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N388 > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

S1

A

first heart sound; closing of AV valves; beginning of systole; loudest at apex

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2
Q

S2

A

second heart sound; closing of semilunar valves; ending of systole; loudest at base

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3
Q

Midsternal line

A

at sternum

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4
Q

Midclavicular line

A

middle of clavicle

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5
Q

anterior axillary line

A

front of body at armpit

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6
Q

Apical pulse

A

pulse site over the apex of the heart

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7
Q

aortic area

A

right of Angle of Louie

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8
Q

pulmonic area

A

left of Angle of Louie

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9
Q

What is the name of the pulse on the top of the foot?

A

Dorsalis Pedis

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10
Q

what is the name of the pulse behind the ankle bone?

A

posterior tibial

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11
Q

what is the name of the pulse in the groin

A

femoral

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12
Q

What is the number representing a normal pulse?

A

2+

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13
Q

1+

A

number representing a weak pulse

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14
Q

3+ / 4+

A

numbers representing a bounding pulse

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15
Q

What is the number of no pulse?

A

0

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16
Q

vertebral line

A

at spinal column

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17
Q

scapular line

A

mid-scapula

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18
Q

An infant’s chest should be?

A

round

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19
Q

An adult’s chest should be?

A

wider than it is deep

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20
Q

How do you position a patient for auscultating the lungs?

A

supine, lying on side or seated

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21
Q

Lungs sounds are more audible if the patient is breathing with their mouth open?

A

True

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22
Q

Lungs sounds are the same regardless of where you’re listening?

A

False. They change as you get closer to major airways

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23
Q

How many bowel sounds is average?

A

1 per breath

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24
Q

Alcohol hand rub

A

before / after touching a patient. Any time you are not washing your hands with soap and water

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25
Q

Auscultation

A

listening. hear sounds in the body. uses an aid.

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26
Q

Palpation

A

touching.

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27
Q

non-therapeutic communication techniques

A

minimizing / diminishing, excessive / personal questions, personal opinions / advice, false reassurance, judgement

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28
Q

SpO2

A

oxygen saturation

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29
Q

oral temp

A

easy, non-invasive, surface temp, altered by hot or cold foods, need a cooperative conscious patient

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30
Q

When to check VS?

A

upon entry / first thing, part of a routine / patient status, behavioral changes

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31
Q

therapeutic communication techniques

A

open / closed questions, active / reflective listening, affirmations, summarizing, silence, touch, empathy, focusing

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32
Q

12-20

A

expected respiratory rate for an adult

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33
Q

normotensive

A

expected blood pressure for an adult

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34
Q

hypotension

A

BP below expected range

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35
Q

tachycardia

A

pulse rate above expected range

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36
Q

60-100

A

expected pulse rate for an adult

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37
Q

febrile

A

fever, elevation in temp, not always caused by infection

38
Q

hyperthermia

A

temp above expected range

39
Q

hypothermia

A

temp below expected range

40
Q

120/80

A

expected BP range for an adult

41
Q

rectal temp

A

core temp, invasive, don’t need a conscious patient, unable to do if patient has had surgery, etc. feces will cause inaccuracy

42
Q

tachypnea

A

respiratory rate above expected range

43
Q

SOLER

A 
sit upright, eye level 
open positon, observe 
lean in, listen 
eye contact 
relax
44
Q

nonverbal therapeutic communication tools

A

SOLER

45
Q

axillary temp

A

under arm, easy, accessible, considered not to be very accurate, affected by environment, requires removal of clothing

46
Q

hypertension

A

BP above expected range

47
Q

Eupnea

A

respiratory rate within expected range

48
Q

tympanic temp

A

ear, easy, accessible, tympanic membrane, core temp, pull Pina up and back, affected by environment

49
Q

korotkoff sounds

A

audible sounds of manual BP

50
Q

bradycardia

A

pulse rate slower than expected range

51
Q

hypoxia

A

blood oxygen level below 95%

52
Q

36 C - 38 C

A

expected temp for an adult

53
Q

1 inhalation + 1 exhalation =

A

1 respiration

54
Q

Hi, I Care

A 
Hand hygiene
introduce yourself
identify patient using 1 identifiers 
confidentiality / privacy 
assess / address patient's needs 
raise, return
educate, explain, exit

hand hygiene

55
Q

pulse sites

A

radial, brachial, femoral, dorsalis pedis, posterior tibial

56
Q

core temp locations

A

tympanic, rectal

57
Q

surface temp locations

A

temporal, oral, axillary

58
Q

bradypnea

A

respiratory rate below expected range

59
Q

ISBARR

A 
communication with patient's provider
introduction 
situation 
background 
assessment 
recommendations 
repeat / read back
60
Q

why do nurses monitor VS?

A

determine a baseline, support a diagnosis, gauge how a patient is responding to treatment, determine plan of care

61
Q

must use soap and water

A

something visible on hands, patient with known GI issues, before / after eating, using the restroom

62
Q

therapeutic communication

A

face to face process of interacting with patients that focuses on advancing physical and emotional well being

63
Q

SOAPS

A 
suction working / supplies available
oxygen working 
ambu bag available / in place 
position of bed / low locked, 
surfaces
64
Q

PERRL

A

pupils equal round & reactive to light

65
Q

HEENT

A

head, eyes, ears, neck throat

66
Q

what is the nursing process?

A

a way of thinking
organizing framework
problem solving approach

67
Q

ADPIE

A 
Assess
Diagnose
Plan 
Implement
Evaluate

steps of nursing process

68
Q

subjective information

A

data collected from patient/family

69
Q

objective information

A

data collected from observation

70
Q

assess (nursing process)

A

collective data
validate data
organize data

71
Q

Diagnose (nursing process)

A

identify health problems, risks, strengths

72
Q

planning (nursing process)

A

setting goals, outcomes, prioritize

73
Q

SMART (nursing process)

A 
goals / outcomes should be 
specific
measurable 
achievable / attainable 
realistic 
timely
74
Q

Implementing

A

interventions

75
Q

evaluating

A

where goals met? what worked what didn’t

go back to the beginning

76
Q

why is patient hygiene important

A

prevents infections
promotes autonomy / independence
gets patient moving

77
Q

NPO

A

nothing by mouth

78
Q

should you do a basin bath

A

no. the basins carry bacteria and can cause infections

79
Q

when should you use CHG wipes?

A

high risk patient. catheter, central line

80
Q

what does oral care prevent?

A

pneumonia

81
Q

fowler’s position

A

legs flat, back up (seated)

82
Q

pressure injury

A

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
Q

how often do you want to move a patient?

A

every 2 hours

84
Q

complication of someone who is immobile

A

pneumonia
orthostatic hypotension
loss of muscle mass, bone mass, joint contracture, loss of balance
psychological, depression, loneliness

85
Q

how to maintain comfort & safety during hygiene

A 
good ergonomics 
maintain privacy
maintain safety
maintain warmth
tell the patient what you're doing
be alert for patient fear & anxiety
86
Q

BMAT

A

bedside mobility assessment tool

87
Q

how to help promote normal urination and defecation

A 
anticipate patient's needs 
respond quickly to requests
privacy
describe urine/stool in EMR
monitor/record output
88
Q

how to measure urine output

A

put in secondary container

measured in ml

89
Q

expected findings of general survey

A 
responsive 
calm
comfortable 
facial symmetry 
build is appropriate 
personal hygiene 
movements independent and voluntary
90
Q

factors that cause variations in pulse, temp, RR and BP

A 
smoking
anxiety, stress
eating or drinking
age, gender
hormones, ovulation
91
Q

factors that cause variations in pulse, temp, RR and BP

A 
smoking
anxiety, stress
eating or drinking
age, gender
hormones, ovulation
92
Q

What do we mean by: “standard assessment”?

A

Systematic, deliberate assessment; data collection used to establish a patient’s baseline and/or for comparison with prior and/or subsequent assessments

N388 (2 decks)

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