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Nursing Final Exam > Exam 1 > Flashcards

Exam 1 Flashcards

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1
Q

The idea that harm is caused by a series of systemic failures in the presence of hazards

A

The Swiss Cheese Model

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2
Q

What are the two different classifications of errors?

A

Latent and Active

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3
Q

What are latent errors and some examples?

A

defects in the design and organization of processes and system.

example: administration decisions, poor equipment, inadequate training

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4
Q

What are active errors and some examples?

A

considered human errors; errors that are seen and felt immediately

medication error, pushing wrong button, operating on wrong body part

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5
Q

What is an unsafe act and what are the two categories they are classified as?

A

an error or violation committed in the presence of a potential hazard

violations and errors

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6
Q

What is it called when a person deliberately deviates from the known rules?

A

Violations

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7
Q

What is an error and what are the 3 categories of errors?

A

an act or decision that was not deliberate or intended

slips- observable error of execution
lapses- unobservable mental error
mistakes- error in decision making or incorrect planning

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8
Q

What are events that are the result of criminal acts, patient abuse, alcohol or substance abuse on behalf of the provider, or acts defined by the organization as being intentionally or deliberately unsafe?

A

Blameworthy events

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9
Q

What is it called when unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, or hospitalization, or that results in death?

A

Harm

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10
Q

What are the 3 types of health-care harm?

A

Errors of commission- something the providers did that resulting in harm

psychological harm

financial harm

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11
Q

What is an established science that uses disciplines such as anatomy, physiology, physics, and biomechanics to understand how people perform under different circumstances?

A

Human Factors Engineering

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12
Q

What two distinct cognitive processing are associated with errors?

A

controlled thinking

automatic thinking

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13
Q

What type of thinking is when we consciously, often slowly, solve problems and make decisions?

A

controlled thinking

errors of planning and knowledge-based

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14
Q

What type of thinking is rapid, effortless thought, during which we are vulnerable?

A

Automatic thinking

errors of execution or memory storage
skill-based

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15
Q

What are simplified thought processes based on patterns and passed experiences?

A

Heuristics

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16
Q

What are Internal (Endogenous) causes of error and some examples of them?

A

factors related to the individual as opposed to the environment that include both psychological and physiological states

limited memory capacity, fatigue, stress, hunger, illness, language limitations

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17
Q

What are external (Exogenous) causes of error and some examples of them?

A

factors related to the individuals environment

noise, heat, light, long work schedule, inadequate training, poorly designed rules and procedures

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18
Q

Examples of ways that tech companies and administrators reduce errors within a work place. (8 examples)

A
  1. Simplify- reduces complexity
  2. Standardize- reduces variation
  3. Create checklists- Surgical Safety checklist
  4. Use redundancies.
  5. Avoid reliance on memory.
  6. Take advantage of habits and patterns.
  7. Promote effective team functioning.
  8. Automate carefully.
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19
Q

What is the state of being checked, restricted, or compelled to avoid or preform some action?

A

constraint

Example: reduced staff, lack of time

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20
Q

What is like constraints, but they make it impossible to do a task incorrectly. They create a hard stop that you cannot pass unless you change your actions?

A

Forcing Functions

Example: use of special luer locks for syringes and indwelling lines that have to be matched before fluid can be infused

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21
Q

What is social redundancy?

A

when one person checks the work of another

high alert meds need a 2nd nurse check, etc.

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22
Q

What is the idea that tech companies should make their products user friendly?

A

user-centered design

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23
Q

What are the 5 main sections in the ADN policy?

A
  1. Professional Standards
  2. Academic Standards
  3. General Operational Policy Standards
  4. Impaired Student Nurse Policy
  5. Student Conduct, Discipline, and Due Process at Polk State College
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24
Q

The attendance policy, cellphone and smart watch policy, and return to lab policy fall under what category under the ADN manual?

A

General Operational

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25
Q

What are some examples of violations of professional standards?

A

breach of confidentiality, misuse of drugs, mistreating a patient, discrimination, abusive/foul language, bad attitudes, cheating/lying.

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26
Q

What is the ADN policy?

A

Requirements, guidelines, policies, and expectations for associate degree nursing students

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27
Q

What is Florence Nightingale famous for?

A

known as the founder of modern nursing

also known for making hospitals cleaner and safer (infection prevention/infection control)

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28
Q

Who was Lieutenant Edward Lyon and what was he famous for?

A

very first male nurse to be commissioned in the army nurse corps

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29
Q

Who was Mary Eliza Mahoney?

A

first African American to study and work professionally as a nurse in the United States

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30
Q

Who was Clarissa Barton?

A

founded the American Red Cross

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31
Q

What are the 6 competencies of Quality and Safety Education for Nurses (QSEN)?

A
  1. Patient Centered Care
  2. Teamwork and Collaboration
  3. Evidence Based Practice
  4. Quality Improvement
  5. Safety
  6. Informatics
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32
Q

What are the 4 professional responsibilities as a nurse?

A
  1. Advocacy
  2. Educator
  3. Manager and Coordinator
  4. Caregiver
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33
Q

What is the RN allowed to delegate? What are the 3 things they CANNOT delegate?

A

they can delegate the TASK ONLY

CANNOT delegate assessments, teaching, or monitoring

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34
Q

What are the 5 rights of delegation?

A
  1. Right Task
  2. Right Circumstance
  3. Right Person
  4. Right Directions & Communication
  5. Right Supervision & Evaluation
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35
Q

What is the term for when two or more professionals work together to solve problems or coordinate care?

A

Interprofessional Collaboration

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36
Q

What is the term for when two or more disciplines are learning how they work together in the hospital and outpatient settings?

A

Interprofessional Education

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37
Q

What is the name of the role, for the person making sure the patient’s needs are met, including collaborating with, and making sure a transitional care nurse is provided if necessary?

A

Patient Care Coordinator

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38
Q

What model manages patients as they transition across the care continuum from inpatient settings to other settings, including skilled nursing facilities and home?

A

Transitional Care Model

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39
Q

How many stages are in Erikson’s Stages of Psychosocial Development? What is the last stage called? What age group is it? What is

A

8 Stages

65 years and older

Integrity vs. Despair

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40
Q

What is the difference between Integrity and Despair?

A

Integrity results in a sense of self-worth and self-acceptance when reviewing one’s life (positive self-esteem)

Despair results in a sense of self-contempt and disgust when reviewing one’s life (negative self-esteem)

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41
Q

What are the 5 main psychosocial changes an older adult experiences and some key points of each one?

A
  1. Retirement- loss of workplace role/identity, isolation, financial issues, loss of structured schedule, loss off supportive network
  2. Social Isolation- functional impairment, chronic illness, reduced mobility all contribute. Assess social network, access to transportation, and desire to interact
  3. Sexuality- involves, warmth, touch, sharing and touching not just intercourse; Helps maintain self-esteem, need throughout lifespan, ask about sexual response
  4. Housing and Environment- ability to live independently; stay at home safely, live with family, nursing homes, assistant living
  5. Death- what loss have they experienced; spouse, child, family, friends, etc.
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42
Q

What are the 8 Basic Needs a nurse looks at in regards of priority of care?

A
  1. Oxygenation
  2. Nutrition
  3. Elimination
  4. Mobility
  5. Physical Safety
  6. Rest, Sleep, & Comfort
  7. Reproduction/Sexuality
  8. Psychological Security
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43
Q

What are the 4 Human Dimensions of Health?

A
  1. Spiritual
  2. Psychological
  3. Sociological
  4. Cultural
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44
Q

What model is characterized by the treatment of the whole person, while still considering mental and social factors, rather than just the symptoms of an illness? What are some examples of this model?

A

Holistic Health Care Model

Examples: meditation, music therapy, reminiscence, relaxation therapy, therapeutic touch, and guided imagery

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45
Q

What is a dynamic, ever-changing state that reflects the functioning of interrelated human body systems and human dimensions which exist on a continuum from optimal wellness to illness and ending in death?

A

Health

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46
Q

What is primary prevention in regards to health promotion and some examples that fall under this category?

A

It is true prevention; to reduce incidence of disease.

Examples: Health Education, Nutrition Programs, Physical Fitness Activities, Sex Education, Genetic Screening, Provision of housing/recreation/working conditions

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47
Q

What is secondary prevention in regards to health promotion and some examples that fall under this category?

A

Focuses on preventing the spread of disease, illness, or infection once it occurs by early diagnosis and prompt intervention.

Examples: Screening activities (mammogram, pap smear, colonoscopy), care from a cardiologist, tracking prevalence/incidence

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48
Q

What are the 7 National Patient Safety Goals?

A
  1. Identify patients correctly.
  2. Improve staff communication.
  3. Use medicines safely
  4. Use alarms safely
  5. Prevent infection
  6. Identify patient safety risks
  7. Prevent mistakes in surgery
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49
Q

What is Tertiary Prevention in regards to health promotion and some examples that fall under this category?

A

occurs when a defect or disability is permanent and irreversible and involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration as well as achieving as high of a level of functioning as possible.

Examples: how to use a wheelchair, accommodating their home, finding work that meets their level

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50
Q

What is the freedom from psychological and physical injury and is a basic human need?

A

Safety

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51
Q

What are the 6 reasons/causes of unintentional deaths?

A
  1. Motor Vehicle Accidents
  2. Poison
  3. Falls
  4. Fire
  5. Disasters
  6. Transmission of Pathogens
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52
Q

What is almost always used for intervention in most poisons? What 3 things does it not work on?

A

Charcoal

iron, alcohol, lithium

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53
Q

What are some examples of healthcare hazards?

A

back injuries, needlesticks, radiation injury, violence, inadequate staffing, inadequate tools and equipment

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54
Q

What are the 3 steps to a “TIME OUT”?

A
  1. Right Patient?
  2. Right Location?
  3. Right Procedure?
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55
Q

What is the 2nd leading cause of unintentional deaths worldwide?

A

Falls

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56
Q

What are the 5 Universal Fall Precautions?

A
  1. Familiarize the client with the environment
  2. Maintain call light within reach.
  3. Keep hospital bed brakes locked.
  4. Keep nonslip, comfortable, well-fitting footwear on the client.
  5. Keep the client’s personal possessions within easy reach.
  6. Place the hospital bed in a low position when a client is resting in bed.
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57
Q

What is a patient safety event that results in death, permanent harm, or severe temporary harm?

A

A sentinel event

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58
Q

What are some examples of a sentinel event?

A
  1. Surgery preformed on the wrong site
  2. Patient suicide
  3. Patient death or serious injury associated with a medication error
  4. Any stage 3 or 4 pressure wound acquired after admission
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59
Q

What was the steps in order in case of a fire?

A

RACE

  1. Rescue and remove all patients in immediate danger
  2. Activate the alarm
  3. Confine the fire
  4. Extinguish the fire
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60
Q

What are the steps in order to using a fire extinguisher?

A

PASS

  1. Pull pin
  2. Aim
  3. Squeeze handles
  4. Sweep
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61
Q

What are the most important nursing considerations when using physical restraints on a client?

A

Must be prescribed and ordered by the provider, renewed every 24 hours, documented every 2 hours, and physically assessed every 60 minutes.

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62
Q

What is the Nursing Plan for each step regarding patient safety? (ADPIE)

A
  1. Assess- Assess for safety concerns
  2. Diagnosis- What is the actual issue we need to improve?
  3. Planning- What comes first to keep the patient safe?
  4. Implement/Intervention- Actually doing the things to make the patient safe.
  5. Evaluation- Has there been improvement or not?
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63
Q

What are health care-associated infections?

A

infections that result from the delivery of health services in a health care agency

64
Q

What is an infection that comes from microorganisms found outside of the individual such as salmonella or clostridium?

A

Exogenous Infection

65
Q

What is an infection that occurs when part of the patient’s flora becomes altered, and overgrowth occurs (Antibiotics causing diarrhea or a yeast infection)?

A

Endogenous Infection

66
Q

What is an infection caused by invasive diagnostic or therapeutic procedures?

A

Iatrogenic Infections

67
Q

What are the 6 links in regards to the spread of infection?

A
  1. Infectious Agent
  2. Reservoir
  3. Portal of Exit
  4. Method of transmission
  5. Portal of Entry
  6. Susceptible Host
68
Q

What is the difference between airborne and droplet?

A

droplet is contagious only within 6 feet and airborne is contagious more than 6 feet

69
Q

What are the 5 methods of transmission of infection and examples that go with them?

A
  1. Direct- hand to hand, kissing, sex.
  2. Indirect- soiled linen, environment, doorknob, stethoscope.
  3. Vehicle borne- needles, water, drugs/solutions, blood, food (transmission by a source).
  4. Vector borne- mosquito, flea, tick, louse.
  5. Airborne and Droplet
70
Q

What are the 5 stages of infection and characteristics of each?

A
  1. Incubation- time of infection until manifestation of symptoms (can infect others).
  2. Prodromal- appearance of vague symptoms (not all diseases have this stage).
  3. Illness- signs and symptoms present
  4. Decline- number of pathogens decline
  5. Convalescence- tissue repair, return to health.
71
Q

How are illnesses classified?

A

Location- local vs systemic
Duration- acute, chronic, or latent

72
Q

What is the absence of pathogenic microorganisms called?

A

asepsis

73
Q

What is medical asepsis and examples of it?

A

“clean technique”- state of cleanliness that decreases the potential for the spread of infection

examples: handwashing, using ppe, environmental cleaning

74
Q

What is surgical asepsis and examples of it?

A

“sterile technique”- absence of all microorganisms with any type of invasive procedure

examples: disinfection, sterilization, use of sterile gloves

75
Q

How long should you wash your hands per the CDC?

A

20 seconds

76
Q

What is the term for the strategies used against contact with blood, body fluids, nonintact skin, mucous membranes, and equipment contaminated with any of these?

A

Standard Precautions

77
Q

What is the correct steps in order to “Don” (apply) PPE?

A
  1. Wash hands
  2. Apply gown
  3. Apply mask
  4. Apply eyewear
  5. Don gloves
78
Q

What is the correct steps in order to “Doff” (remove) PPE?

A
  1. Remove gloves
  2. Remove eyewear
  3. Remove gown
  4. Remove mask
  5. Wash hands
79
Q

What patients need Protective Isolation and what are some significant things involved with protective isolation?

A

immune-compromised patients such as stem-cell implants, chemotherapy, burn patients, HIV, leukemia

6-12 air exchanges, HEPA filter, humidifiers, N95 masks, one nurse assigned to the room

80
Q

What is the term for “all people inhabiting a specific area”?

A

Population

81
Q

What is the term for “members who share interests, language, or customs”?

A

Community

82
Q

What type of nursing is the practice of nursing in the community with the primary focus on the health care of individuals, families, and groups within their communities?

A

Community Based Nursing

83
Q

What type of nursing is a nursing specialty that requires understanding the needs of a population, or a collection of individuals who have one or more personal or environmental characteristics in common?

A

Public Health Nursing

84
Q

What is the windshield survey?

A

When you assess the environment as you drive around a location

examples: how many homeless people, rural or city, accessibility to healthcare, predominant ethnic groups present

85
Q

What are the 5 domains for social determinants of health?

A
  1. Economic stability
  2. Education access and quality
  3. Healthcare access and quality
  4. Neighborhood and built environment
  5. Social and community context
86
Q

What are the 3 components of a community and examples of each?

A
  1. Structure of Locale (Environment)- name, 911 services, water and sanitation, housing, economic status, transportation, safety
  2. People- age distribution, sex distribution, education level, ethnic groups, religious groups
  3. Social Systems- education system, government, communication systems, welfare, health system, volunteer programs
87
Q

What are the 6 roles of a community health nurse?

A
  1. Educator
  2. Advocate
  3. Case Manager
  4. Counselor
  5. Collaborator
  6. Epidemiologist
88
Q

What is the term used for groups of patients who are more likely to develop health problems because of excess health risks, who are limited in their health care services, or who depend on others for care? What are some examples of these groups?

A

Vulnerable Populations

immigrants, uneducated, unemployed, low-income, abused, mentally or physically challenged, very young or very old

89
Q

What is the purpose of a physical assessment? (3 main reasons)

A
  1. Obtain physical and mental baseline
  2. Confirm or question data found in history
  3. Obtain new data to help establish nursing diagnosis and nursing plan
90
Q

What is subjective data and some examples of it?

A

apparent only to the person effected, must be described by patient

pain, itching, worrying

91
Q

What is objective data and some examples of it?

A

detectable by an observer or can be tested by using an accepted standard

vital signs, mood, odor

92
Q

What are the 7 main things in regard to a 60 second assessment?

A
  1. ABC Evaluation- Airway, breathing, circulation
  2. Tubes and Lines
  3. Respiration Equipment
  4. Patient Safety Survey
  5. Environmental Survey
  6. Sensory- see, smell, hear
  7. Critical Thinking- info for further clarification
93
Q

What is the difference between denotative and connotative?

A

denotative- literal meaning of word
ex: red- a color

connotative- emotional meaning of a word
ex: red- danger or blood

94
Q

What are the 3 elements of personal communication?

A
  1. Spoken words - 7%
  2. Voice/Tone- 38%
  3. Body Language- 55%
95
Q

What are some examples of therapeutic communication?

A

active listening, sharing observations, sharing empathy, sharing hope, sharing humor, sharing feelings, using touch, silence, providing information, clarifying, focusing, paraphrasing, asking relevant questions, summarizing, self-disclosure, confrontation

96
Q

What are some examples of non-therapeutic communication?

A

asking personal questions, giving personal opinions, changing the subject, automatic responses, false reassurance, sympathy, asking for explanations, defensive responses, passive or aggressive responses, arguing

97
Q

What are the 4 phases of a therapeutic relationship?

A
  1. Pre-interaction phase- occurs before meeting the patient.
  2. Orientation/Introductory phase- when the nurse and the patient meet and get to know each other.
  3. Working phase- when the nurse and the patient work together to solve problems and accomplish goals, use of nursing interventions to meet outcomes.
  4. Termination phase- occurs at the end of relationship.
98
Q

What does the acronym “SOLER” mean in regards to active listening?

A

S- sit facing the patient.
O- observe an open posture.
L- Lean toward the patient.
E- establish and maintain intermittent eye contact.
R- Relax

99
Q

What are the 4 formats of Nurse’s Notes?

A
  1. Narrative- story-like
  2. SOAPIER- subjective data, objective data, assessment, plan, implementation, evaluation, revision.
  3. Focus- 3 columns addressing concerns, problems, and strengths
  4. Electronic (EMR)- documentation by bedside
100
Q

What are the steps to ISBAR/SBAR and information that goes with it?

A

Identify- Identify yourself and patient to the provider.

Situation- What is the reason you are calling: “no urine in catheter.

Background- What is the patient’s history (stage 4 kidney failure), Why were they admitted to the hospital.

Assessment- vital signs, (color, consistency, I’s & O’s, Iv fluids, odor)

Recommendation- I think they might need, I’m not sure what to do, I want to order…

101
Q

What are the exact steps for taking a telephone order from a provider?

A
  1. Date/Time
  2. Text/Order
  3. Followed by providers name/credentials.
  4. Your signature and credentials.
  5. Followed by “read back for verification and validated.”
102
Q

What are the 5 steps in the Nursing Process?

A
  1. Assess
  2. Diagnose
  3. Plan
  4. Implement
  5. Evaluate
103
Q

What are the 3 main parts of the nursing diagnosis?

A
  1. Problem- the diagnosis
  2. Etiology/Cause- (R/T- related to)
  3. Defining Characteristics (AEB- as evidence by)

Example: Risk of Constipation R/T immobility AEB change in bowel pattern

104
Q

What does the acronym “SMART” stand for when making goals for a nursing plan?

A
  1. Specific
  2. Measurable
  3. Attainable
  4. Realistic
  5. Time Bound

-Example: The patient will report satisfaction with his level of pain relief on day 1

105
Q

What are the 3 different types of nursing implementation/interventions?

A
  1. Independent- activities the nurse can do alone
  2. Dependent- interventions that require a doctors order
  3. Collaborative- therapies that involve the combined knowledge and skills of other services (nutritionist, physical therapy, social services)
106
Q

What is the correct direction to bathe a patient?

A

from head to toe or clean to dirty

107
Q

What is the correct direction to wash the extremities when giving a patient a bed bathe?

A

Distal to proximal (from furthest part from body to closest part to body)

example: move from hands up to shoulders

108
Q

What is the correct way to wash a patients eyes when providing a bed bathe?

A

NO soap, wipe one eye from inner part to outer part, rinse or turn cloth before doing other eye

109
Q

What is the most important consideration before cleansing the perineum when providing a bed bathe?

A

Change water, make sure water is clean

110
Q

What are the important steps for foley catheter care on females and males?

A

Females: 1. Wash downward from pubic area toward rectum. 2. Wash middle and both sides of perineum using separate section of cloth. 3. Cleanse catheter from meatal opening outward using back and forth motion

Males: 1. Retract foreskin and cleanse meatus outward and discard cloth. Repeat until clean, rinsed, and dry. 2. Return foreskin to natural position 3. Cleanse shaft and scrotum 4. Cleanse catheter from meatal opening outward using back and forth motion

111
Q

What are the different positions of a patient in bed?

A

Semi-Fowlers- 30 to 45 degrees
High-Fowlers- 90 degrees
Lateral- on side
Prone- face down on belly
Supine- face up on back
Orthopneic- sitting with arms on table and head down

112
Q

What are the 6 vital signs and normal ranges for each?

A
  1. Temperature- 36 to 38 degrees ( 96.8 to 100.4)
  2. Pulse- 60-100 bpm
  3. Pulse Oximetry- Above 95%
  4. Respirations- 12-20 breaths/min
  5. Blood pressure- 120/80
    6- Pain
113
Q

When is there considered a pulse deficit?

A

When the apical pulse and radial pulse are off by MORE THAN 2

114
Q

What colors are the oral temp probes and the rectal temp probes?

A

Oral is BLUE

Rectal is RED

115
Q

What are the most important nursing considerations when administering an enema?

A
  1. expel any air from container
  2. tell client to breathe slowly through mouth
  3. Insert toward umbilicus about 3 to 4 inches
  4. Instruct patient to retain solution about 2 to 5 minutes
116
Q

How many times do you clean the urethral area with an antiseptic swab when collecting a midstream urine sample? How much should you collect?

A

3 times

90-120ml

117
Q

What are the important steps in collecting a urine sample from indwelling catheter?

A
  1. Clamp catheter for 15 minutes
  2. Clean port with alcohol for 15 seconds and let dry
  3. Withdraw urine from port with syringe
  4. Transfer urine from syringe to container and not touch inside
  5. Unclamp catheter and make sure urine is free flowing
118
Q

What do you label your urine samples with?

A

Patient name, DOB, date/time, initials

119
Q

What is an immediate and strong desire to void that is not easily deferred?

A

Urgency

120
Q

What word is used for pain or discomfort associated with voiding?

A

Dysuria

121
Q

What word is used to describe the delay in start of urinary steam when voiding?

A

hesitancy

122
Q

What is polyuria?

A

voiding excessive amounts of urine

123
Q

What is frequency in voiding?

A

more than 8 times during waking hours or decrease is less than every 2 hours

124
Q

What is the word to describe diminished urinary output in relation to fluid intake?

A

Oliguria

125
Q

What is nocturia?

A

awakened from sleep due to the urge to void

126
Q

What word is used to describe the presence of blood in the urine?

A

Hematuria

127
Q

What is the difference between acute retention and chronic retention in relation to urinary voiding?

A

acute retention- suddenly unable to void when bladder is full

chronic retention- bladder doesn’t empty completely during voiding and urine is retained in the bladder

128
Q

What are the things you would assess in a urinary assessment?

A
  1. Bladder distention
  2. How often
  3. Clear vs. Cloudy?
  4. Color
  5. Odor
  6. Any blood?
129
Q

What is the average urine output an hour? What is the normal specific gravity of urine?

A

30ml per hour

1.005 to 1.030 gravity

130
Q

What is the normal amount of urine left in the bladder after voiding?

A

less than 50 mL

131
Q

What is the normal lab value for serum B.U.N.?

A

7-20mg/deciliter

132
Q

What are the normal serum creatinine lab values for adult females? What are the normal lab values for adult males?

A

females: 0.59-1.04 mg/deciliter

males: 0.74- 1.35 mg/deciliter

133
Q

What are the four types of oral medications used for constipation?

A
  1. osmotic laxatives
  2. lubricant laxatives
  3. stimulant laxatives
  4. stool softeners
134
Q

What are the four techniques, in correct order, for doing a physical assessment?

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation
135
Q

What are the four types of physical assessments?

A
  1. Comprehensive- interview plus head-to-toe
  2. Focused- on specific presenting problem
  3. System- specific, limited to one body system
  4. Ongoing- performed as needed to evaluate
136
Q

What are the 6 main things to focus on in the skin/integumentary area of a physical assessment?

A
  1. Color
  2. Temp
  3. Condition- sweaty, cry, etc.
  4. Turgor- elasticity
  5. Integrity- intact or not?
  6. Nails- clubbed, cap refill etc.
137
Q

What does “mottled” and “cyanotic” mean when referring to skin color?

A

cyanotic- bluish

mottled- blotchy, red-purplish marbling of skin

138
Q

What does the acronym “PERRLA” mean?

A

Pupils are
Equal
Round and
Reactive to
Light and
Accommodation

139
Q

What are the different stages of edema?

A

2mm = 1
4mm = 2
6mm = 3
8mm = 4

140
Q

What are the different strengths for a pulse? What number is considered a normal pulse?

A

Absent, not palpable = 0
Weak, diminished = 1
Expected, Easy = 2
Full, increased = 3
Bounding, strong = 4

141
Q

What does the oxygen saturation (Sp02) measure?

A

The amount of “oxygen-carrying” hemoglobin in the blood. Must be 95% or higher

142
Q

What are the four different classifications of unwell lung sounds and what do they sound like? Where do you most commonly hear them?

A
  1. Crackles- Rice Krispies; common in base of lungs and dependent lobes; vesicular
  2. Ronchi- Snoring sound; primarily the trachea and bronchi
  3. Wheezing- blockage of airflow; heard over all lung fields
  4. Stridor- high pitched turbulent; bronchial/neck
143
Q

What are the 3 classifications of good lung sounds? What do they sound like? Where are they best heard? How long do they last?

A

Bronchial- loud, high, hallow; over trachea; inspiration shorter than expiration

Broncho-vesicular- medium, blowing; between scapulae and anteriorly 1st and 2nd interspaces; inspiration and expiration equal

Vesicular- low, soft, breezy; outer edges of lungs, apices, bases; inspiration longer than expiration

144
Q

Where can you find the Point of Maximum Impulse? What valve is it over?

A

Fifth intercoastal space at the left of the mid-clavicle line

mitral valve

145
Q

What is an audible vascular sound associated with turbulent blood flow called?

A

BRUIT aka “Brew-ee”

146
Q

What are the 5 areas for listening to the heart? Where are they located?

A
  1. Aortic- Right 2nd intercostal
  2. Pulmonic- Left 2nd Intercostal
  3. Erb’s Point- Left 3rd Intercostal
  4. Tricuspid- Left 4th Intercostal
  5. Mitral- Left 5th Intercostal
147
Q

What does the S1 sound represent?

A

Closure of the atrioventricular valves

Mitral and tricuspid

LUB sound

148
Q

What does the S2 sound represent?

A

Closure of the semilunar valves

aortic and pulmonic

DUB sound

149
Q

What is the correct order in which to assess the abdomen?

A
  1. Inspect
  2. Auscultate
  3. Palpate
150
Q

What are the 4 different shapes of a chest?

A
  1. elliptical- normal
  2. barrel- often COPD
  3. Pectus Excavatum (Funnel)- caves inward
  4. Pectus Carinatum (Pigeon)- points out
151
Q

What are the 4 ways to describe bowel sounds?

A
  1. Normal- 5-30 bowel sounds per minute
  2. Hypoactive- less than 5 bowel sounds per minute
  3. Hyperactive- more than 30 bowel sounds per minute
  4. Borborygmi- very intense hyperactive sounds
152
Q

What is Romberg’s Test used for?

A

Balance and proprioception (stand still with eyes closed)

153
Q

What is the difference between kyphosis and lordosis? What test is used to assess for scoliosis?

A

kyphosis is a humpback whereas lordosis is curves inward above butt

Adam’s Forward Bent Test

154
Q

What does the acronym “SPICES” stand for when assessing older adults?

A
  1. Sleep Problems
  2. Problems with eating/feeding
  3. Incontinence
  4. Confusion
  5. Evidence of falls
  6. Skin breakdown
155
Q

What are the other ways to explain the 5 steps of the nursing process?

A
  1. Recognize Cues- Assess
  2. Analyze Cues & Prioritize Hypothesis- Diagnosis
  3. Generate Solutions- Plan
  4. Take Action- Implement
  5. Evaluate Outcomes- Evaluate

Nursing Final Exam (5 decks)

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