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UK ABSN FALL 2022 > Nur 323 > Flashcards

Nur 323 Flashcards

1
Q

What are the pulse locations in the body?

A
  1. Brachial
  2. Radial
  3. Popliteal
  4. Dorsalis pedis
  5. Posterior tibial
  6. Femoral
  7. Carotid
  8. Temporal
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2
Q

What are the 7 rights of medication administration?

A
  1. Right patient
  2. Right medication
  3. Right dose
  4. Right route
  5. Right time
  6. Right to refuse
  7. Right documentation
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3
Q

What are some, “every patient, every time,” items in the general survey?

A
  1. Respiratory effort
  2. Skin color (physical appearance category)
  3. Demeanor
  4. Nutrition (body structure category)
  5. Symmetry (body structure category)
  6. Posture (body structure category)
  7. Position (body structure category)
  8. Gait (mobility category)
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4
Q

What are the rights of every patient?

A
  1. Right to be treated with respect
  2. Right to obtain medical record
  3. Right to privacy of medical record
  4. Right to make treatment choices
  5. Right to informed consent
  6. Right to refuse treatment
  7. Right to make decisions about end-of-life
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5
Q

What is the prone position?

A

A body position where a patient is lying face down, or on his/her stomach

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6
Q

Describe the supine position.

A

A body position where a person is lying face up, or facing upward toward the ceiling

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7
Q

What are the 10 Commandments of Sterile Technique?

A
  1. Consider anything below the waist unsterile
  2. Consider any part of your sterile field that falls, or hangs below the table, as unsterile
  3. The edge of the sterile field is 1” (2.5 cm). Anything outside the 1” border is unsterile
  4. Any coughing, sneezing, or excessive talking across the sterile field make it unsterile
  5. Reaching across the sterile field makes it unsterile
  6. Facing away, or turning away from sterile field makes it unsterile
  7. An opened sterile package must be used immediately or it’s unsterile
  8. Do not use packaged sterile products after the expiration date
  9. If a package isn’t labeled, “sterile,” it is unsterile
  10. Any doubt about sterility of an object, consider it unsterile
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8
Q

What are the anterior lung fields?

A

When a patient is facing you: 1. Right upper lobe
2. Right middle lobe
3. Right lower lobe
4. Left upper lobe
5. Left lower lobe

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9
Q

What breath sounds are heard over the anterior (pt facing you) chest?

A
  1. Bronchial (trachial; heard by auscultating the neck)
  2. Bronchiovesicular (along the sides of the sternum)
  3. Vesicular (over the lungs)
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10
Q

What are the posterior (facing pts back) lung fields?

A
  1. Left upper lobe
  2. Left lower lobe
  3. Right upper lobe
  4. Right lower lobe
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11
Q

What are the breath sounds heard over the posterior chest?

A
  1. Bronchovesicular (along each side of the spine & down to the 5th intercostal space)
  2. Vesicular (below 5th intercostal space & over to outer edge of ribs)
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12
Q

How does the nurse control the external environment BEFORE an interview?

A
  1. By providing privacy
  2. By refusing interruptions
  3. By controlling the physical environment of the interview
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13
Q

How does a nurse control the physical environment of a patient interview?

A
  1. Providing a comfortable temperature
  2. Providing adequate lighting
  3. Limiting noise and/or distractions
  4. Providing eye level seating with no barriers
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14
Q

What are the phases of a health history interview?

A
  1. Introduction phase
  2. Working phase
  3. Termination phase
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15
Q

What order are assessment techniques performed in (exception is the abdominal assessment)?

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation
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16
Q

What part of the hand is used for assessing vibrations?

A

The base of the fingers

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17
Q

What part of the hand is used for assessing temperature?

A

The dorsal (back) of the hand & fingers

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18
Q

What part of the hand is best for assessing swelling, skin texture, pulsatility, and presence/absence of lumps?

A

The fingertips

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19
Q

During a general survey, what is meant by, “physical appearance?”

A
  1. Age
  2. Sexual development
  3. Level of consciousness
  4. Skin color
  5. Facial features
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20
Q

During a general survey what would you look at to assess body structure?

A
  1. Stature
  2. Nutrition status
  3. Symmetry
  4. Posture
  5. Position
  6. Build
  7. Physical deformities, if any
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21
Q

What is mobility on a general survey?

A
  1. A patient’s gait
  2. A patient’s range of motion
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22
Q

On the general survey what should you look at when assessing behavior?

A
  1. Facial expression
  2. Mood/affect
  3. Speech
  4. Dress
  5. Personal hygiene
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23
Q

The highest point of the lung is _________.

A

Apex

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24
Q

The lowest point of the lung is called the _________.

A

Base

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25
Q

What is subjective data?

A

What the patient reports about him/herself

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26
Q

What is objective data?

A

What the nurse sees without emotion or bias

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27
Q

What are some barriers that restrict a patient’s response, or barriers to communication?

A
  1. False reassurance
  2. Giving unwanted advice
  3. Using authority
  4. Using avoidance language
  5. Distancing
  6. Professional jargon
  7. Using leading or biased questions
  8. Talking too much
  9. Interrupting
  10. “Why”
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28
Q

What do different levels of consciousness look like in a person/patient?

A
  1. Alert: awake & fully aroused
  2. Lethargic (somnolent): not fully alert; drifts off to sleep when not stimulated; responds to commands/questions but slower than normal
  3. Obtunded: sleeps most of the time; difficult to arouse; acts confused when aroused; mumbled speech
  4. Stupor (semi-coma): Spontaneously unconscious; Responds ONLY to vigorous shaking/pain; speech is mumbled or they groan
  5. Coma: complete unconsciousness; no response to pain or external stimuli
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29
Q

What are some communication techniques that encourage free expression?

A
  1. Facilitation: responses that encourage pt to say more
    Ex: “go on”
  2. Silence: giving the pt time to think & respond
  3. Reflection: response that echoes the pt
  4. Empathy: recognizing the pt emotions & putting them in words
  5. Clarification: responses that get the pt to explain more
  6. Confrontation: congruent/ incongruent behaviors & words
  7. Interpretation: linking things together
  8. Explanation: sharing factual & objective info
  9. Summary: review of nurse understanding of what the pt reported
30
Q

What is the grading scale for assessing pulse?

A
31
Q

What is the grading scale for pitting edema?

A
32
Q

What do you do if you assess the popliteal pulse but cannot find it?

A

Proceed with the exam bc the popliteal pulse is often impossible to palpate

33
Q

What are hyperactive bowel sounds?

A
34
Q

What are hypoactive bowel sounds?

A
35
Q

What are the names of the abdominal quadrants?

A
36
Q

In what order do you auscultate the abdomen?

A
37
Q

What is the technique used when assessing the pt for abdominal pain?

A
38
Q

What is PERRLA?

A
39
Q

What does accommodation test for?

A
40
Q

How long does the nurse listen to the mitral area?

A

At least 60 seconds

41
Q

Hand washing is the single most effective and easiest way to prevent the spread of infection. When do you perform hand hygiene?

A
  1. In & out of patient rooms
  2. Before you eat
  3. After you use the restroom
  4. Before touching any part of your body
  5. Before gloving
  6. After removing gloves
  7. When hands are visibly dirty/soiled
42
Q

What is the most effective position to promote lung expansion and decrease diaphragmatic pressure?

A
43
Q

What is the quad cough?

A
44
Q

What is diaphragmatic breathing?

A
45
Q

What are the 4 P’s of purposeful rounding?

A
  1. Pain: assess pt pain
  2. Personal needs: toileting, drink
  3. Positioning: assess comfort
  4. Personal possessions: are their personal items within reach
46
Q

Patients wear armbands for a number of reasons. Give some example of patient armbands.

A
  1. Pink for restricted extremity
  2. Green for latex allergy
  3. Purple for DNR
  4. Yellow for fall risk
  5. Red for allergies
47
Q

When changing a patient position, what should you be aware of?

A

Friction or shearing

48
Q

What is friction?

A

The effects of rubbing; the resistance a moving body meets from the surface on which it’s moved; a force that occurs in a direction to oppose movement

49
Q

What is shearing?

A

The force exerted against the skin while the skin remains stationary & bony prominences move

50
Q

What layer of skin does friction damage?

A

Epidermis: the top layer of skin

51
Q

What layer of skin does shearing damage?

A

Deep dermal tissue & underlying tissues

52
Q

State the basic rules of body mechanics.

A
  1. Keep your body aligned & feet spread apart for a wide base
  2. Bend the legs not the back
  3. Use the stronger muscles in your shoulders, upper arms, thighs, hips
  4. Raise the pt bed—don’t bend & reach
  5. Push, pull, side heavy object—do not lift
  6. Do not lean over a patient to provide care
  7. Side rails down when lifting patients
53
Q

How often do you observe a violent patient wearing restraints?

A

Every 15 mins

54
Q

How often do you observe a nonviolent patient wearing restraints?

A

1 hour

55
Q

How often do you remove restraints, reposition, and meet basic needs?

A

Every 2 hours

56
Q

What are standard precautions?

A

The min level of protection from infection that applies to all patients (every pt, every time) regardless of suspected or confirmed infection/disease

57
Q

When should you use a face shield?

A

During procedure that are likely to generate splashes or sprays of bodily fluids, blood, bodily secretions, bodily excretions

58
Q

When should you wear gloves?

A

Anticipated contact with blood, mucous membranes, non-intact skin, potentially contaminated intact skin

59
Q

When/why should you wear a gown?

A

To protect your skin & clothing when potential contact with bodily fluids, blood, excretions, secretions can occur

60
Q

What are contact precautions?

A
61
Q

What are airborne precautions?

A
62
Q

What are droplet precautions?

A
63
Q

What are expected ranges for an oral temp?

A

96.4-99.1

64
Q

What factors influence body temp?

A

Menstruation, age, exercise, infection, illness, diurnal cycle

65
Q

What is the expected range for an adult pulse?

A

60-100 bpm

66
Q

What factors can influence resting pulse rate?

A

Disease, med hx, age, exercise, medications

67
Q

What are expected ranges for adult respiratory rate?

A

12-20 breaths per minute

68
Q

What factors influence changes in respiratory rate?

A

Age, exercise, anxiety, pain, smoking, medication

69
Q

What is systolic blood pressure (top #)?

A

The pressure exerted when blood is ejected into arteries

70
Q

What is diastolic blood pressure (bottom #)?

A

The pressure blood exerts within arteries between heart beats

UK ABSN FALL 2022 (4 decks)

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