Exam 1
The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective? A.Clubbing of fingers B.RR 26 C.HR 110 D.SpO2 96%
D
The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal? A.Vesicular breath sounds audible over peripheral lung fields B.Resonance on percussion of lung fields C.Respiratory rate of 18 breaths/min D.Fine crackles on the base of the lungs bilaterally
D
A nurse is assessing the respirations of a 60-year-old female patient and finds that the patient is breathing so shallowly that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation? A.Notify the primary care provider. B.Perform a pain assessment. C.Administer oxygen. D.Auscultate the lung sounds and count respirations.
D
A nurse is caring for client who suddenly begins to have respiratory difficulty. In what position would the nurse place the client to facilitate respirations? A.Supine B.Prone C.Dorsal recumbent High-Fowler's
D
standard precaution
(universal precaution): infection prevention practices to all clients.
Which nursing actions follow guidelines for preventing complications with enteral feedings? (Select all that apply.) A.Elevate the head of the bed at least 30 degrees during the feeding and for at least 1 hour afterward. B.Give large, infrequent feedings. C.Flush the tube before and after feeding. D.Clean and moisten the nares every 4 to 8 hours. E.Change the delivery set every other day according to agency policy. F.Check the residual before intermittent feedings and every 8 hours during continuous feedings.
A C D
A client is experiencing hypoxia. Which of the following are early manifestations of hypoxia? Select all that apply. A.Tachypnea B.Bradycardia C.Hypotension D.Restlessness E.Use of accessory muscles
A D E
A client is experiencing hypoxia. Which of the following are early manifestations of hypoxia? Select all that apply. A.Tachypnea B.Bradycardia C.Hypotension D.Restlessness Use of accessory muscles
A D E
What are the three modes of transmission?
1. Contact: occurs when microorganisms move from an infected person to another person. Including indirect and direct. Direct: without having a contaminated object or person between the tow. Indirect: with a contaminated object or person between the two. 2. Droplet: occurs when airborne droplets from the respiratory tract of a client travel through the air and into the mucosa of a host. 3. Airborne: occurs when small particulates move into the airspace of another person. These articles can remain in the air and travel over relatively long distances, leading to the potential for others outside the client's room to inhale them. Examples include: Tuberculosis, rubeola (measles), varicella (chickenpox).
List five interventions that can be implemented to avoid the use of restraints.
1. Engage the client in social interactions 2.Offer the client diversional activities 3.De-escalate the situation 4.Place the client in a room near the nurse's station 5.Encourage family members' presence at the bedside
The nurse is assessing a patient with a heart rate of 55. Which of the following patients would be most likely to have a pulse rate of 55? 1.A 70-year-old telephone salesman who is dehydrated 2.A 20-year-old runner who had surgery 4 days ago for a fractured leg 3.A 67-year-old who presented with an exacerbation of his COPD 4.An infant who has a temperature of 100.1°F
2. A 20-year-old runner who had surgery 4 days ago for a fractured leg; Athletes who train for endurance are likely to have a low resting heart rate because of a high cardiac output. Answer 1 is incorrect because dehydration usually presents with tachycardia. Answer 3 is incorrect because patients with COPD usually present with tachycardia. Answer 4 is incorrect because infants have a higher pulse rate than adults, and fever will also increase the heart rate.
How do we count/assess RR?
30 sec x 2
You have trouble auscultating Mr. Walker's bowel sounds. How long should you auscultate before charting that bowel sounds are absent?
5 minutes
What is the HR range for an adult?
60-100
What temperate range is defined as a fever?
>100.4
A nurse is planning a high-energy diet for a patient. What nutrient provides energy to the body and should be increased in the diet? a. Carbohydrates b. Vitamins c. Minerals d. Water
A
An adult client has an order for oxygen at 2 L/min. Which method of oxygen delivery should the nurse use in this situation? A.Nasal cannula B.Face mask C.Non-rebreather Partial non-rebreather
A
Auscultating the abdomen is begun in the right lower quadrant (RLQ) because: A.Bowel sounds are always normally present here. B.Peristalsis through the descending colon is usually active. C.This is the location of the pyloric sphincter. D.Vascular sounds are best heard in this area.
A
Right upper quadrant tenderness may indicate pathology in the: A.Liver, pancreas, or ascending colon. B.Liver and stomach. C.Sigmoid colon, spleen, or rectum. D.Appendix or ileocecal valve.
A
The nurse is caring for a client with emphysema, who has been having difficulty breathing while eating. Which of the following is an appropriate nursing intervention to include in the client's care plan to address this problem? A.Provide six small meals daily B.Provide three large meals daily C.Encourage the client to eat immediately before breathing treatments D.Encourage the client to alternate eating and using a nebulizer during mealtime
A
The nurse is reassessing a patient's pain level after pain medication administration following a pain level of 9/10. The patient states that his pain level is now a 3/10. What should the nurse do next? A.Verify orders for medications and offer more pain medication, if appropriate. B.Continue to assess patient's pain level. C.Document the pain level in the chart. D.There is no need for action, because the patient's pain is manageable.
A
The nurse knows that the proper technique for assessing lungs in an adult patient is that auscultation is performed: A.from right to left using a "z" pattern. B.from top to bottom using landmarks for accuracy. C.using the bell of the stethoscope to hear vascular sounds. D.to the anterior chest wall and abdomen to determine diaphragm function.
A
What is the minimal amount of time that a nurse should scrub hands that are not visibly soiled for effective hand hygiene? A.15 seconds B.45 seconds C.30 seconds 60 seconds
A
A charge nurse is observing a newly licensed nurse perform anterior chest auscultation on a client. Which of the following actions indicates the nurse needs more guidance? Select all that apply. A.The nurse is auscultating over the client's gown B.The nurse uses the bell part of the stethoscope to auscultate lung sounds C.The nurse moves the stethoscope in a "z" or ladder sequence during auscultation D.The nurse places the stethoscope on the intercostal spaces E.The nurse asks the client to cough before beginning auscultation
A B
A nurse has a provider order to apply wrist restraints to maintain a client's safety. What should the nurse do when applying this type of restraint? Select all that apply. A.Check the site of the restraint every hour B.Remove the wrist restraints to provide skin care every 2 hours C.Ensure the wrists are well padded when applying D.Permit 4 finger widths to slide between the client's skin & restraints E.Tie the straps of the wrist restraints to the bedside rails using a tight knot
A B C
The nurse is caring for a client with emphysema. When teaching the client pursed-lip breathing, the nurse will include which instruction(s)? Select all that apply. A.Inhale slowly through the nose for a count of three. B.Shape the lips as if you were about the blow a whistle. C.Keep abdominal muscles in a relaxed state D.Over time, begin to increase the length of the exhale. E.Exhale slowly through pursed lips. F.Ensure that the exhale lasts twice as long as the inhale.
A B D E F
When a fire occurs in a client's room, what would be the nurse's priority actions? Select all that apply. A.Rescue the client B.Make sure doors are open C.Evacuate patients & visitors to a safe area D.Sounds the alarm E.Run for help Open the windows
A C D
What is a normal SpO2 reading?
A healthy person with no lung disease normally has an SpO2 of 95% to 100%, but a value of >95% is clinically acceptable in the presence of a normal hemoglobin. COPD: 88-92%
What is the pulse oximeter measuring?
A sensor attached to the person's finger or earlobe has a diode that emits light and a detector that measures the relative amount of light absorbed by oxyhemoglobin (HbO2) and unoxygenated (reduced) hemoglobin (Hb). The pulse oximeter compares the ratio of light emitted with light absorbed and converts this ratio into the percentage of oxygen saturation. Because it only measures light absorption of pulsatile flow, the result is SpO2.
An overweight, middle-aged client presents with a 15-year history of hypertension. Which health strategy(ies) will the nurse teach this client? Select all that apply. A. Eat a low-fat, low-sodium diet B.Engage in regular aerobic activity at least 5 times per week C.Avoid fast food venues D.Maintain a low-fiber diet E.Engage in muscle strengthening exercises at least 2 times each week
A, B, C, E
When inspecting the anterior chest of an adult, the nurse should include which assessments? Select all that apply. A.Symmetric chest expansion B.Configuration of the chest C.Tactile fremitus D.Use of accessory muscles E.Skin color of chest F.Temperature and moisture of chest G.Patient's facial expressions
A, B, D, E, G
A nurse is following medical asepsis when caring for clients in a critical care unit. Which nursing actions follow these principles? Select all that apply. A.The nurse carries soiled items away from the body B.The nurse places soiled bed linen on the floor C.The nurse moves soiled equipment away from the body when cleaning it D.The nurse opens a window & dusts the room in the direction of the window E.The nurse pour discarded liquids into a basin then pour them into the drain
A, C
The nurse is teaching a client about variables that can cause temporary alterations in blood pressure. Which variation(s) will the nurse include when teaching the client? Select all that apply. A.Physical activity B.Advanced age C.Acute pain D. Gender
A, C
A nurse is setting up a sterile field. Which actions follow recommended guidelines for a sterile procedure? A.The nurse considers the outer 1-inch edge of the sterile field to be contaminated B.The nurse places the cap of an opened solution on the table with edges down C.The nurse discards a sterile field when a portion of it becomes contaminated D.The nurse calls for help when realizing a supply is missing E.The nurse drops a sterile item on a sterile field from the height of 12 inches F.The nurse holds a facility-wrapped item with top flap opening toward the body
A, C, D
For which clients would the nurse be required to use droplet precautions? Select all that apply. A.Rubella B.Tuberculosis C.Influenza D.Mumps E.MRSA Diphtheria
A, C, D, F
A nurse in the clinic must obtain the vital signs of each client via an electronic thermometer before patients are assessed by the primary health-care provider. Which client characteristics indicate that the nurse should take the client's temperature via the rectal, rather than the oral route? SELECT ALL THAT APPLY. A.Mouth breather B.History of vomiting C.Presence of confusion D.Intolerance of the semi-Fowler position E.Client with a wired mandible
A, C, E
Which technique is correct when the nurse is assessing the radial pulse of a patient? SELECT ALL THAT APPLY. A. Count the pulse for 1 minute if the rhythm is irregular. B. If the pulse is regular, count the pulse for 15 seconds and then multiply by four. C. Count the initial pulse for a full 2 minutes to detect any variation in amplitude. D. Count the pulse for 10 seconds and multiply by six, if the patient has no history of cardiac abnormalities. E. If the pulse is regular, count the pulse for 30 seconds and then multiply by two.
A, E
The nurse assess a patient, who complains of pain of 9/10, in RLQ, appears to be guarding, grimacing, and moaning, laying in a fetal position on the right side. Based on this information, do you think the patient is experiencing acute or chronic pain?
Acute
A nurse is instructing a group of newly licensed nurses various fall prevention interventions for hospitalized clients. Which of the following instructions should be included? Select all that apply. A.Keeping the bed in the high position B.Locking the wheels of the bed C.Providing adequate lighting D.Do not use any footwear E.Place the call light and belongings within the client's reach F.Refrain from placing brakes on the wheelchair
B C E
A 50-year-old patient asks how he can reduce his risk of colon cancer. What is the most appropriate response by the nurse? A."A diet high in animal protein reduces the risk." B."Regular exercise to reduce body fat helps prevent colon cancer." C."Taking antacids for heartburn can help prevent colon cancer." D."Taking vitamin C daily helps reduce the risk."
B
A client signed consent for a right knew replacement surgery, but received a left knee replacement surgery instead. This is considered a: A.Near miss event B.Sentinel event C.Client safety event Adverse event
B
A nurse is educating a client who has congested lungs on how to keep secretions thin and more easily coughed-up and expectorated. What would be one self-care measure to teach? A.Limit oral intake of fluids to <500 mLs per day B.Increase oral intake of fluids to 2-3 quarts per day C.Use a cough suppressant when throat becomes sore Take warm baths every night for a week
B
The nurse notices a colleague is preparing to check the blood pressure of a client who is obese by using a standard-sized adult blood pressure cuff. Which of the following findings should the nurse expect? A.Yield a falsely low blood pressure. B.Yield a falsely high blood pressure. C.Be the same, regardless of cuff size. D.Vary as a result of the technique of the person performing the assessment.
B
The nurse on a busy surgical ward use hand hygiene when caring for post-surgical patients. Which action represents the appropriate use of hand hygiene? A.Using gloves in place of hand hygiene B.Keeping fingernails less than ¼ inch long C.Using hand hygiene instead of gloves in contact with blood D.Using gel nail polish to protect nails
B
The student nurse is percussing a patient's posterior chest. The student nurse knows that a normal sound of percussion over the chest is: A.Dullness B.Resonance C.Hyperresonance D.Tympanic
B
A patient is crying and says, "Please get me something to relieve this pain." What should the nurse do next? A.Verify that the patient has an order for pain medications and administer order as directed. B.Assess the level of pain and ask patient what usually works for his or her pain, administer pain medication as needed, then reassess pain level. C.Assess the level of pain and give medications according to pain level, and then reassess pain. D.Reposition the patient, then reassess the pain after intervention.
B Answers A, C, and D are incorrect because pain management should be collaborative, and the patient is not part of the decision-making process in these answers.
The nurse is attempting to insert an NG tube and, as the tube is passing through the pharynx, the patient begins to retch and gag. What nursing interventions are appropriate in this situation? (Select all that apply.) A.Inspect the other nostril and attempt to pass the nasogastric tube down that nostril. B.Ask the patient if he or she needs to pause before continuing insertion. C.Continue to advance tube when the patient relates that he or she is ready. D.Have the emesis basin nearby in case patient begins to vomit. E.Give small air boluses until gastric contents can be aspirated. F.Insert a nasointestinal tube.
B C D
A nurse is removing an NG tube and notes epistaxis. What nursing interventions would the nurse perform in this situation? (Select all that apply.) A.Notify primary care provider and anticipate order to reinsert NG tube. B.Occlude both nares until bleeding has subsided. C.Offer facial tissue to blow nose. D.Record the amount of blood in the suction container. E.Ensure that patient is in upright position. F.Document epistaxis in patient's medical record.
B E F
The nurse obtained the above assessment data for a newly admitted client. The nurse prioritized that this client has a risk for falls. What information in the client data places the client at risk? Select all that apply. A.age of 61 years B.history of a fall C.fractured leg D.administration of oxycodone E.vital signs
B, C, D
What do we assess with VS?
BP, HR, RR, Temp, Pulse, and Pain
A nurse is assessing a client who is being admitted to the hospital. Which is the most important information that indicates whether the client is at risk for physical injury? A.Weakness experienced during a prior admission B.Medication that increases intestinal motility C.Two recent falls that occurred at home The need for corrective eyeglasses
C
A nurse is caring for a client diagnosed with hepatitis B. Which type of precautions should the nurse initiate? A.Droplet precautions B.Contact precautions C.Standard precautions Airborne precautions
C
A nurse is educating a preoperative client on how to effectively deep breathe. Which instruction would be included? A."Breathe through the mouth when you inhale and exhale" B.Breathe in through the mouth and out through the nose" C.Make each breath deep enough to move the bottom ribs" D."Practice deep breathing at least once a week"
C
A nurse performing an abdominal examination on a 37-year-old woman would document which finding as abnormal? A.No aortic pulsations to light or deep palpation B.Bowel sounds 5-30 times a minute in the lower quadrants C.Bulges observed when coughing D.Silver-white striae and a faint vascular network
C
The absence of bowel sounds is established after listening for: A.1 full minute. B.3 full minutes. C.5 full minutes. None of the above.
C
The nurse is performing a nutritional assessment of an obese patient who visits a weight control clinic. What information should the nurse take into consideration when planning a weight reduction plan for this patient? A.To lose 1 pound/week, the daily intake should be decreased by 200 calories. B.One pound of body fat equals approximately 5,000 calories. C.Psychological reasons for overeating should be explored, such as eating as a release for boredom. D.Obesity is very treatable, and 50% of obese people who lose weight maintain the weight loss for 7 years.
C
What consideration based on gender would a nurse make when planning a menu for a male patient with well-defined muscle mass? A.Men have a lower need for carbohydrates. B.Men have a higher need for minerals. C.Men have a higher need for proteins. D.Men have a lower need for vitamins.
C
When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. How should the nurse interpret these findings? A.Normal sounds auscultated over the trachea B.Bronchial breath sounds that are normal in that location C.Vesicular breath sounds that are normal in that location D.Bronchovesicular breath sounds that are normal in that location
C
Which is an expected finding of an abdominal examination of an adult? A.Abdomen has a rounded contour B.Venus hum over the epigastrium C.High-pitched gurgles 5 to 30 times a minute D.Swishing sounds over the abdominal aorta
C
Which of the following is TRUE about bowel sounds? A.Bowel sounds are usually loud, high-pitched, rushing, and tinkling sounds B.Bowel sounds are usually low-pitched, gurgling, and irregular C.Bowel sounds are usually high-pitched, gurgling, and irregular D.Bowel sounds originate from the movement of air and fluid through large intestine
C
Which of the following nursing interventions is the most effective in breaking the chain of infection? A.Administering medication B.Providing good skin care C.Practicing hand hygiene Wearing gloves at all times
C
A client admitted with C. Diff infection requires special infection control precautions. Which of the following nursing care actions are appropriate? Select all that apply. A.Initiate airborne precautions B.Practice meticulous hand hygiene using 95% alcohol-based hand sanitizer C.Donning PPE before entering client's room D.Disposing of body fluids in designated biohazard bags/toilets E.Assessing client with your stethoscope
C & D
Place the steps for removing protective equipment in the order in which they should occur when the nurse has completed patient care: A.Remove gown. B.Remove mask/respirator. C.Remove gloves. D.Remove goggles/face shield.
C D A B
The nurse notes "acute pain" as the patient's top concern/priority nursing diagnosis. Which of the following statements accurately describes the next step in the nursing process for this patient's care plan? A.The patient will verbalize decreased pain by the end of my shift. B.I will administer pain medication as prescribed by primary health care provider. C.Assess pain level using pain scale 0-10 and PQRST D.The patient's pain will decrease to 6/10 within the next two hours.
D
Upon inspection, a nursing student notices a client's abdomen appears bulging and stretched in appearance. The nurse should describe this finding as: A.Obese B.Herniated C.Scaphoid D.Protuberant
D
Which technique does the nurse use to palpate a patient's abdomen? A.Asks the patient to breath slowly though the mouth B.Uses the heel of the hand to perform deep palpation C.Uses the left hand to lift the rib cage away from the abdominal organs D.Depresses the abdomen 1 cm for light palpation
D
While reading a physician's progress notes, a student notes that an assigned client is having hypoxia. What abnormal assessments would the student expect to find? A.Hyperthermia, dry skin, cyanosis B.Decreased skin turgor, flushed skin, edema C.Hypotension, reddened skin, moist mucous membranes D.Dyspnea, tachycardia, cyanosis
D
Name two causes for hyperactive bowel sounds.
Diarrhea and early obstruction
Mr. Walker's abdomen is distended, and his bowel sounds are hypoactive. How do you explain these findings?
Effects of anesthesia, abdominal surgery, and decreased mobility
What are objective indicators of pain?
Grimacing, guarding, and crying, sweating, restlessness
•Before charting that Mr. Walker has absent bowel sounds, listen over the ileocecal valve. Where is this site located and what is the rationale for listening over it?
Location: RLQ Rationale: Active site; connects small and large intestine
What are some common treatments of fever?
Modifications of the external environment may be implemented to increase heat transfer from the internal to the external environment, including the use of cool sponge baths, cool packs, and hypothermia (cooling) blankets. Oral fluids are increased to maintain cellular and intravascular status and prevent dehydration. Simple carbohydrates are included in the diet to prevent tissue breakdown from the hypermetabolic state.
orthostatic hypotension
Normally, when a person changes positions from supine to standing, a slight decrease (<10 mm Hg) in systolic pressure may occur - However, with a change in positioning, a drop in systolic pressure of > 20 mm Hg or increase in pulse > 20 beats/min is known as orthostatic hypotension
droplet precaution
Nurse needs to don a surgical mask when entering the room; which can occur within 6 to 10 feet of the client. Infectious agents include Influenza virus, adenovirus, SARS-CoV1, Rhinovirus (common cold) etc.
What is PQRST?
P= (precipitating cause) - What were you doing when the pain started Q= (Quality) - Describe what your pain feels like? R= (region) - Show me the location where you are experiencing pain. S= (Severity) - ON a scale of 0-10, how would you rate your pain? T= (Timing) - When did your pain first begin? Have you experienced this pain before?
Name two causes for hypoactive bowel sounds or absent bowel sounds
Pain medication and immobility
What are subjective indicators of pain?
Pain scale, along with quantity and quality of pain
After inspecting Mr. Walker's abdomen, you auscultate it. What is the rationale for performing auscultation before palpating the abdomen?
Palpation could alter bowel sounds
Consider the following VS: HR 62, Temp. 100.3 F, RR 8, BP 132/84, SpO2 96% RA, Pain 6 What is the most concerning to you and why?
RR of 8
•Lou Walker, age 63, had a colon resection 3 days ago. He is NPO and has a nasogastric tube connected to low suction. You begin his abdominal assessment with inspection. What three movements should you look for when inspecting the abdomen?
Respirations, aortic pulsations, peristalsis
What are the three things we assess for when palpating a pulse?
Rhythm Force of Contraction Rate
What are some questions we ask someone before taking their BP?
What is your normal BP.Inflate the cuff 30 mmHg higher than the normal BP. - is there any reason I shouldn't use this arm (swelling, surgery, injury)
How & When do you take orthostatic VS?
When you suspect volume depletion; When the person is known to have hypertension or is taking antihypertensive medications; When the person reports fainting or syncope Technique Have patient rest supine for 2-3 minutes, taking a baseline pulse and BP Repeat measurements with person sitting and then while standing
sentinel event
a critical, unexpected adverse event that caused severe physical or psychological harm to a client, including death, permanent injury, and severe or temporary injury.
near miss
a potential error or event or circumstance that could have caused harm, but that was caught and avoided
adverse event
a situation or circumstance that caused unexpected harm to the client.
client safety event
an unexpected event or circumstance that occurred with or without injury to the client, but had the potential to cause harm to the client
Which artery do we palpate for when taking BP?
brachial
What is the goal of nursing regarding infection?
break the links of the chain to end the cycle -Infectious agent: disinfecting, sterilizing, cleaning or using antimicrobial treatment -Reservoir: proper hand hygiene, preoperative prep including surgical/ clinical environment to prevent infection -Portal of exit: containment of blood or body fluids -Modes of transmission: using appropriate hand hygiene and proper barrier device -Susceptible host: increase host's line of defense (immunization, nutrition, hygiene, blood glucose control etc.)
Medical Asepsis
decreases the number of micro-organisms on surfaces as a mean to reduce infection risk. For example, isolation precaution.
Physical Signs of Stress
headache, not feeling hungry, heavy chest, back pain, upset stomach, tight muscles
What is tachypnea? Dyspnea?
increased respirations <20 difficulty breathing
•Acute Pain
less than 6 months, sudden onset. Damage caused by trauma or injury, incisional pain from surgery, and pain pain from environmental factors such as heat or cold
Consider the following VS: HR 105, Temp. 97.1 F, RR 10, BP 105/78, SpO2 95% RA, Pain 8 What is the most concerning to you and why?
pain level but notice that SpO2 and RR are on the low end and HR is high
What is the most reliable indicator of pain?
patient's self-report
contact precaution
prevent transmission of infectious agents by direct or indirect contact. Common pathogens that require clients on Contact precaution, include Vancomycin-resistant enterococcus (VRE), C diff, Noroviruses, other intestinal tract pathogens, respiratory syncytial virus (RSV). Other situations including: large amounts of wound drainage, fecal incontinence etc. Nurse should have PPE (gown and gloves at minimum).
Surgical Asepsis
prevent transmission of pathogens to the client and protect the client from surgical-site infections. That is, postsurgical infections that arise in either the incision, the tissue around the incision, or the organs. - STERILE TECHNIQUE
Factors increasing host susceptibility:
usually has compromised immune system (such as age, underlying disease including HIV/AIDS, malignance, transplant; medications such as immunosuppressants, antineoplastics, antimicrobials, corticosteroids, gastric suppressants (PPI), indwelling device, procedures, radiation therapy etc. )
•Chronic Pain
sudden or slow onset of any intensity and is constant or recurring without an anticipated or predictable end. Pain has a duration for lasting longer than six months. Examples include arthritis, back pain, and headaches.
What is the first sound heard when taking a manual BP?
systolic
airborne precaution
the client should be assigned to a private room; door should be always closed. A negative-pressure room is preferred. The nurse should wear a respirator or mask (N95 or higher) prior to entering the room.
What's the pulse's strength grading scale?
•0 = Absent, unable to palpate •1+ = Diminished, weaker than expected •2+ = Brisk, expected •3+ = Increased, strong •4+ = Full volume, bounding
stress crisis coping
•the mental, emotional, or physical response and adaptation to real or perceived changes and challenges. •an emotionally significant life event or major changes in an individual's life that pushes the person well beyond their ability to effectively cope. •the strategies that an individual adopts to deal with a stressor.
