Over all notes

Question 1

Pre-hypertension

Answer 1

Systolic: 120-139
Diastolic: 80-89

Question 2

Respiration (Cheyne-Stokes)

Answer 2

Before death

Question 3

Where is the body temperature relatively constant

Answer 3

Core

Question 4

Checking vital signs for an adult: pulse rate of 120

Answer 4

tachycardia (tachy: fast, cardia: heart beat)

Question 5

Bradycardia

Answer 5

slow pulse rate (below 60)

Question 6

Pulse location for emergency

Answer 6

carotid artery

Question 7

BP of 140/90

Answer 7

hypertension

Question 8

Normal temp

Answer 8

97°F-99.6°F

Question 9

Average heart rate

Answer 9

60-100

Question 10

When do you check the brachial artery

Answer 10

When doing blood pressure

Question 11

Reached above temp

Answer 11

hyperthermia → damaged body cells

Question 12

What does a temp below 93.3°F indicate

Answer 12

Death can occur

Question 13

Tympanic thermometer

Answer 13

Ear

Question 14

How do you do a adult tympanic reading

Answer 14

Adult: up & back

Question 15

How do you do a child’s Tympanic reading

Answer 15

Child: down & back

Question 16

Dyspnea

Answer 16

Difficulty breathing

Question 17

conditions to bring dyspnea

Answer 17

The amount and type of activity

Question 18

Respiration is controlled by

Answer 18

medulla oblongata

Question 19

Hypothalamus

Answer 19

Controls body temperature

Question 20

Incident report

Answer 20

Incident events

Question 21

How long do you check client vital signs

Answer 21

60 seconds

Question 22

OBRA

Answer 22

Regulation of standard

Question 23

Institution

Answer 23

Owner of patients medical records

Question 24

Subjective

Answer 24

symptoms (what the patient feels & says)

Question 25

Narrative charting

Answer 25

Describes occurrences in chronological order w/ subjective & objective

Question 26

How to fix Error

Answer 26

cross off, mark error, & initial name

Question 27

When do you chart

Answer 27

ASAP as often as possible

Question 28

Kardex

Answer 28

concise, centralized source of info. of client or treatment

Question 29

Additional treatments that were done

Answer 29

Charting by exception

Question 30

Traditional block

Answer 30

organize of scientific problems utilizes narrative charting for nurse’s notes

Question 31

HIPPA

Answer 31

Confidentiality and privacy of patient information

Question 32

H&P:

Answer 32

history and physical

Question 33

I & O:

Answer 33

I & O: intake and output

Question 34

DNR:

Answer 34

do not resuscitate

Question 35

NPO:

Answer 35

nothing by mouth

Question 36

STAT:

Answer 36

immediately

Question 37

Patient’s access to charts/info

Answer 37

not right away, follow established procedures of facility or institution

Question 38

How do you document right and wrong

Answer 38

``` Do not erase (use correction fluid) Only chart for yourself Title, date, time, name, signature cannot use own words when documenting use approved medical terms can be used ```

Question 39

Joint Commission

Answer 39

accredited agency that specifies guidelines for charting

Question 40

Nursing diagnosis

Answer 40

ADPIE | Initial step of nursing process: assessment/gathering info. (nursing health history)

Question 41

Newly admitted patien

Answer 41

Star with assessment

Question 42

Family

Answer 42

Secondary source of patient information

Question 43

Head to toe assessment

Answer 43

Organized approach

Question 44

Evaluation

Answer 44

identify outcome (did plan work or not work)

Question 45

Found patient on floor

Answer 45

first initial response → assess for any injuries

Question 46

Fever

Answer 46

Objective

Question 47

Postoperative

Answer 47

reassess the client again for expected outcome Revision of care plan Client expected outcome vs. evaluation

Question 48

Assessing eyes for pupil reflex

Answer 48

Penlight

Question 49

To use penlight

Answer 49

Darken the room | Shine the light in one pupil

Question 50

SOAPE

Answer 50

Problem oriented medical records

Question 51

QRSTUV

Answer 51

``` R = region of the body affected Q = quality/quantity ```

Question 52

Palpation

Answer 52

To identify tenderness

Question 53

Nursing diagnosis

Answer 53

Focuses on health problems

Question 54

Medical diagnosis

Answer 54

Is only for physicians

Question 55

Evaluation

Answer 55

Modification of plan of care

Question 56

Implementation/intervention

Answer 56

process of carrying out the plan | consider etiology, patient centered goal & desired outcome, risk factors when doing nursing diagnosis

Question 57

Normal blood pressure

Answer 57

120/80 mm Hg