Vital Signs
What is considered a normal Heart Rate?
60-100 BPM
What term is used when the Heart Rate is greater than 100 BPM?
Tachycardia
How many listening locations are there when listening to the lungs: Anterior, posterior, and laterally?
10 anterior
10 posterior
1 left lateral
2 right lateral
What is the medical term for vomit?
Emesis
Name 3 possible abnormal objective assessment findings with the Genitourinary System.
Foul smelling urine, cloudy urine, pink/red urine, kidney stones in urine, flecks in the urine, low urine output.
What is the normal pain rating scale?
0-10
Name at least 2 abnormal objective cardiac assessment findings.
Murmur, Gallop, Friction Rub, Irregular rhythm.
Name at least 2 abnormal lung sounds.
Crackles, Wheezing, Ronchi, Stridor, Coarse, Absent.
How many areas do you listen to bowel sounds and how long do you listen for at each site?
4 quadrants- 1 min per quadrant
What are at least 2 subjective assessment complaints r/t urination?
Frequency, burning, urgency, suprapubic tenderness
What is a normal SpO2 with oxygen delivery method?
>95% on Room Air
Name the 5 listening points of the heart.
Aortic, pulmonic, tricuspid, mitral, and Erb's point areas
Name at least 3 oxygen delivery devices.
Room air, simple mask, venturi mask, non-rebreather, ambu bag, ventilator.
What is the correct order to assess the abdomen in?
Inspect, Auscultate, and Palpate.
What are symptoms of dehydration?
Low urine output, dark yellow/amber/concentrated urine, potent smelling urine, urinating fewer than 4 times a day, worsening kidney function, decreased skin turgor.
Name at least 2 non-pharmacological ways to improve pain.
Heat, Ice, Meditation, Massage, Guided Imagery, Relaxation Techniques.
Name at least 3 abnormal subjective assessment findings for the cardiac system.
Chest pain, SOB, Palpitations, Edema, Syncope, Cold Fingers/Toes, Calf Pain, Dizziness/Lightheadedness.
What are 2 interventions to prevent a patient from getting pneumonia while hospitalized?
IS, Cough and deep breath, ambulation, HOB elevated
What are non-pharmacological ways to promote bowel function?
Ambulation, increasing fluid intake, high fiber diet, abdominal massage, leaning forward on the toilet.
What is the term for a stoma in the abdominal wall that redirects urine away from the bladder?
Urostomy
If you walk into a patient room and the heart rate is reading 0 BPM. What is the first thing you do?
Palpate the carotid artery for a pulse, Call a Code Blue, and pull the emergency cord.
If a patient becomes lightheaded/dizzy, name 2 nursing interventions.
Have the patient either sit down or lay down, obtain VS (specifically BP and HR), page the physician, note urine output, orthostatic blood pressures.
The patient is having DIB, SpO2 is 85% on 6L of oxygen delivered via a simple mask. The goal SpO2 for this patient is an SpO2 greater than 92%. What should you do?
Put the patient on a non-rebreather. Page/re-page the physician.
Name 3 subjective assessment questions for the gastrointestinal assessment.
Pass flatus, last bowel movement, nausea/vomiting, abdominal pain, appetite.
You have taken your patient to the bathroom 4 times in a 60-minute period. Each time the patient voids approximately 25-50 ml. What should the nurse do next?
Page the physician since this is a sign of a UTI.
Obtain a urine sample for a UA and Urine Culture.
Ensure to maintain appropriate peri-care during hospital stay.