Fundamentals Unit 3 Exam

Conditions that may warrant a call out of the Rapid Response Team (RRT) may include what?

- a sudden change in vitals or mental status - seizures - chest pain despite giving nitrogylcerin - low oxygen saturation despite efforts to oxygenate

examples of barrier restraint

- all 4 side rails up - concave mattress - lapboards - seatbelts - cribs

What are some universal fall precautions?

- using non-skid socks - place the bed in a low position - lock the wheels of beds and wheelchairs - make sure room is free of clutter - provide education to client - place call light and belongings in reach

What injury preventions should you take during seizures?

- yell for help - place the client on their side and protect thier head - loosen clothing - monitor : start time and duration, how the seizure looks, ABCs, incontinence

3+ pitting edema

-Deep pit (6mm) -Remains several seconds after pressing

2+ pitting edema

-Deeper pit after pressing (4mm) -Lasts longer than 1+ -Fairly normal contour

What are examples of standards of compliance to promote safety?

1. indentify clients correctly 2. staff communication 3. use medications safely 4. use alarm safely 5. prevent hospital acquired infections 6. suicide reduction 7. prevention of adverse events in surgery

normal cap refill

2 seconds or less

what is the normal grading/quality when palpating pulses?

2+ ** anything less than 2 is weak ** anything more than 3 is increased or bounding

normal size for pupils

3-5 mm

how many sites are there when performing anterior auscultation

6

how many sites are there when performing posterior auscultation

9

What is jaundice?

A yellowing of the skin and eyes

What is clubbing?

Enlarged fingertips due to long standing deprivation of oxygen

I protect private and personal health information for clients. What am I?

HIPPA

What does ISBARR stand for?

I = identify (state the team member's name and title) S = situation (provide why the patient is needing care) B = background (medical history, medications, advanced directives) A = assessment (provide the most recent set of vitals or other data that is relevant like diagnostic testing and lab work) R = recommendations (any suggestions that may be helpful) R = read back (repeat the orders that are given and clarify anything that is unclear)

a tool to have clear communication for effective client care

ISBARR

Can you palpate both carotid arteries at the same time?

No, palpate one at a time

What is pallor?

Pale skin

what does PERRLA stand for

Pupils are Equal, Round, Reactive to Light and Accommodate

What does RACE stand for?

R = rescue A = alarm C = contain E = extinguish

What is petechiae?

Round pinpoint, non-raised, purplish-red spots, caused by mucosal or dermal hemorrhage.

What are your three priority actions if an active shooter is on site?

Run, hide, and fight

4+ pitting edema

Severe • Deep pit (8 mm) • Remains up to 2 minutes

what are retractions

Skin pulls between and around the ribs during inhalation.

A client who is NPO prior to a procedure is delivered a food tray, which the client consumes. The procedure was then delayed. This incident is an example of which of the following? a. client safety event b. near miss c. sentinel event

a

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? a. record the time and length of the seizure b. restrain the client's extremities c. place the client in the prone position d. monitor the client's hemoglobin level

a

A nurse is conducting a general survery on a client and notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe this involuntary movement? a. fasciculation b. spasticity c. tic d. myoclonus

a

A nurse is documenting their assessment and documents that the client states, "I have a dry cough every morning when I wake up." Which of the following types of data is the nurse documenting? a. subjective b. social determinants of health c. objective d. olfactory

a

A nurse is performing medication reconciliation and notices that a client who routinely takes Celebrex (a nonsterodial anti-inflammatory drug) at home is prescribed Celexa (an antidepressant) instead. The client does not have a history of depression. This incident is an example of which of the following? a. near miss b. sentinel event c. patient safety event

a

what is cyanosis

a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.

What is ecchymosis?

a discoloration of the skin resulting from bleeding underneath, typically caused by bruising.

Which of the following is a hospital-acquired injury? Select all that apply. a. blood transfusion incompatibility b. wrong site surgery c. ineffective insulin usage d. dysphagia following to stroke e. dehydration due to diarrhea

a, b, c

A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client. Select all that apply. a. fall history b. medical diagnosis c. use of assistive devices d. mental status e. DNR status

a, b, c ,d

A nurse is caring for a client who is at risk for suicide. Which of the following actions should the nurse take? Select all that apply. a. place the client on round-the-clock surveillance b. remove objects from the room that the client could use to harm themselves. c. search items brought into the client's room by visitors d. refrain from asking the client if they intend to harm themselves e. screen the client for suicidal ideation

a, b, c, e

A nurse is documenting information in a client's medical record. Which of the following information did the nurse collect during the general survey? Select all that apply. a. use of assistive devices b. past medical history c. current medication list d. height and weight e. behavior and mood

a, d, e

abnormal findings when auscultating the heart

abnormal rate and rhythm or extra heart sounds

abnormal findings for the cardiovascular system

abnormal temperature, abnormal pulse quality, asymmetry, edema, or tenting

unexpected findings when auscultating the lungs

adventitious breath sounds and decreased breath sounds

communication that is verbally, and sometimes physically abusive

aggressive

our client is wearing glasses when you are about to perform your eye exam. What should you do?

ask the client to remove their glasses prior to your assessment.

honest and clear communication that does not violate the rights of others

assertive

lisenting to sounds of the heart, lungs, stomach, intestines, and arteries

ausculation

A charge nurse is observing a newly licensed nurse perform an anterior chest auscultation on a client. For which of the following actions should the charge nurse intervene? a. the nurse asks the client to cough before beginning the auscultation b. the nurse is auscultating through the client's gown c. the nurse places the stethoscope on the intercostal spaces d. the nurse moves down the chest in a ladder sequence

b

A nurse in the PACU is determining if a client has pain. The client is drowsy and opens their eyes to verbal stimuli but is unable to communicate their pain level. Which of the following actions should the nurse take? a. admnister an antagonist to reverse the effects of the anesthesia b. use an alternative method for determining the client's pain level c. administer a pain medication as prescribed for severe pain d. wait until the client is awake, alert, and able to vocalize their pain level

b

A nurse is checking a client's allergy bracelet before administering a medication and finds the client is allergic to that medication. The nurse does not administer the medication to the client. This is an example of which of the following unexpected events? a. near-miss event b. client safety event c. adverse event d. sentinel event

b

A nurse is preparing to perform palpation on a client during a physical assessment. Which of the following findings is the nurse assessing during palpation? a. unexpected sounds made by tapping on the client's skin b. skin temperature, moisture, or unexpected findings c. heart sounds, lung sounds, and bowel sounds d. the client's cleanliness and grooming

b

Which of the following conditions is associated with jugular venous distention? a. severe dehydration b. heart failure c. peripheral arterial disease d. heart murmur

b

Which of the following entries display proper documentation by the nurse? a. the client is feeling better b. the client's abdomen is soft and nondistended c. the client's status is unchanged d. the client appears in pain

b

A nurse is educating a newly licensed nurse about The Joint Commission's National Patient Safety Goals. Which of the following goals does the nurse include when providing the education? a. preventing diabetes b. preventing surgical-site infections c. preventing myocardial infarctions d. preventing cerebrovascular infections

b. This is considered a hospital acquired infection and you want to avoid this.

a deformity in which the chest becomes expanded in size.

barrel chest ** Lung diseases that cause the chest to repeatedly over-expand or to remain in that position can lead to barrel chest, such as emphysema, cystic fibrosis, and asthma.

A ________ restraint entails restraining the client's movement within a setting through the use of barriers.

barrier

unexpected findings when palpating carotid arteries

bounding, very strong, diminished, weak pulses

A charge nurse is teaching a newly licensed nurse how to recognize manifestations of decreased oxygenation in a client. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. a client using thoracic breathing is experiencing a lack of oxygen b. a pulse oximeter reading of 95% indicated respiratory distress c. clubbing of the fingers indicates a chronic state of impaired perfusion d. a pinkish hue on the cheeks of a client with light skin tone indicates they are struggling to breathe

c

A client has signed an operative consent for a lumpectomy of the right breast but recieves a masectomy of the left breast. This incidnet is an example of which of the following? a. patient safety event b. near miss c. sentinel event

c

A nurse is caring for a client who is crying and appears upset after recieving news that they will need to have a surgical procedure. Which of the following actions should the nurse take to display empathy towards the client? a. tell the client that everything will be just fine b. change the subject while the client is discussing their feelings c. show interest in the client's feelings by acknowledging that they are upset d. tell the client that it is wrong to be crying over this situation

c

A nurse is documenting a client's vital signs in the medical record following a general survery. Which of the following entries should the nurse place in the record? a. fever 101 b. pulse rate is tachycardic c. oxygen saturation 96% on oxygen 2L/min via nasal cannula d. blood pressure 108/65 mm Hg

c

a nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first? a. instruct the client to deep breathe and cough b. provide the client with an incentive spirometer c. elevate the head of the client's bed d. reassess by auscultating the client's lungs

c

a nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take? a. use the soft end of a cotton swab over the client's abdomen b. ausculate the tender areas of the client's abdomen through clothing c. palpate the tender areas of the client's abdomen last d. use deep palpation when assessing the client's abdomen

c

which of the following is an extra or unexpected heart sound? select all that apply. a. S1 b. S2 c. S4 d. S3 e. murmur

c, d, e

A ________ restraint involves the administration of medications to a client to reduce their movement or control behavior.

chemical

examples of extra heart sounds

clicks, pericardial friction rub, murmurs

What are risks when it comes to physical restraints?

client injuries - bruises, fractures, circulatory impairment, skin tears

difference between comprehesive and focused assessments

comprehensive involves the whole body, and focused involves a specific part/complaint

unexpected findings when inspecting a client's breathing

confusion, anxiety, agitation, tripod positioning, pursed lip breathing, difficulty breathing

does light and close objects cause the pupils to constrict or dilate?

constrict

This lung sound is high-pitched and sounds like popping. It is caused by air being forced through an airway and is heard during INSPIRATION. ***THINK pneumonia, pulmonary edema, and heart failure. FLUID/MUCUS IN THE AIRWAY

crackles https://youtu.be/z2Ra9UxndI0?si=OEe4J8taI7bfg_Df

grating sensation or sound by friction between bone and cartilage

crepitus

A nurse discovers a small fire in a client's room. After removing the client to safety, which of the following actions should the nurse take next? a. extinguish the fire b. close the windows in the client's room c. close the client's door d. activate the fire alarm

d

A nurse is planning to assist in implementing the Transforming Care at the Bedside plan on a med-surg unit. Which of the following interventions should the nurse include in the plan? a. require nurses to spend 50% of their time at the bedside of clients b. perform change-of-shift report at the nurses' station. c. complete client rounds every 4 hours d. use a standarized communication tool ​

d

What is the correlating scale rating for mild pitting edema that is barely noticeable? a. 4+ b. 3+ c. 2+ d. 1+

d

Which of the following areas should the technique of palpation be used as a part of the assessment? a. eye structure b. trachea c. tongue d. sinus cavities

d

Which of the following is the first step the nurse should perform during the abdominal assessment? a. palpation b. percussion c. ausculation d. inspection

d

While conducting a general survery on a client who is being admitted to a long-term care facility, a nurse is assessing the client's emotional state. Which of the following findings should the nurse record as an unexpected finding? a. the client is sitting in a relaxed posture b. the client is cooperative in answering the nurse's questions c. the client tells the nurse that vists from their friends and family make them smile d. the client reports they feel sade and lonely most of the time

d

unexpected findings when examining the mouth

dark and swollen tongue, bleeding, reddened gums, thrush, edematous uvula or tonsils, canker sores

does distance and darkness cause the eyes to constrict or dilate?

dilate

what are abnormal findings when inspecting the abdomen?

distention, intense pulsations, jaundice, purple/pink striae

accumulation of excess fluid in the interstitial spaces between the tissues

edema

bulging or protruding of eye or eyes

exophthalmos

What is tenting of the skin?

gently pinching/lifting the skin. ***If a client is dehydrated, the skin is slow to return to normal and tends to stick up.

examples of mechanical restraints

hand mitten, wrist restraint, 4 point restraint, belt/vest restraint

expected findings of auscultating the abdomen

high-pitched sounds, gurgling 5-30/min in each quadrant

bowel sounds that occur more than 30 times per minute

hyperactive bowel sounds

unexpected findings when auscultating the abdomen

hyperactive bowel sounds, hypoactive bowel sounds, absence of bowel sounds, vascular swishing sound

bowel sounds that occur less than 5 times per minute

hypoactive bowel sounds

anytime something happens that needs to be evaluated and corrected to prevent future errors/harm is called what?

incident reporting

visual observation of the client

inspection

barriers to written communication

language barriers, literacy levels, and visual impairments

should you palpate painful abdominal areas first or last?

last

location of pulmonic valve

left 2nd intercostal space

location of tricuspid valve

left 4th intercostal space

location of mitral/apical valve

left 5th intercostal space at midclavicular line

unexpected findings when examining the neck

limited range of motion, deviated trachea (see photo) or swelling in the neck, impaired swallowing

unexpected findings when examining the head

lumps, lesions, edema, masses, patchy hair loss, abnormal hair growth

A ____________ restraint consists of the use of materials, straps, fabric, and leather devices that can be fastened around the wrists or ankles.

mechanical

Give examples of client identifers.

name, date of birth, photo, address, phone #, social security number.

Should you restrain a patient when they are actively having a seizure?

no

expected findings when palpating the abdomen

non-tender, relaxed

are slight aortic pulsations normal or abnormal?

normal

difficulty breathing when lying supine

orthopnea

The absence of hair means what when referring to the cardiovascular system?

oxygen levels are low

using palmar sufaces of the hands and fingers to feel areas of the body for various findings

palpation

communication that makes you want to avoid conflict, so the individial says nothing or simply agrees

passive

communication that appears passive on the surface, but the individual is demonstraing anger in a subtle, indirect or secretive way

passive aggressive

A _________ restraint consists of manually holding or immobilizing the client using physical strength. example : holding a patient down to give an injection

physical

This lung sound is a deep, harsh grating sound. It is caused by friction of inflamed and roughened pleural surfaces against one another during movement of the chest wall. **THINK pleuritis

pleural friction rub https://youtu.be/zm0jaBHmm10?si=yQnm7R4HLZcoPzzZ

unexpected findings when examining the ears

rash, edema, and drainage (bloody or watery)

what should you inspect for when looking at a client's breathing?

rate, rhythm, symmetry, depth, effort, chest shape, positioning, skin and nails

What is erythema?

redness of the skin

This lung sound is a low, deep-pitched rumbling noise (sounds like a snore). It is caused by respiratory secretions and clears when you cough. **THINK COPD and bronchitis

rhonchi https://youtu.be/CSpJhkIVez8?si=ayYmkmHVZWE-MIw0

location of aortic valve

right 2nd intercostal space

________ is an enviornmental restraint that involves placing the client alone in a securely locked room without their consent

seculsion

Risks involving chemical restraints

sedation, loss of consciousness, medication reaction

risks involving seclusion

self-harm and emotional distress

1+ pitting edema

slight indentation (2mm)

what should the lungs sound like when you auscultate?

soft-sounds *** WIND BLOWING IN TREES

how should you auscultate the abdomen?

start in the RLQ then move clockwise, note location of where bowel sounds were heard and frequency

misalignment of the eyes, causing the eyes to not look in the same direction

strabismus

This lung sound is a high-pitched, inspiratory wheeze. It occurs due to an obstruction of the airway. It is also considered a medical emergency and needs medical intervention right away! **THINK croup, epiglottitis, foreign body

stridor https://youtu.be/vDdJo0RPKa8?si=OTXkgnF7lz0fv6gQ

what are you palpating for when referring to the cardiovascular system?

temperature, texture, turgor, moisture, capillary refill, edema, arterial pulses for strength

unexpected findings when palpating the abdomen

tenderness, masses, and involuntary rigidity

describe accessory muscle use

using muscles other than those typically used for breathing to take in and expel air

the four modes of communication

verbal, nonverbal, written, electronic

This lung sound is high-pitched and may occur during inspiration and/or expiration. The airway is obstructing/narrowing/constricting. **THINK asthma

wheezing https://youtu.be/795uTkubs-M?si=9_FarH87cHjEqJ8W

should there be a silent period between each heart sound and between each heart beat?

yes