Fundamentals: General survey
a nurse is measuring the respiratory rate of a client who has a irregular breathing pattern. For how many seconds should the nurse count the clients respirations?
60 seconds ( 1 full minute)
the average adults resting heart rate should be ______ to _____ per minute
60 to 100
a pulse ox of less than ____ is considered life threatening while normal pulse ox is between 95-100%
90
the most accurate reading for temperature is ______
temporal
________ is a patient who is unconscious but will respond to physical or painful stimuli with movement or incoherent vocalizations
Stupor
the nurse is taking a rectal temperature on a client. which of the following actions does the nurse perform? (Select all that apply)
-lubricate the probe over -insert probe into rectum 1-1.5 in
normal respiration rate is _____ to ____ breaths/per minute
12 to 20
peripheral pulse assessment for strength:
Absent-0 weak/thready- +1 increased strong pulse- +3 bounding- +4
An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?
BP
the nurse is performing an initial assessment on a clients skin. which observations will require further assessment of the clients circulation?
Cyanosis is noted on fingers
Discuss the process of the general survey and its importance
Introduction for the physical exam -Study of the whole person -Covers the general state of health -Any obvious physical characteristics
_____ is when a patient is confused and speaks in one word sentences when awake and falls asleep without constant stimuli
Obtundation
a nurse is performing an admission assessment on as client. the nurse determines the clients radial pulse rate is 68/min and the simultaneous apical pulse is 84/min. what is the clients pulse deficit (per minute)
16
a nurse is assessing a clients behavior during the initial survey. which of the following does the nurse include in the assessment? (Select all that apply)
clients clothing and speech
a nurse is measuring the BP of a client who has a fractured femur. The BP reading is 140/94 mmHg, and the client denies any history of hypertension. which of the following actions should the nurse take first
ask the client if they are having pain
a nurse is measuring the oxygen saturation of a client who has cyanosis of the extremities. using a pulse oximeter, where does the nurse place the sensor probe? (Select all that apply) a. forefinger b. thumb c. forehead d. bridge of nose e. earlobe f. great toes
c d e
a nurse is instructing an assistive personal (AP) about caring for a client who has a low platelet count. which of the following instructions is the priority for measuring vital signs for this client?
do not measure the clients temperature rectally
unexpected findings of temperature is ______ and _______
hypo/hyperthermia
The nurse is caring for a client who is easily awakened by calling name but quickly falls back to sleep. The nurse would document this as which of the following?
lethargy
you should always identify the patient by asking for ______ and _____
name and date of birth
a nurse is caring for a client in the emergency department who has a oral temperature of 38.8 C (101 F), pulse rate 114/min, and respiratory rate 22/min. the client is restless with warm skin. which intervention should the nurse take? (Select all that apply)
obtain culture specimens before initiating antimicrobials encourage the client to rest and limit activity assist the client with oral hygiene
the nurse is instructing a group of assistive personal in measuring a clients respiratory rate. which of the following guidelines should the nurse include? (Select all that apply)
place the client in semi-fowlers position have the client rest an arm across the abdomen observe one full respiratory cycle before counting the rate
When performing passive range of motion on a client, the nurse notes resistances to manipulation of the right arm. The nurse would document this as which of the following?
rigidity
______ Hypertension: systolic btw 140-159mmHg and diastolic greater than 90mmHg
stage 1
_____ Hypertension: systolic greater or equal to 160mmHg and diastolic greater than 90mmHg
stage 2
which of the following is considered an unexpected finding for a 40 year old clients pulse?
strong radial pulse on the left compared to right
an expected finding for facial features is looking for _____
symmetry of face
a nurse is reviewing the vital signs for a patient who was admitted with shortness of breath. the nurse notes the patients respiratory rate is 24/min. the nurse should use which of the following terms when documenting this finding?
tachypnea
______ is when respirations are greater than 20 and _____ is when respirations are lower than 12
tachypnea bradypnea
a nurse is assessing a patient who is admitted with abdominal pain. the patient reports that the pain is "in the stomach and is crampy, dull ache." which type of pain should the nurse identify this patient is experiencing?
visceral