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Nursing Fundamentals > Exam > Flashcards

Exam Flashcards

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1
Q

Subjective data

A

Data collected from patient or family members during interview process

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2
Q

Objective data

A

observed through senses - hearing, sight, smell and touch

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3
Q

Pulse deficit

A

apical pulse rate 90bpm, radial pulse 79 - pulse deficit - 11

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4
Q

Bounding

A

Dorsal Pedis pulse +3

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5
Q

Steps in accessing abdomen

A

inspect, auscultate, palpate, percuss

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6
Q

assessment

A

step of nursing process done when nurse collects data

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7
Q

steps of nursing process in order

A

assess, diagnose, plan, implement, evaluate

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8
Q

measurable and timeline

A

when a nurse makes a goal, it must contain these characteristics

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9
Q

implementation

A

step of nursing process when nurse puts plan into action

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10
Q

evaluation

A

step of nursing process where nurse reflects on patient and if they have or have not resolved problem

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11
Q

EHR

A

hospitals required to have this charting system

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12
Q

narrative charting

A

tells story of patient

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13
Q

charting by exception

A

done in hospitals, least amount of charting info

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14
Q

J Baker SPN

A

correct initials to sign following documented nurses note

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15
Q

SOAPIER

A

S - subjective assessment
O - objective assessment
A - nursing assessment
P - planning
I - implementation
E - evaluation
R - revision

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16
Q

Radial

A

pulse found in wrists

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17
Q

bilaterally

A

when palpating pulses, you should check them

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18
Q

Dorsalis Pedis

A

pulse checked following knee surgery

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19
Q

Palpate irregular pulse for

A

1 minute

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20
Q

pulses from head to toe

A

temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis

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21
Q

Normal heart rate for adult

A

60-100 per minute

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22
Q

reverse Trendelenburg

A

when a patient experiences hypotension put them in

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23
Q

hypoxemia

A

low oxygen in the blood

24
Q

Reye’s syndrome

A

aspirin given to children under 15 can experience this acute fatal syndrome that affects CNS and liver

25
Q

incident report

A

form filled out when an abnormal incident occurs to staff, patients or visitors in health care facility

26
Q

crackles

A

when assessing patient’s lungs, they cough, and you hear rice crispy sounds, sounds wet. Ineffective airway clearance.

27
Q

walked to patients’ room, patient found face down on floor, assessed for injuries, no obvious injuries, patient put back to bed

A

when you hear loud thud from nurses’ station, enter patients’ room, find patient lying face down on hardwood floor with no obvious injuries, help them back in bed and document

28
Q

anxiety and fear affect

A

HR, RR, BP

29
Q

3-part nursing diagnosis

A

impaired gas exchange R/T Decreased lung capacity AEB OX Sat of 82% - 3 uses evidence, 2 does not

30
Q

Nursing Process

A

decision making framework used by all nurses to determine needs of their patients and decide how to care for them

31
Q

inspection

A

visual examination of patient’s body for rashes, breaks in skin, appearance of nose, eyes, ears, etc

32
Q

Palpation

A

touching or feeling torso, limbs for pulses, abnormal lumps, temp, moisture, vibrations

33
Q

Auscultation

A

listening for abnormal sounds in lungs, heart, bowels

34
Q

Percussion

A

tapping movements to detect abnormalities of internal organs

35
Q

ecchymosis

A

caused by bruising of skin - air on side of caution for abuse

36
Q

edematous

A

condition of being swollen due to excess accumulation of fluid in body’s tissues

37
Q

Stridor

A

life threatening upper airway obstruction caused by foreign body tumor, swelling, bronchial spasms. shrill high pitched harsh crowing sound heard upon inspection.

38
Q

wheezing

A

continuous melodious, musical, whistling sounds. Constriction of airway during inspiratory or expiratory. During asthma attack.

39
Q

pleural friction

A

grating, creaking sound caused by inflamed, edematous pleural surfaces rubbing together during breathing.

40
Q

pulmonic valve

A

second intercostal space left of sternum - left base heart sound

41
Q

tricuspid valve

A

edge of sternum, fourth intercostal space, left of sternum, left lateral sternal border

42
Q

mitral

A

heard at PMI

43
Q

aortic valve

A

second intercostal space just right of sternum, known as right base heart sound

44
Q

central cyanosis

A

blue discoloration around lips, tongue and chest - low oxygen levels in blood due to lung/heart issues

45
Q

peripheral cyanosis

A

blue discoloration in fingers, toes, nails - poor blood circulation, cold temps, normal oxygen levels in blood

46
Q

documentation

A

remember rules

47
Q

narrative charting

A

tells story in chronological order, admission to discharge, condition, complaints, problems, assessment findings activities, treatments, care provided, effectiveness of interventions

48
Q

Maslow’s

A

physiological, safety and security, love and belonging, self-esteem, cognitive, aesthetic, self-actualization transcendence

49
Q

indirect vs direct interventions

A

direct - interactions with patient (bathing)
indirect - assistance without patient present (documenting)

50
Q

when to document

A

directly after care, so details are not forgotten

51
Q

aphasia vs dysphagia

A

aphasia - inability to speak or understand language.
dysphagia - difficulty coordinating/organizing words correctly in a sentence

52
Q

temperatures

A

oral, axillary, tympanic, skin, rectal, temporal
most accurate rectal
avoid rectal for cancer or diarrhea

53
Q

capillary refill check

A

gently squeeze nailbed of extremity to empty capillaries of blood, nailbed will turn pale until pressure is removed, should take less than 3 seconds to turn pink again

54
Q

delegating vital signs

A

do not delegate if something feels off or if patient is in distress

55
Q

ABC’s

A

Airway, breathing, circulation

Nursing Fundamentals (3 decks)

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