Vital Signs
The UAP reports a temperature of 37.1 C (98.8 F), pulse 92/minute, respiratory rate of 18/minute, and BP 98/55 mmHg. What should be done next?
The nurse should assess the patient & reassess the BP.
In what order do you perform an abdominal assessment?
Inspect
Auscultate
Percussion
Palpate
What qualities should you identify when assessing peripheral pulses?
Rate
Regularity
Strength
Equality (compared to the other side)
How are drug-resistant organisms formed?
Using antibiotics for non-bacterial infections.
Using inappropriate antibiotics to treat a bacterial infection.
Not completing the full prescribed course of antibiotics.
What are the 5-P's used to describe characteristics of circulation in the extremities
Pain
Pulse
Pallor
Paresthesia
Paralysis
Name 3 ways (other than orally) that you can assess body temperature.
Axillary
Tympanic
Temporal
Rectal
Invasive vascular lines
Skin probe
What is the anatomical landmark for auscultating the pulmonic valve?
2nd intercostal space, left sternal border
Describe the location of the popliteal pulse.
Posterior at the knees.
What is the difference between medical & surgical asepsis?
Medical - confining/preventing microorganisms to prevent transmission, using "clean" techniques, avoiding cross-contamination with "dirty" objects.
Surgical -sterile technique that keeps an area or object free of all microorganisms for procedures & surgery
Name 3 common spinal alignment anomalies.
Kyphosis
Scoliosis
Lordosis
What inaccuracy occurs when a BP cuff that is too small or too large used?
Large - falsely low reading
Small - falsely high reading
What lung sound could be described as a high-pitch whistling & what is occurring when it's heard
Wheezing
What are the four terms used to describe the strength of a peripheral pulse?
Absent (0)
Diminished (1)
Normal (2)
Bounding (3)
What main steps should be taken after initial flushing/washing occurs when you have a blood-borne exposure like a needle stick injury or splash?
Get consent & test patient for Hepatitis B, C, & HIV
Get HCW tested (with consent) for Hepatitis B, C, & HIV
HCW offered post-exposure prophylaxis when appropriate
Ongoing monitoring & psychological counseling as needed
What is the term used to describe the different rumbling sounds heard from digestion?
Borborygmi
What is the landmark for auscultating an apical heart rate in an adult?
Mid-clavicular, 5th intercostal space.
What do crackles (rales) sound like upon auscultation? What does it indicate?
What is the anatomical location of the posterior tibial pulse?
Medial side behind the ankles.
What different systemic methods does the body has/does to protect itself from infection?
Skin is a barrier.
The respiratory system (cilia/mucus) traps foreign bodies inhaled.
The GI system has its own bacterial flora & is acidic to prevent colonization of pathogens.
What does assessing visual accommodation mean?
Using a test like moving a finger between the eyes to assess pupil & movement equality of the eye structures (focus)
What is the terminology used to describe a respiratory rate < 12 in an adult?
Bradypnea
What are the 4 different possible bowel sound frequency terms?
Absent
Hypoactive
Normoactive (active)
Hyperactive
You are unable to palpate someone's radial pulse in one arm. What is your next intervention?
Assess the pulse with a Venous Doppler & report findings to the PCP.
What are the 2 types of immune response?
Innate immunity - immediate defense from antigens.
Adaptive immunity - long-term immunity after antigen exposure (humoral, cellular & immunologic).
What is the method for testing skin hydration & what would happen if a patient was dehydrated?
Skin turgor. Tenting.