Head
When the nurse asks the neurologically impaired patient to follow the motion of the nurse's fingers, the patient's eyes track the fingers with jerking movements, which should be documented as
NYSTAGMUS
What is normal capillary refill
less than 3 seconds
What is expected color of mucous membranes?
PINK
Where is apical pulse?
Left 5th intercostal space mid-clavicular
When listening to bowel sounds, where should the nurse auscultate first?
RLQ
A nurse is caring for a patient on bed rest admitted for pneumonia. On what body system will we do a focused assessment?
Respiratory
Auscultation of lungs
how can the nurse assess for facial symmetry?
ask client to smile, puff out cheeks
When testing for hydration you pinch your patients collarbone, this is assessing what?
Skin Turgor
What is the best way to help prevent skin breakdown in patients?
Turn and reposition q2hr. Float heels
Name 9 pulse sites?
Temporal, Carotid, Brachial, Radial, Apical, Femoral, Popliteal, Posterior tibial, Dorsalis Pedis, Pedal
How can you assess a clients strength in BUE and BLE
Squeeze fingers, push and pull away.
Plantar and Dorsiflexion
Normal Respiratory rate
12-20 breaths per minute
when assessing hair for lice or parasites always wear
gloves
Where is the best areas on the body to test hydration?
hydration- Collarbone area, back of hand
When caring for a patient with a stage 4 wound, what would you expect to see?
eschar, slough, maceration, full thickness loss
What is normal heart rate in an adult?
60-100 BPM
If a patient is complaining about SOB what is basic intervention you can do?
Raise HOB
What is normal o2 Saturation for an adult?
95-100% R/A
Normal size of pupils is?
Between 2-3mm
Where is the best place to test capillary refill?
Nailbed
Bluish skin color due to decreased amounts of oxygen.
Cyanosis
How do you grade a pulse?
0=absent
+1= weak/thready
+2= normal expected
+3=increased
+4 bounding
Percussion is a technique by which the nurse can assess sounds relative to the underlying structures that indicate the presence of:
air or fluid
What are the characteristics we are assessing with respirations
Rate, rhythm, & depth
What does PERRLA stand for?
Pupils Equal Round React Light Accommodation
What is the minimum urinary output per hour for an adult?
30ml/hr
You notice your patient has a black and blue mark on their right rib, what nursing term will you select to chart this finding?
Ecchymosis
what are the two sounds you hear when listening to an apical pulse
S1-S2- lub-dub
What are the ABCs?
Airway, Breathing, Circulation.
whistling sounds in lobes of lungs
may indicate asthma or allergic reaction
Wheezing
When you inspect & palpate hair what are you checking
Hair color, distribution, baldness, presence of lumps, lesions, / parasites
If you have a patient who is NPO, what should you be sure to do for the patient to help keep mucous membranes moist?
provide oral care
What are 2 types of edema?
Pitting & Non-pitting
if pulse is less than 60 what is this called
bradycardia
The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes spontaneously, obeys all commands, and is oriented. The nurse documents a score of
15 best score
what is it called when respirations less than 12
bradypnea
How can you assess a patient's EOMs
Have them follow your finger or pen light
How do you perform orthostatic B/P?
Taking B/P & Pulse
lying, standing, sitting
How do you grade edema?
1+ 2mm indentation
2+ 4mm
3+ 6mm
4+ 8mm
What is Apical pulse greater than 100
tachycardia
When examining a patient's pupils with a light, the nurse notes that one pupil reacts to light while the other does not. What part of PERRLA is abnormal?
Reactive to light
Another name for not breathing
apnea