HA and VS
This technique of physical assessment always comes before palpation when examining the abdomen.
What is auscultation?
This process involves rhythmic contractions of intestinal muscles that move waste through the digestive tract.
What is peristalsis?
This serves as a roadmap for patient care and a necessary tool for following the nursing process.
What is a nursing care plan?
This term refers to the clinical indication for a drug or its intended action.
What is a therapeutic class?
A patient with tuberculosis must be placed on this type of precaution and anyone entering must wear an N95 respirator.
What are airborne precautions?
This temperature site is considered the most accurate core body temperature, but has several contraindications such as low platelet count or rectal surgery.
What is the rectal temperature site?
This type of incontinence occurs when a person cannot reach the toilet due to environmental barriers, physical limitations, memory loss, or disorientation.
What is functional incontinence?
This term describes the expected result or end point of a patient's health issue.
What is a patient outcome?
This device delivers a controlled dose of medication with each compression of the canister.
What is a metered-dose inhaler?
Used for procedures such as catheter insertion or operating room surgeries, this form of asepsis aims to eliminate all microorganisms.
What is surgical asepsis?
This vital sign must be assessed if the peripheral pulses are difficult to assess, irregular, weak, or very rapid OR in children less than 2 years old.
What is the apical pulse?
This urinary catheterization method involves inserting a catheter to drain urine and then immediately removing it, often used for retention or bladder-emptying issues after surgery.
What is intermittent catheterization or straight catheterization?
This type of assessment gathers data about a specific health problem rather than the whole patient.
What is a focused assessment?
This process involves comparing current medication orders to what the patient reports taking, the chart, or pharmacy records.
What is medication reconciliation?
This term refers to the natural area where a pathogen lives, grows, and multiplies - examples include people, animals, soil, and water.
What is a reservoir?
These small, pinpoint, round red or purple spots on the skin are caused by capillary bleeding.
What are petechiae?
This skin condition results from prolonged contact with urine or feces and is characterized by redness, maceration, denuding, and inflammation in areas such as the perineum, buttocks, inner thighs, sacrum, and coccyx.
What is incontinence-associated dermatitis?
This type of nursing clinical judgment identifies the likelihood that a patient will develop negative health effects due to a health condition or life situation.
What is a risk nursing diagnosis?
To locate this intramuscular injection site, place three fingers from the edge of the acromion process, form an imaginary triangle, and inject in the center.
What is the deltoid IM injection site?
This stage of pressure injury involves partial-thickness skin loss with exposed dermis. The wound is shallow with a pink or red, viable wound bed and may appear as an intact or ruptured blister.
What is a stage II pressure injury?
This adventitious breath sound is caused by air moving through narrowed airways and is often heard in patients with asthma.
What is a wheeze?
This program manipulates controllable factors such as diet, fluid intake, exercise, and timing to create soft, formed stools without the need for laxatives.
What is a bowel training porgram?
During this phase of the nursing process, planned evidence-based actions are carried out to help the patient achieve their health goals.
What is the implementation phase?
A patient experiencing respiratory distress and bronchospasm due to a medication is an example of this type of event, which is an unintended harmful effect from a drug that can cause injury.
What is an adverse drug event?
This complication occurs when an abnormal passage forms between two internal organs, vessels, or from an organ to the outside of the body.
What is a fistula?