ENPC 6th Ed. Chap 5 Initial Assessment Flashcards
Are vital signs a priority on patient arrival?
NO (75)
How can you measure urine output by weighing diapers?
One gram of weight is equivalent to 1ml of urine (79)
What amount of urine output would be concerning?
< 1ml/kg/hr can reflect poor end organ perfusion (79)
How is alertness evaluated in the Primary Survey A?
Using the AVPU mnemonic (71)
Besides Airway and Alertness, what else should be considered during the Primary Survey A?
The need for a C-collar (70)
How is an oral airway measured?
From the corner of the mouth to the angle of the jaw (71)
How is an NPA measured?
From the nares to the top of the earlobe (71)
How may a nurse approximate a ped ETT size?
By using an ETT the size of the little finger (71 BX)
Where should the nurse auscultate to confirm bilateral breath sounds?
Mid axillary to reduce the likelihood of referred breath sounds (71)
Where should the nurse palpate for a pulse in an infant?
brachial (71)
Where should the nurse palpate for a pulse on a child?
Carotid or femoral (72)
Describe how the pulses may be in a patient compensating for shock?
“a weak peripheral pulse compared to a central pulse” (71)
What circulatory assessment should prompt the nurse to initiate a PALS algorithm intervention?
HR <60 AND signs of poor perfusion (72)
What is the volume for a fluid bolus in an neonate and time frame to give it over?
10ml/kg over 5-10 min. (72)
What is the volume for a fluid bolus in a child?
20ml/kg (72)
What is the volume of a blood transfusion in a child?
10ml/kg (72)
What does a PEWS score of > 2 indicate?
indicates a likely need for intervention (80)
Mnemonic for just keep reavaluating?
VIPP (vitals, identify abnormalities, primary survey, pain) (80)
How is disability assessed?
Using GCS (72)
In what time frame can the Primary Survey be completed?
In 2 minutes if no issues are found (74)
At what points of the Survey does PERRLA and Cardinal fields of gaze take place?
PERRLA during “Disability” and Cardinal Fields during “Head to Toe” of face and neck (78)
When are heart tones auscultated?
During “Head to Toe” Chest (78)
When are breath sounds auscultated?
During Primary Survey “Breathing” (71) and during “Head to Toe” chest (78)
During the Head to Toe assessment, under Pelvis and Perineum, what should the nurse assess for?
contraindications to inserting a Foley (blood at the meatus, scrotal/perineal edema or ecchymosis) (78)
