Vital Signs
Normal Heart Rate
60-100 bpm
Mr. S is complaining of pain in his chest, difficulty breathing, and a cough. What are these reports by the patient considered?
Subjective data
Rapid Breathing
tachypnea
After a Foley catheter has been removed, the nurse should assess the patient for:
urinary retention
When administering first aid in emergency situations, the nurse must first survey victims for severity of injuries. What term correctly describes this process?
..
Triage
Normal Respiratory Rate
12-20 Breaths per minute
The nurse is taking care of a patient with a leg wound. The nurse notices redness, swelling, and purulent drainage while completing the assessment and recognizes that these are cardinal signs of what process?
Infection
Without/no breathing
apnea
When explaining the difference between a colostomy and an ileostomy, the nurse explains which of the following about an ileostomy?
It drains semiliquid stool
The Good Samaritan law will protect all people who offer assistance. What is necessary for this protection?
The person acts prudently
Rapid Heart Rate
Tachycardia > 100bpm
The LPN/LVN is working on a medical floor and assisting the RN with patient assessments. A new patient is admitted to the floor and the RN takes a health history and performs an assessment. What is this considered the first step of?
The nursing process
A patient with a tracheostomy has been assessed and needs suctioning. How long will the nurse perform suction?
A maximum of 10 seconds
Before inserting a nasogastric tube, what measurement should the nurse take?
Tip of the nose to the earlobe to the xiphoid process
A nurse is assessing victims in an emergency situation. What will the nurse assess for first?
Abnormal breathing
Which center in the brain regulates body temperature?
Hypothalamus
Post cleft lip repair, there may be some scar contracture, redness and firmness in the surgical area. What two educational points should the nurse teach the parents?
What are: "Parents should gently massage the area, and avoid sunlight until the scar heals."
When an older adult patient with chronic emphysema comes to the emergency department in respiratory distress, at what rate should the nurse begin oxygen per nasal cannula?
2 L/min
(............) is the inability to control urine or bowel elimination and can be a psychologically distressing and socially disruptive problem, especially among older adults.
incontinenece
When assessing the adult victim for pulselessness, the CPR rescuer should palpate the most reliable and accessible pulse. Which pulse will be palpated?
Carotid
A patient has been admitted with syncope (fainting). The health care provider orders the patient to be tested for orthostatic hypotension. What is the best description of how to perform this test?
Taking a B/P lying, followed by sitting, then standing
While the nurse is performing a physical assessment, the patient complains of dyspnea. This symptom indicates a problem with which body system?
Respiratory
The nurse instructs a patient receiving home O2 therapy to drink plenty of fluids to help keep bronchial secretions liquefied. What is the recommended fluid?
Water
During insertion of a Foley catheter, the patient grimaces as the balloon is inflated. What is the immediate reaction of the nurse?
Advance the catheter into the bladder
The patient arrived at the emergency department in pain and bleeding profusely with the following vital signs: BP 80/54, P 102, RR 22. What does the nurse recognize that these symptoms indicate?
Circulatory shock