Exam 1
what is the order of assessment technique for a head to toe?
inspection, palpation, percussion, ausucultation
what techniques does the nurse use to assess the ear?
inspection and palpation
order is for 40 mg daily. available is 10mg/tablet. how many tablet will the nurse administer?
4
what pulses when assessing cardiovascular system can you assess bilaterally?
pedal, radial, brachial,
hyperactive bowel sounds
if client reports pain medication not working and pain scale 10/10, which assessment finding (v/s) could indicate this?
increased blood pressure and pulse, respiratory
a client with skin breakdown is likely to have what kind of lesion
ulcers
pressure ulcer
order to run fluids at rate of 175mL/hr. drop factor is 15 gtt/mL. what is the drip rate? round to whole number
44
when assessing a client's orientation status, what might the nurse ask the client
(anything that asks about client's name, place, time, situation)
when performing an abdominal assessment, the nurse will ask the client to do what first?
empty the bladder
urinate first
what is the best way to determine the severity of a client's pain?
pain scale
ask the client their pain level
client's breath sounds are a snoring like wheeze. this is called what?
rhonchi
order 300mg over 20 mins. available is 300mg/50ml. what is the infusion rate ______ml/hr
150
which heart valve is located between the left atrium and left ventricle?
mitral valve
when assessing a client's deep tendon reflex by testing their Achilles reflex, the nurse should expect what response from the client?
plantar flexion of the foot
out of the following report, which subjective information received is of most concern: client reports pain to their leg with numbness. vitals are: heart rate 111, BP 105/65, RR 25, o2 93% room air.
pain in the leg with numbness is subjective data
what might be a sign of acute respiratory distress in a client with asthma?
shortness of breath
difficulty talking
tachypnea/elevated respiratory rate
low oxygen levels
2200 (10pm)
a nurse is taking care of a client who cannot report pain due to being cognitively impaired. what action should the nurse take when assessing client's pain level
observe for nonverbal signs of pain
the nurse understands that a client with liver failure may present with jaundice of the skin and sclera due to what?
a buildup of bilirubin
what is the correct sequence for a head-to-toe assessment:
general survey-head and neck-chest-abdomen-lower extremities.
a client reports a headache, using OPQRST, what questions would you ask
onset
precipitating factors
quality-describe pain
region-location of pain
severity-rate pain
t-treatment for the pain
order for 15mg/kg every 12 hours. client weight is 12kg. strength of med is 250mg/5 ml. how many mL will the nurse administer per dose? round to tenth place.
3.6
what is the mnemonic for stroke AND what is the definition of each
F-facial drooping
A-arm weakness
S-speech
T-timing
the nurse is teaching a client about self breast exams, what should the nurse teach the client
perform 7-9 days after period
positions: standing leaning forward, sitting hands on hips, above head, arm to side.
stand in front of mirror
inspect and palpate whole breast
use pads of fingers
perform in shower warm soapy water