Thin Skin
This scale evaluates risk for pressure injuries by scoring moisture, activity, nutrition, and more.
What is the Braden Scale?
Normal breath sounds heard over the outer lung fields.
What are vesicular breath sounds?
Tools used for inspection and palpation of a coated tongue.
What are gloves and a penlight?
Excess wax can cause this type of hearing loss.
What is conductive hearing loss?
Raised, firm red bumps less than 1 cm are this type of lesion.
What are papules?
A client weighs 175 lbs. Rounded to the nearest tenth, that’s this many kilograms.
What is 79.5 kg?
Redness on the sacrum after just 2 hours in bed is an early sign of this condition.
What is a Stage 1 pressure injury?
n abnormally slow rate (<12 breaths/min) is called this.
What is bradypnea?
The reflex where both pupils constrict when light is shined in one eye.
What is the consensual light reflex?
Asking about loud noise or music exposure helps assess this kind of loss.
What is sensorineural hearing loss?
Flat, discolored spots without elevation are known as these.
What are macules?
The provider orders 10 mg morphine; supply is 5 mg/mL. How many mL?
What is 2 mL?
A superficial blister or shallow ulcer with exudate describes this stage of pressure injury.
What is Stage 2 pressure ulcer?
A deep, rapid breathing pattern seen in diabetic ketoacidosis.
What are Kussmaul respirations?
Involuntary, rhythmic eye movements are documented as this.
What is nystagmus?
A buzzing or ringing sound in the ears.
What is tinnitus?
Small purple dots caused by broken capillaries are documented as these.
What are petechiae?
Order: 40 mg lisinopril. Tablets: 10 mg each. How many tablets?
What are 4 tablets?
These small, purple pinpoint spots on the legs indicate tiny vessel bleeding.
What are petechiae?
Crackles in the lower lobes suggest fluid from this type of condition.
What is pneumonia or heart failure?
Palpating just in front of the ears while the client opens and closes their mouth assesses this joint.
What is the temporomandibular joint (TMJ)?
Difficulty hearing in noisy environments, especially in older adults, often points to this age-related loss.
What is presbycusis?
A client reports a new mole that is getting larger. The nurse should use this guideline to describe its features before reporting.
What are the ABCDE criteria (Asymmetry, Border, Color, Diameter, Evolution)?
Infuse 500 mL over 5 hours. What is the pump rate?
What is 100 mL/hr?
Frequent repositioning, moisture management, and nutrition all work together as this type of intervention.
What is pressure injury prevention?
This finding on palpation signals lung consolidation, such as with pneumonia.
What is increased tactile fremitus?
Sluggish pupillary light response points to dysfunction of this cranial nerve.
What is CN III (oculomotor nerve)?
Dizziness and balance problems most often involve this cranial nerve.
What is CN VIII (Vestibulocochlear/Acoustic)?
What are the ABCDE criteria (Asymmetry, Border, Color, Diameter, Evolution)?
What is a sebaceous cyst?
A vial reads 25 mg/mL. The order is 75 mg. The nurse should draw up this volume.
What is 3 mL?