Nurse Health Skills
What is the normal adult resting respiratory rate?
12–20 breaths per minute.
A nurse is assisting a patient with limited mobility to move from the bed to a wheelchair. The patient begins to feel dizzy when sitting at the edge of the bed.
What should the nurse do first?
Have the patient sit at the edge of the bed longer, assess vital signs, and ensure safety before attempting the transfer to prevent a fall.
This term refers to all fluids a patient consumes orally, such as water, juice, and soup.
Intake
A patient drinks a full 8 oz cup of water with breakfast.
Question:
How much intake should the nurse document in milliliters?
240 mL
What do the following mean:
- Anatomy
- Physiology
- Pathophysiology
- Study of form and structure of organisms
- Study of processes/function of living organisms
- Study of how disease occurs and body’s response
Why is hand hygiene considered the most important nursing skill in patient care?
It prevents the transmission of microorganisms and reduces healthcare-associated infections.
A nurse is measuring a patient’s blood pressure for a routine assessment. The patient asks why it needs to be checked every day.
What is the nurse’s best response?
Checking blood pressure regularly helps monitor heart health and detect changes early.
This type of output is measured using a bedpan or urinal and recorded in milliliters.
A patient receives 500 mL of IV fluids and drinks 1 cup (240 mL) of juice during the shift.
Question:
What is the patient’s total intake for the shift?
740 mL
What are the 7 stages of life?
Infancy: birth to 1 year
Early childhood: 1–6 years
Late childhood: 6–12 years
Adolescence: 12–18 years
Early adulthood: 19–40 years
Middle adulthood: 40–65 years
Late adulthood: 65 years and older
This position is used to prevent aspiration when feeding a patient with swallowing difficulties.
High fowlers position
A nurse is preparing to administer insulin. What three safety checks must be completed before giving the medication?
Verify the correct patient, correct insulin type and dose, and correct timing/route (also checking blood glucose levels).
This minimum amount of urine output per hour indicates adequate kidney function in an adult.
30 Milliliters per hour
During a 12-hour shift, a patient has the following output: urine 900 mL, emesis 150 mL, and wound drainage 100 mL.
Question:
What is the total output?
1,150 mL
What was Maslow's hierarchy of needs?
A psychological theory proposing humans are motivated by five levels of needs, arranged in a pyramid.
This term describes redness, warmth, swelling, pain, and loss of function at a wound site.
Inflammation
A postoperative patient suddenly becomes short of breath, tachycardic, and anxious. What nursing assessment and action should be prioritized first?
Assess airway and oxygen saturation immediately and administer oxygen, as this may indicate a pulmonary embolism.
This intake source must be included in I&O documentation even though it is not taken by mouth.
Correct Response:
IV fluids
A patient on strict intake and output has consumed 1,800 mL in 24 hours. Output is 1,000 mL. The patient has gained 1.5 kg overnight and has mild ankle edema.
Question:
What should the nurse do next?
Report the findings to the provider because the patient is retaining fluid.
This gross motor milestone is usually achieved by most infants around 12 months of age.
Walking independently
This pulse site is used to assess circulation during cardiopulmonary resuscitation in adults.
Carotid pulse
A patient with sepsis shows a blood pressure of 84/50 mmHg, urine output of 15 mL/hr, altered mental status, and a lactate of 4.2 mmol/L. Using nursing judgment, what interventions should be initiated immediately and why?
Initiate sepsis protocol: administer IV fluids, oxygen, obtain blood cultures, administer broad-spectrum antibiotics, and notify the provider because the patient is in septic shock and requires rapid intervention to prevent organ failure.
An adult patient has a urine output of 20 mL per hour for several hours. This finding is most concerning for this condition related to fluid balance.
decreased kidney function (or inadequate urine output/oliguria)?
A patient with kidney failure has an order for fluid restriction of 1,200 mL/day. By noon, the patient has consumed 900 mL. The patient requests more water and has dry mucous membranes.
Question:
What is the nurse’s best action and why?
Educate the patient on spacing fluids and adhere to the restriction while providing mouth care, because exceeding the limit can worsen fluid overload and compromise renal function.
This stage of Erikson’s psychosocial development focuses on developing independence and typically occurs during toddlerhood.
Autonomy vs. Shame and Doubt