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NUR 2200 > Exam 1 outline > Flashcards

Exam 1 outline Flashcards

1
Q

SBAR definition?

A

To standardize communication across the board

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2
Q

SBAR stands for:

A

o Situation: introducing yourself, where you’re calling from
o Background: relevant background information
o Assessment: vitals, lung sounds, heart sounds, skin assessment
o Recommendations: what do I think we should do?

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3
Q

ABCs stand for:

A

Airway, Breathing, Circulation, Safety, Prevention

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4
Q

HAI stand for:

A

Hospital acquired infection

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5
Q

Examples of HAI:

A

UTI, Pneumonia, Surgical site infections

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6
Q

How to prevent HAI?

A

Hand washing, PPE

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7
Q

5 ways to prevent UTI?

A

o Keep foley bag below bladder level
o Empty foley more than once a shift
o Foley care as needed plus regularly
o Do not let drainage valve touch inside of container when
emptying

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8
Q

Orthostatic BP definition?

A

You stand and your BP drops

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9
Q

For Orthostatic BP how much does systolic drop?

A

20 mmHg

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10
Q

For Orthostatic BP how much does diastolic drop?

A

10 mmHg

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10
Q

For Orthostatic BP how much does pulse rate drop?

A

30

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11
Q

How to take Orthostatic BP?

A

Lying to Sitting to Standing (2 minutes after each position
change take the BP and pulse)

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12
Q

Symptoms of Orthostatic BP:

A

Dizziness, fainting, lightheadedness

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13
Q

Verbal communication examples

A

Hello I am Kyristen

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14
Q

Nonverbal communication examples:

A

Eye contact, posture, pointing, gestures, tone

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14
Q

What Nonverbal communication can be unreliable because of cultural differences?

A

Eye contact

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15
Q

Edema

A

o Excess fluid –> heart failure
patients
o Can be pitting or nonpitting

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16
Q

Inflammation characteristics?

A

Redness, warm, swelling, pain

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17
Q

When should you be Washing Hands?

A

Preform hand hygiene before and after procedures

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18
Q

What should you do with visibly soiled hands?

A

wash hands

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19
Q

What should you do with not visibly soiled hands?

A

Hand hygiene (sanitizer) or wash hands

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20
Q

UAP stands for:

A

Unlicensed assistive personnel

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21
Q

What can UAP do?

A

o Take vitals
o Help with bathing and positioning
o Report findings to the nurse

22
Q

What can UAP not do?

A

o Pass meds
o Assess patients
o Procedures

23
Q

If a UAP reports abnormal findings to a nurse, what should the nurse always do?

A

Always the nurses responsibility to double check any abnormal
findings from the UAP.

24
Q

Physical Exam Technique:

A

o Inspect- looking at the body
o Palpate- feeling the body with fingers or hands
o Percuss- producing sounds, usually by tapping on specific areas of the body
o Auscultate- listening to sounds, usually with a stethoscope

25
Q

Stethoscope Bell used to hear?

A

Low-pitched, abnormal heart sounds

25
Q

Stethoscope Diaphragm used to hear?

A

o High-pitched
o Normal heart sounds
o Lungs sounds
o Bowel sounds

26
Q

Ambulation definition?

A

The ability to walk or stand around independently of with the help of a device.

26
Q

Post-surgical ambulation, what does is it do?

A

o Keeps patient mobile
o Prevents muscle atrophy (Wasting)

26
Q

How to use Crutches:

A

o 2-3 fingers down from the axilla
o 15-30 degrees for elbows
o 2 inches lateral 4-6 inches in front

26
Q

Psychosocial aspects are ______ while physical aspects are ________.

A

Mental, Physical

27
Q

Braden scale:

A

o Risk of skin breakdown ( 6 categories of Braden scale)
o A tool used to assess a patients risk of developing pressure ulcers, or sores.

28
Q

Repositioning:

A

o Helps to avoid skin breakdown
o Nonpharmacological intervention

29
Q

Sims (Position):

A

o left lying
o left leg straight
o right leg bent

30
Q

Vesicles:

A

o A type of skin lesion
o small, fluid- sacs or blisters

31
Q

Papule:

A

o A type of skin lesion
o Oil-filled inflamed bump

32
Q

Varicella (chicken pox) is what type of skin lesion?

A

Vesicles

33
Q

A patient has Nerve damage in feet. What will they experience?

A

Altered sensory

34
Q

SpO2 is:
What does O2 stand for?

A

o SpO2 is the amount of oxygen saturation in blood
o O2 means oxygen

35
Q

what is the mnemonic OLD CARTS used for?

A

o To guide nurses interview of a patient while documenting a history of present illness.
o Used to assess pain

36
Q

What does OLD CARTS stand for:

AR can be linked together.

A

o Onset- Gradual or acute
o Location- Where is the pain located?
o Duration- How long has the pain Been present

o Characteristics- How patient describes the pain
o Alleviating or aggravating factors- what makes the pain worse?
o Radiating or relieving factors - What makes the pain better?
o Timing - does it occur e.g. after certain situations?
o Severity- 1-10 scale or subjective grading.

37
Q

Pain can be felt with in what 2 ways?

A

Pharmacological and nonpharmacological

38
Q

What can occur if the BP cuff is to tight?

A

Too tight = false low reading

39
Q

What can occur if the BP cuff is too loose?

A

Too loose = false high reading

40
Q

Mobility

A

The ability to move or be moved freely and easily.

41
Q

ADLS stand for:

A

Activities of daily life

42
Q

What are normal changes in older adults?

A

o Body slows down
o Slower wound healing
o Lower body temp
o Less collagen, slower skin turgor

43
Q

What are not normal changes in older adults?

A

Confusion

44
Q

Passive ROM (Range of motion) helps patients with?

A

Joint mobility

45
Q

Active ROM (Range of Motion) helps patients with?

A

Muscle strengthening

46
Q

How to use Canes:

A

o Keep on stronger side
o Greater trochanter to the floor

47
Q

Sterile (surgical) vs medical asepsis (clean):

A

o Sterile gloves, keep sterile, strict
o Clean- physical exam, less strict

48
Q

SpO2 stands for:

A

(O2) Oxygen saturation in blood

49
Q

What is a resting (SpO2) oxygen saturation level?

A

95%-100%

50
Q

Immobility

A

Inability to move or be moved

NUR 2200 (2 decks)

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