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Foundations of Nursing > Test 1 > Flashcards

Test 1 Flashcards

1
Q

What is clinical judgment?

A

taking into account all aspects of a patients information in order to make a decision

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2
Q

What is critical thinking?

A

Knowing that everyone has allergies but they will all react in a different way

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3
Q

Identify critical thinking indicators

A
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4
Q

evaluate the relationship between clinical judgement and nursing process

A
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5
Q

Discuss the 5 aspects of ADPIE

A

Assessment
Diagnosis
Planning
Implement
Evaluation

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6
Q

What is SMART

A

Specific
Measurable
Attainable
Realistic
Timely

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7
Q

How do you determine appropriate NANDA nursing diagnoses and prioritize them

A
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8
Q

What is the lowest level to the highest level of Maslow’s Hiearchy

A

physology needs
needs for saftey and security
needs for love and belonging
self-esteem needs
self actualization

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9
Q

Identify and discuss phases of patient interview

A

Orientation
Working
Termination

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10
Q

What is primary data?

A

Something directly from the pateint

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11
Q

What is secondary data?

A

A chart, lab result

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12
Q

What do you do during the inspection phase of an assessment?

A

Using vision to inspect the patient

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13
Q

What do you do during the palpation phase of an assessment?

A

use touch to acess the patient

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14
Q

What do you do during the ausculation phase of an assessment?

A

Listening to sounds using your stetoscope

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15
Q

What do you do during a skin assessment?

A

Check skin color
Skin integrity

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16
Q

What is primary lesions and their descriptions

A

A type of somehting on your skin that has formed

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17
Q

Normal vs abnormal nail assessment

A

Capillaries refill within 3 seconds
nail shape is normal

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18
Q

Review head,ears,eyes,nose & throat assessment

A

No lumps bumps on head
PERRLA eyes
No excess drainage ears
nose septum is midline
trachea is midlime

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19
Q

Identify adventitious breath sounds with the description and their location

A

Crackles-pneumonia
Rhonchi-harsh gurgling
Wheezing- high pitched whisteling
Stridor-high pitched musical sound on inspriation

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20
Q

Describe auscultation of the heart

A

heart sounds/rate/rhythm
pulse deficit
cardiac murmors

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21
Q

Where is Erb’s Point located?

A

third intercostal space left side of the sternal border

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22
Q

Where is the Tricuspid valve located?

A

fourth intercostal space left side of the sternal border

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23
Q

Where is the pulmonary valve located

A

second intercostal space left of the sternal border

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24
Q

Where is the aortic valve located?

A

second intercostal space right of the sternal border

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25
Q

Where is the Mitral valve located?

A

middle under the nipple

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26
Q

How do you preform a peripheral vascular assessment, and what are the locations?

A

Inspection and palpation of peripheral pulses.

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27
Q

Describe the abdominal assessment and what order.

A
  1. Inspection
  2. Ausculation
  3. Palpation
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28
Q

Explain EMR and HIPAA

A

EMR is a medical record and HIPAA ensures that you have privacy of your information

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29
Q

Describe how to properly document in a medical record

A

Be clear and specfic and write it like a narrative-like you are telling a story

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30
Q

Understand verbal and telephone orders

A

Usually only happens in an emergency
must be taken by an RN
Must put order in immediately
Must document it as a phone/verbal order
includes date, time, physicians name, and RN signature

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31
Q

What is SBAR?

A

Situation
Background
Assessment
Reccomendation

32
Q

What should be included a flow sheet?

A
33
Q

What should be included in a charting by exception?

A

Abnormal or exception to normal things

34
Q

What is the normal heart rate range

A

60-100

35
Q

Name situations that would require a vital sign assessment

A

all unless the doctor states otherwise

36
Q

What are factors that can influence body temperature

A
37
Q

What are different tools for assessing body temperature

A
38
Q

S/S of a fever

A

Anorexia
increased heart rate
increased breathing
Headache
hot, dry skin
flushing
thirst
shivering
complaints of feeling cold
sweating
cyanotic nail beds

39
Q

Where is the popiteal pulse located?

A

behind the knee

40
Q

Where is the carotid pulse

A

neck

41
Q

where is the brachial pulse

A

inner elbow

41
Q

where is the radial pulse

A

wrist

42
Q

Where is the femoral pulse

A

femor

43
Q

Where is the posterior tibial pulse

A

ankle

44
Q

Where is the dorsalis pulse

A

top of foot

45
Q

Where is the apical pulse

A

5th intercostal space left midclavicular line below the nipple

46
Q

Explain the physiology and regulation of breathing and ventilation

A

your brain tells you to breathe you do not have to think about it

47
Q

What is tachypnea

A

fast breathing

48
Q

What is eupnea

A

regular breathing

49
Q

What is bradypnea

A

slow breathing

50
Q

What is apnea

A

no breathing

51
Q

What is hypertension vs hypotension

A

hyper- high
hypo-low

52
Q

What factors contribute to blood pressure

A

Age, weight, gender

53
Q

Droplet Precautions

A

Flu, Pneumonia

54
Q

Contact Precautions

A

MRSA, C-Diff

55
Q

Airbone Precautions

A

Chicken pox, TB

56
Q

What is medical asepsis

A

freedom from and prevention of disease-causing
Example: washing hands before surgery

57
Q

What is the ability to focus and filter clinical data and to recognize what is important or least important

A

clinical reasoning

58
Q

What are types of formatted charting

A

PIE
ADPIE
SOAP
DAR

59
Q

The ability to express ideas and concerns to other members of the team while respecting the thought of others

A

assertiveness

60
Q

What does CUS communication stand for?

A

concern
uncomfortable
saftey

61
Q

Where is the temporal pulse

A

head

62
Q

What is normal SBP

A

100-120

63
Q

What is normal DBP

A

60-80

64
Q

What is normal temperature

A

97.6-99.5

65
Q

What is normal oxygen saturation

A

95-100

65
Q

How many respirations are normal

A

12-20

66
Q

What is the pain scale

A

0-10

67
Q

Why are vital signs taken

A

to monitoe the functioning of body systems
detect changes in health status of the patient
identity early warning signs
evaluate the effectiveness of interventions

68
Q

What does EMR stand for

A

Electronic health record

69
Q

What does CPOE stand for

A

computerized provider order entry

70
Q

What happens during the S in SBAR

A

Situation
indetify yourself and the facility/site you are calling from, Name and DOB of patient symptm onset and severity

71
Q

What happens during B in SBAR

A

Background
Date/time of admission, admitting diagnosis, relevent medical history, lab results,notible chnages

72
Q

What happens during A in SBAR

A

Assessment
suspected underlying cause or concerns

73
Q

What happens during R in SBAR

A

Reccomendations
reccomendation and expectation, be clear and specific about urgency of request and expected timeframe

74
Q

What is chicken pox

A

vesicle

75
Q

What is hives

A

wheal

Foundations of Nursing (1 decks)

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