NRS122

Question 1

Subjective:

Answer 1

Subjective data is that collected when interviewing the patient . Also known as symptoms. ( Or what is said)

Question 2

Lowest GCS score:

Answer 2

3

Question 3

4 components of inspection:

Answer 3

Inspection:

RESP: Rate- tachypnoea, bradypnoea, apnoea
Rhythm- steady rhythm, Cheyne-stokes (very deep to very shallow with periods of apnoea)
Chest expansion- equal, unequal (check for the trachea position- tension pnemothorax), intercostal retraction (indrawing between the ribs).
Volume of air being exchanged- hypoventilation, hyperventilation
Secretions- Haemoptsis (blood in sputum), productive cough, non productive cough

CVS: Colour- skin, lips
JVP

Auscultation:

RESP: tridor- a harsh sound heard during inspiration with laryngeal obstruction (eg anaphylactic reaction)
Wheeze- high pitched musical squeak or whistling sound during expiration as air moves through narrowed or partially obstructed airways (eg asthma)
Bubbling (crackles)- gurgling sounds heard as air passes through moist secretions in the respiratory tract.

CVS: Heart sounds- normal (lub-dub), added sounds (murmurs)
Rate- bradycardic, tachycardic
Rhythm- regular, missed beats, added beats, no recognisable rhythm

Palpitation: RESP:Assess for swelling, pain, wounds

CVS: Pulses- rate, rhythm

Percussion: Assess for air, blood, secretions or a void section of lung

Question 4

AMPLE:

Answer 4

A - Allergies
M - Medications
P - Past medical history
L - Late ate and drank
E - Events leading to presentation

Question 5

What is always the first priority for assessment?

Answer 5

Airway. Always attended first because injury or compromise to the airway will lead to quick decline of the pt even death if not assessed and managed correctly.

Question 6

Minimum urine produced for 70kg adult

Answer 6

0.5ml/kg/hr

35mL per hour

Question 7

Where is the ileostomy?

Answer 7

Last part of the small intestine

Question 8

Rehab is what type of education:

Answer 8

Secondary Health Care

Question 9

When do you usually collect a sputum specimen?

Answer 9

First thing in the morning because it collects overnight and is more likely to be released in the morning.

Question 10

What is AVPU?

Answer 10

Alert, verbal, pain, unconscious

Question 11

What is the difference between trade name and generic name of medications?

Answer 11

Trade Name: Company name

Generic Name: Name of the chemical

Question 12

6 elements of a drug order:

Answer 12

• Full name of person, DOB and Allergy status
• Date the drug was ordered
• Name of the drug to be administered ( preferably in generic name)
• Frequency of administration
• Route of administration
• Signature of person writing the order
• And that the medication has not already been administered

Question 13

10 rights of medications:

Answer 13

1. Right patient
2. Right drug
3. Right dose
4. Right route
5. Right time
6. Right education
7. Right documentation
8. Right to refuse
9. Right assessment
10. Right evaluation /outcome

Question 14

3 elements of informed consent:

Answer 14

1. The consent is freely and voluntarily given and is not coerced.
2. The consent given is based on all the information and that the person giving consent is fully informed.
3. The person giving consent has the legal capacity to give or to refuse consent for treatment.