Vital Signs
List four sites where a temperature can be taken (per ATI)
-oral
-rectal
-axillary
-temporal
List at least three therapeutic communication techniques?
-Active listening
-open-ended questions
-claryfying
-back-channeling
-probing
-closed-ended questions
-summarizing
What are three factors that cardiac output is determined by?
-Heart rate
-contractility
-blood volume
-venous return
What are we inspecting when we first assess the respiratory system (name at least three)?
-shape
-symmetry
-Intercostal space (ICS)-no retractions
-Respiratory effort
-cough
-trachea
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
1) Increased heart rate
2) Increased blood pressure
3) Increased respiratory rate
4) Increase hematocrit
1,2,3
Name four factors leading to bradycardia?
-Long-term physical fitness
-Hypothermia
-Medications
-Changing body positions
-Chronic, severe pain
-Hypothyroidism
-Relaxation
The difference between objective and subjective data and an example of each?
-Subjective is stated by the patient or a patient's family member and cannot be seen or measured
-Objective data are physical, measurable symptoms that can be evaluated by the nurse
What is does the pneumonic "MONA" stand for, and what situation do we apply it to?
Morphine
Oxygen
Nitroglycerin
Aspirin
Name at least two Adventitious Lung Sounds?
-crackles
-rales
-wheezes
-rhonchi
-stridor
-Pleural Friction rub
-Absence of breath sounds
A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
1) Check the client's vital signs.
2) Request a dietitian consult.
3) Suggest that the client rests before eating the meal.
4) Request an order for an antiemetic.
1
How do we (as nurses) measure and document the strength, or amplitude of a patient's pulse?
0=Absent
1+=diminished, weak
2+=Brisk, expected
3+=Increased, strong
4+=Full volume, bounding
List three of the five components of the General Survey?
-Physical Appearance
-Body Structure
-Mobility
-Behavior
-Vital signs
List the five auscultatory sites for the heart?
Aortic
Pulmonic
Erb's point
Tricuspid
Apical/mitral
Which adventitious lung sound requires immediate intervention?
what is stridor?
A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?
1) analgesic
2) anti-inflammatory
3) antiplatelet aggregate
4) antipyretic
4
The percent of the hemoglobin that is bound with oxygen in the arteries.
What is Oxygen Saturation (SaO2) of the blood?
Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature?
Dorsal surface
What position should the patient be in when you are measuring the jugular veins, and where on the patient do you measure Jugular Venous Pressure?
-Bed to 30-45 degree angle
-measure at less less than 2.5 cm (1 inch) above the sternal angle
When do systolic and diastolic murmurs occur?
systolic-after S1
diastolic-after S2
A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication?
1) Decreased blood pressure
2) Increase of HDL cholesterol
3) Prevention of bipolar manic episodes
4) Improved sexual function
1
A blood pressure that decreases when a client changes position from lying to sitting or standing, and can result from various causes, such as dehydration.
What is orthostatic (postural) hypotension?
List four of the eight Health History Components
-Demographic -source of history
-chief concern -history of present illness
-past health history -current health status
-family history -psychosocial history
-Health promotion behaviors
These are the five locations to listen for bruits.
-Carotid arteries
-Abdominal Aorta
-Renal Arteries
-Illiac arteries
-Femoral arteries
These are blowing or swishing sounds that indicate obstructed peripheral blood flow AND are measured with this side of the stethoscope.
What are bruits and they are auscultated using the bell
A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.)
1) Dyspnea
2) Bradycardia
3) Barrel chest
4) Clubbing of the fingers
1,3,4