 cm above anticubital fossa

Question 25

How to indicate systolic BP:

Answer 25

• Slowly release the pressure bulb valve, allowing the manometer needle to fall slowly and continuously at a rate of 2-3 mm Hg per second
• Observe the point on the manometer at which the first Korotkoff sound is heard= systolic BP value

Question 26

How to indicate diastolic BP:

Answer 26

Point at which all Korotkoff sounds disappear

Question 27

For greater accuracy on taking BP and to decrease patients anxiety:

Answer 27

Take pt’s BP again in 2 minutes

Question 28

If it’s the pt’s first BP reading:

Answer 28

Take BP on both arms, then use arm with higher pressure

Question 29

F/u care after checking blood pressure:

Answer 29

Teach the patient how to prevent HTN by: exercising daily, weight loss, stopping smoking, reducing sodium and saturated fat intake, and maintaining good potassium and calcium intake.

Question 30

Normal BP in adults:

Answer 30

Systolic: less than 120 mm Hg
Diastolic: less than 80 mm Hg

Question 31

Normal BP in patients with elevated BP:

Answer 31

Systolic: 120-129 mm Hg
Diastolic: less than 80 mm Hg

Question 32

Normal BP in patients with stage 1 HTN:

Answer 32

Systolic: 120-129 mm Hg
Diastolic: 80-89 mm Hg

Question 33

Normal BP in patients with stage 2 HTN:

Answer 33

Systolic: 140 mm Hg
Diastolic: 90 mm Hg

Question 34

What does the systolic measurement represent?

Answer 34

The pressure exerted against the arterial wall

Question 35

2 step BP method:

Answer 35

• Palpate brachial artery with fingers while inflating cuff then note where pulse reappears (systolic) and disappears (diastolic) then…
• Take BP with stethoscope as normal

Question 36

Using a blood pressure cuff that is too wide would cause:

Answer 36

BP to be low

Question 37

Using a blood pressure cuff that is too loose would cause:

Answer 37

BP to be high