vital signs
What is the expected range for heart rate?
60-100 bpm
what is objective data vs subjective data
objective- what the nurse sees (via physical assessment, general survey, lab results)
subjective- what the patient tells you (pain, history, chief complaint)
how long should you wash your hands for
approx. 15 secs
what are the four techniques (in correct order)
inspection
palpation
percussion
auscultation
Which finding is considered to be subjective?
A) temperature of 101.2 F
B) pulse rate of 96 beats/min
C) measured weight loss of 20 pounds since the previous measurement
D) Pain lasting 2 hours
D) Pain lasting 2 hours
What is the expected blood pressure
120/80 mm Hg
what is autonomy
the right of the patient to make their own decisions of their body
when should you wash your hands
entering/exiting a patient's room, when soiled
In what system does the order of techniques change? Why? What is then the order?
Gastrointestinal. Order: Inspection, auscultation, palpation, percussion. Changes order because palpating before ausculating can change bowel sounds
You are reviewing concepts related to steps in the nursing process for determining prioritization and developing patient outcomes. To what are these actions attributed?
A) Planning
B) Assessment
C) Implementation
D) Diagnosis
A) Planning
What is the expected range for temperature
96.8-100.4
what does each letter in "OLDCARTS" stand for
O- onset
L- location
D- duration
C- characteristics
A- alleviating/ aggrevating factors
R- related symptoms
T- treatments
S- severity (scale 0-10)
when should you use gloves
when there is blood or other infectious disease present
what is the purpose of percussion?
Locate organ borders, identify organ shape and position & determine if an organ is solid or filled with fluid or gas
A patient says she is very nervous and nauseated, and she feels like she will vomit. This data would be what type of data?
A) Objective
B) Reflective
C) Subjective
D) Introspective
C) Subjective
95%-100% (room air or O2)
what are the pulse points, show where
radial
temporal
carotid
apical
brachial
femoral
popliteal
posterior tibial
dorsalis pedis
demonstrate how to properly put on/ take off gloves
put gloves on
take off first glove grabbing the band, pulling it down and put it in other hand
go underneath second glove and pull off
why do we inspect first?
to get a general idea of what is going on (skin, emotion, any source of blood etc.)
A nurse assesses an oral temperature for an adult patient. The patient's temperature is 37.5°C (99.5°F). What term would the nurse use to report this temperature?
a. Febrile
b. Hypothermia
c. Hypertension
d. Afebrile
D. Afebrile
What is the expected range for respirations
12-20 breaths/min
what is the order of the nursing process
1. assessment
2. analysis
3. planning
4. implementation
5. evaluation
demonstrate how to properly wash your hands
despense paper towel
turn on water
get soap
wash for 15 secs
rinse with fingers down
grab paper towel and dry well
turn off water with paper towel
demonstrate how to palpate
.
Which vital sign measures the force of blood against the walls of arteries during contraction of the heart?
a. pulse oximeter
b. blood pressure
c. respiratory rate
d. pulse
B. Blood pressure