Respiratory
A high-pitched sound heard on inspiration caused by upper airway obstruction.
Stridor
The correct head-of-bed elevation for Fowler’s position
30-60 degrees
A common sign of a urinary tract infection in an older adult
confusion or disorientation
An opening into the ileum rather than the colon
What is an ileostomy?
This charting format includes subjective, objective, assessment, and plan.
What is SOAP charting?
The nurse should use this assessment method to determine whether a patient with a tracheostomy needs suctioning
Auscultating Breath Sounds
This is the nurse’s priority assessment when a patient dangles at the bedside for the first time after bed rest.
assessing for orthostatic hypotension, dizziness, or nausea
Running water in the sink helps stimulate this physiologic response.
What is initiating urination
This stool characteristic suggests the presence of occult blood
What is black, tarry stool (melena)?
This documentation best describes pain using objective and subjective data.
What is “Periumbilical sharp pain rated 7–8 for 3 hours, no relief from antacids”?
This oxygen flow rate should generally not be exceeded in a patient with COPD.
1-2 L/min
The safest action when moving a 250-lb immobile patient with unilateral weakness up in bed
using a lift sheet and additional assistance
The type of urinary incontinence caused by nerve damage after spinal cord injury
What is reflex incontinence
The nurse should immediately report this stoma assessment finding.
What is a pale stoma?
This information belongs on the face sheet.
What is patient identification, insurance, and admitting diagnosis?
This suction pressure range is appropriate for oral suctioning in an adult patient.
80-120 mmHg
This finding indicates altered perfusion during a neurovascular check
numbness of the distal limb
Normal urinalysis findings include this color and this specific gravity
What are straw-colored urine and a specific gravity of 1.015
During digital removal of fecal impaction, this vital sign change requires stopping the procedure immediately.
What is a drop in pulse rate (bradycardia)?
When a patient refuses blood work, the nurse documents this.
What is “Refuses to have blood drawn; states tests are ‘useless.’ MD notified”?
In older adults, these age-related respiratory changes increase the risk for complications
impaired cilia, thinning alveolar membrane, incomplete expiration, and decreased oxygen saturation?
When ambulating with crutches on stairs, the nurse teaches the patient this technique
up with the good leg first
This nursing action helps prevent recurrent cystitis
What are increasing fluids, wiping front to back, wearing cotton underwear, emptying bladder every 2–3 hours, and avoiding wet bathing suits?
The ostomy drainage bag should be emptied at this level to prevent complications.
What is when the bag is one-half full?
This is the correct response when a patient leaving AMA demands the original medical record.
What is explaining the record belongs to the facility and offering a copy?