Intro Module 1
How much oxygen is in ambient or room air?
21%
What is the normal pulse pressure?
30-50
Which of the following is an example of a direct, closed-ended question?
"How many times in the last month have you slipped and fallen?"
MAP is calculated by
(systolic +2*diastolic) /3 IE (180+95+95)/3=123
What is the normal hemoglobin range?
12-18 gm/dL
After recording the blood pressure of a client, the primary health care provider confirms a diagnosis of pheochromocytoma. Which blood pressure reading may have helped confirm the diagnosis?
190/90 mm Hg
A nursing student is recording the radial pulse rate in a client with dysrhythmias and documented a radial pulse of 80 beats per minute. The registered nurse (RN) reassesses the client and notices a pulse deficit of 15. Which would be the client's apical pulse?
65
What is the normal PaO2?
80-100mmHg
What is the normal O2Sat?
95% and higher
What is the best indicator of blood oxygenation status?
ABG normal is 80-100. Normal SPO2 is 95% and higher
The first step of the nursing process is assessment. What action do you perform during assessment?
Acquire and validate information about the patient's health
What factors affect temperature?
Age, environment, time of day, exercise, stress and hormones. (temp is lowest 1-4am)
What can affect pulse rate?
Age, gender, exercise, autonomic nervous system, fever, medications, hemorrhage (hypovolemia), stress, position changes
What factors affect respiration?
Age, gender, medications, stress, exercise, altitude
What are the ABC's?
Airway, Breathing, Circulation
Thickening, hardening or loss of elasticity of arterial walls?
Arteriosclerosis
The phases of the nursing process?
Assessment, Diagnosis, Planning (includes Outcome), Implementation, Evaluation
What is the collapse of alveoli?
Atelectasis
What is it called when you reinforce your interest in what a patient has to say by using active listening prompts such as "go on" or "uh-huh"?
Back channeling
What is cyanosis?
Blue coloring of the skin due to lack of oxygen
The nurse understands that clozapine is contraindicated in the client with which condition?
Bone marrow depression
Slower, but regular respirations?
Bradypnea
Which term refers to a blowing sound created by turbulence caused by narrowing of arteries while assessing for carotid pulse?
Bruit
Which client finding would the nurse document as a pulse deficit?
Capillary refill greater than 3 seconds indicating pulse deficit
What is the measurement of exhaled carbon dioxide?
Capnography
How would the nurse document client findings of abnormal respirations with alternating periods of apnea and rapid breathing?
Cheyne-Stokes respirations
Which factor may affect the accuracy of pulse oximetry readings in a client with dyspnea?
Client has poor distal capillary refill and cold extremities
The nurse assesses the integumentary system of four clients. Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time?
Client with epilepsy
When formulating a nursing diagnosis, which of these should you do first?
Cluster assessment data into meaningful patterns.
The third step of the nursing process is planning. What action do you perform during planning?
Collaborate with the patient and family to prioritize interventions.
What is Assessment?
Collection of data to help establish a goal of making a clinical nursing judgment.
What is COCA?
Color, Odor, Consistency, Amount
What is the transfer of heat from one surface to another with direct contact?
Conduction
What is the transfer of of heat away by air movement?
Convection
What type of nursing diagnosis applies when a patient has an increased likelihood of developing a problem or complication?
Risk nursing diagnosis
What should you do if you detect an irregular pulse?
Count it for the full minute, preferably at the apical site.
What are critical signs of hypothermia?
Decreased body temp, decreased bp and urinary output
Which disorder is caused by the deficiency of antidiuretic hormone?
Diabetes insipidus
Term meaning shortness of breath (SOB)?
Dyspnea
Normal respiratory rate and rhythm?
Eupnea
What is the transfer of heat when a liquid is changed to a gas?
Evaporation
What type of nursing diagnosis applies when a patient has an interest in improving his or her health status by making behavioral changes?
Health promotion nursing diagnosis
What causes pulsations?
Heart contracts and ejects blood into the circulation, pulsations can be palpated at various arterial sites in the body
What is the condition where blood pressure is chronically elevated? What is the range?
Hypertension; above 140/90
Elevated body temperature?
Hyperthermia
Difference between hypoventilation and hyperventilation?
Hypo-not enough O2 in blood; Hyper-too much O2 in the blood.
Blood pressure below 100/60 mm Hg?
Hypotension
Decreased body temperature?
Hypothermia
The second step of the nursing process is diagnosis. What action do you perform during diagnosis?
Identify a pattern to reach a diagnostic conclusion.
What is the evaluation phase? Did the implementations work?
If not, re-evaluate and change plan of care; also, be comparing things like labs and diagnostics to determine if there is improvement or worsening.
During the patient interview, the patient shows signs of acute respiratory distress. What should you do next?
Immediately assess the affected body system.
Which of the following is an example of a problem-focused nursing diagnostic statement?
Impaired nutritional status: deficient food intake related to inability to absorb nutrients.
Soft swishing sounds of breathing are heard when the nurse auscultates a client's chest. Which term would be used when documenting this assessment finding?
Vesicular breath sounds
Two nurses work together to reposition a patient in bed to aid to facilitate pressure injury prevention. This is an example of which kind of intervention?
Independent nursing intervention
Consulting with another health care provider about patient care is an example of which type of care?
Indirect care
Which landmark is correct for the nurse to use when auscultating the mitral valve?
Left fifth intercostal space, midclavicular line
If the hemoglobin is low what happens?
Less perfusion to the tissues
In which order should nursing diagnoses be listed in the patient's record?
List nursing diagnoses from highest priority to lowest priority, in chronological order
An intervention that addresses a patient's long-term health care needs, rather than a specific illness, would generally be assigned which priority?
Low
What is included in the planning phase?
Making SMART goals... Specific, measurable, attainable, realistic, timed
Which device that we discussed provides the highest concentration?
Non rebreather
Which roles would norepinephrine's mechanism of action perform in managing anaphylaxis?
Norepinephrine functions as a peripheral vasoconstrictor
The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion?
Plasma proteins moving out of the intravascular compartment
what are the different types of nursing diagnoses you might see?
Problem focused Risk Health promotion
Be sure you know you normal ranges for vital signs
RR 12-20 bp 120/80, hr 60-100bpm, temp 36-38C, cuff size is upper 2/3 of arm.
While caring for a postoperative client, the nurse observed a pulse deficit during physical assessment. Which pulses are used to assess a pulse deficit?
Radial and apical pulse
What is the transfer of heat from one surface to another without direct contact?
Radiation
After percussing a client's posterior chest and hearing low-pitched hollow sounds over the whole chest, how will the nurse document the finding?
Resonance
what is central cyanosis?
Soft palate, tongue, and conjunctiva of the eyes are the primary sties to assess for signs of central cyanosis. LATE sign
During the interview, the patient provides information about his or her symptoms and health status. What is this data called?
Subjective data
Difference between subjective and objective data?
Subjective, from the client; Objective, from the nurse's senses
What is the lipoprotein that is produced and coats the inner surface of alveoli?
Surfactant
Increased respiratory rate; rapid, shallow breaths?
Tachypnea
What are the steps for pursed lip breathing?
Take a deep breath in to the count of 2 Exhale slowly through pursed lips as if blowing through a straw to the count of 1, 2, 3, 4
Where are the pulse sites?
Temporal, Carotid, Apical, Brachial, Radial, Femoral, Popliteal, Dorsalis pedis, Posterior tibial
The foundation of the nursing profession; is the systematic approach to problem-solving and providing individualized care?
The Nursing Process
The nursing student under the supervision of the registered nurse (RN) is performing a pulse assessment. While preparing to assess the client, the RN asks the nursing student to check the apical pulse after assessing the radial pulse. Which would be the reason behind for this change?
The client may have peripheral artery disease
What is the nursing diagnosis based on?
The pathophysiology of the disease process.
What is determined in the Evaluation phase?
The patient's reactions to nursing interventions and judging whether the goals of the plan of care were achieved.
Amount of air moving in and out with each breath
Tidal Volume
A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen?
To increase oxygen concentration to heart cells
When do you assess vital signs?
Upon admission, physician order, facility policy; before and after- surgery, diagnostic procedure, medication administration, nursing interventions, patient becomes symptomatic
What is the process of moving gases in and out of the lungs? When you inhale and exhale?
Ventilation
Which masks delivers exact amount of oxygen?
Venturi mask
What is included in the assessment phase of the nursing process?
assessment, involves the gathering and analysis of information about a patient's health status.
What is peripheral cyanosis?
blue fingertips, toes, nose and ear lobes
What are the steps for incentive spirometry?
breath in deep breath, seal lips, hold for 3 seconds blow long and consistently
What is atelectasis?
collapsed alveoli. You will hear absent or diminished breath sounds with atelectasis. - results in hypoventilation
How can we prevent atelectasis?
deep breaths, cough, turn, and deep breathe. Incentive spirometry
What are signs of hypoxia?
first sign is irritability. Others include apprehension, restlessness, inability to concentrate, decreased level of consciousness, dizziness, and behavioral changes.
What occurs in the implementation phase of the nursing process?
put the planning phase into practice, be evidenced based