Exam 1 Flashcards
1
Q
S1
A
first heart sound; closing of AV valves; beginning of systole; loudest at apex
2
Q
S2
A
second heart sound; closing of semilunar valves; ending of systole; loudest at base
3
Q
Midsternal line
A
at sternum
4
Q
Midclavicular line
A
middle of clavicle
5
Q
anterior axillary line
A
front of body at armpit
6
Q
Apical pulse
A
pulse site over the apex of the heart
7
Q
aortic area
A
right of Angle of Louie
8
Q
pulmonic area
A
left of Angle of Louie
9
Q
What is the name of the pulse on the top of the foot?
A
Dorsalis Pedis
10
Q
what is the name of the pulse behind the ankle bone?
A
posterior tibial
11
Q
what is the name of the pulse in the groin
A
femoral
12
Q
What is the number representing a normal pulse?
A
2+
13
Q
1+
A
number representing a weak pulse
14
Q
3+ / 4+
A
numbers representing a bounding pulse
15
Q
What is the number of no pulse?
A
0
16
Q
vertebral line
A
at spinal column
17
Q
scapular line
A
mid-scapula
18
Q
An infant’s chest should be?
A
round
19
Q
An adult’s chest should be?
A
wider than it is deep
20
Q
How do you position a patient for auscultating the lungs?
A
supine, lying on side or seated
21
Q
Lungs sounds are more audible if the patient is breathing with their mouth open?
A
True
22
Q
Lungs sounds are the same regardless of where you’re listening?
A
False. They change as you get closer to major airways
23
Q
How many bowel sounds is average?
A
1 per breath
24
Q
Alcohol hand rub
A
before / after touching a patient. Any time you are not washing your hands with soap and water
25
Auscultation
listening. hear sounds in the body. uses an aid.
26
Palpation
touching.
27
non-therapeutic communication techniques
minimizing / diminishing, excessive / personal questions, personal opinions / advice, false reassurance, judgement
28
SpO2
oxygen saturation
29
oral temp
easy, non-invasive, surface temp, altered by hot or cold foods, need a cooperative conscious patient
30
When to check VS?
upon entry / first thing, part of a routine / patient status, behavioral changes
31
therapeutic communication techniques
open / closed questions, active / reflective listening, affirmations, summarizing, silence, touch, empathy, focusing
32
12-20
expected respiratory rate for an adult
33
normotensive
expected blood pressure for an adult
34
hypotension
BP below expected range
35
tachycardia
pulse rate above expected range
36
60-100
expected pulse rate for an adult
37
febrile
fever, elevation in temp, not always caused by infection
38
hyperthermia
temp above expected range
39
hypothermia
temp below expected range
40
120/80
expected BP range for an adult
41
rectal temp
core temp, invasive, don't need a conscious patient, unable to do if patient has had surgery, etc. feces will cause inaccuracy
42
tachypnea
respiratory rate above expected range
43
SOLER
```
sit upright, eye level
open positon, observe
lean in, listen
eye contact
relax
```
44
nonverbal therapeutic communication tools
SOLER
45
axillary temp
under arm, easy, accessible, considered not to be very accurate, affected by environment, requires removal of clothing
46
hypertension
BP above expected range
47
Eupnea
respiratory rate within expected range
48
tympanic temp
ear, easy, accessible, tympanic membrane, core temp, pull Pina up and back, affected by environment
49
korotkoff sounds
audible sounds of manual BP
50
bradycardia
pulse rate slower than expected range
51
hypoxia
blood oxygen level below 95%
52
36 C - 38 C
expected temp for an adult
53
1 inhalation + 1 exhalation =
1 respiration
54
Hi, I Care
```
Hand hygiene
introduce yourself
identify patient using 1 identifiers
confidentiality / privacy
assess / address patient's needs
raise, return
educate, explain, exit
```
hand hygiene
55
pulse sites
radial, brachial, femoral, dorsalis pedis, posterior tibial
56
core temp locations
tympanic, rectal
57
surface temp locations
temporal, oral, axillary
58
bradypnea
respiratory rate below expected range
59
ISBARR
```
communication with patient's provider
introduction
situation
background
assessment
recommendations
repeat / read back
```
60
why do nurses monitor VS?
determine a baseline, support a diagnosis, gauge how a patient is responding to treatment, determine plan of care
61
must use soap and water
something visible on hands, patient with known GI issues, before / after eating, using the restroom
62
therapeutic communication
face to face process of interacting with patients that focuses on advancing physical and emotional well being
63
SOAPS
```
suction working / supplies available
oxygen working
ambu bag available / in place
position of bed / low locked,
surfaces
```
64
PERRL
pupils equal round & reactive to light
65
HEENT
head, eyes, ears, neck throat
66
what is the nursing process?
a way of thinking
organizing framework
problem solving approach
67
ADPIE
```
Assess
Diagnose
Plan
Implement
Evaluate
```
steps of nursing process
68
subjective information
data collected from patient/family
69
objective information
data collected from observation
70
assess (nursing process)
collective data
validate data
organize data
71
Diagnose (nursing process)
identify health problems, risks, strengths
72
planning (nursing process)
setting goals, outcomes, prioritize
73
SMART (nursing process)
```
goals / outcomes should be
specific
measurable
achievable / attainable
realistic
timely
```
74
Implementing
interventions
75
evaluating
where goals met? what worked what didn't
| go back to the beginning
76
why is patient hygiene important
prevents infections
promotes autonomy / independence
gets patient moving
77
NPO
nothing by mouth
78
should you do a basin bath
no. the basins carry bacteria and can cause infections
79
when should you use CHG wipes?
high risk patient. catheter, central line
80
what does oral care prevent?
pneumonia
81
fowler's position
legs flat, back up (seated)
82
pressure injury
Pressure injuries are sores (ulcers) that happen on areas of the skin that are under pressure. The pressure can come from lying in bed, sitting in a wheelchair, or wearing a cast for a long time. Pressure injuries are also called bedsores, pressure sores, or decubitus ulcers.
83
how often do you want to move a patient?
every 2 hours
84
complication of someone who is immobile
pneumonia
orthostatic hypotension
loss of muscle mass, bone mass, joint contracture, loss of balance
psychological, depression, loneliness
85
how to maintain comfort & safety during hygiene
```
good ergonomics
maintain privacy
maintain safety
maintain warmth
tell the patient what you're doing
be alert for patient fear & anxiety
```
86
BMAT
bedside mobility assessment tool
87
how to help promote normal urination and defecation
```
anticipate patient's needs
respond quickly to requests
privacy
describe urine/stool in EMR
monitor/record output
```
88
how to measure urine output
put in secondary container
| measured in ml
89
expected findings of general survey
```
responsive
calm
comfortable
facial symmetry
build is appropriate
personal hygiene
movements independent and voluntary
```
90
factors that cause variations in pulse, temp, RR and BP
```
smoking
anxiety, stress
eating or drinking
age, gender
hormones, ovulation
```
91
factors that cause variations in pulse, temp, RR and BP
```
smoking
anxiety, stress
eating or drinking
age, gender
hormones, ovulation
```
92
What do we mean by: “standard assessment”?
Systematic, deliberate assessment; data collection used to establish a patient’s baseline and/or for comparison with prior and/or subsequent assessments
