Head/Neuro
When assessing if a patient is AOX3, what 3 questions do they need to answer correctly?
Name
Date- Month/Year
Location- Hospital
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, raise eyebrows
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 bed bound patients?
Turn and reposition q2hr. Float heels
Name 6 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 in adult
12-20 breaths per minute
What are 2 subjective neurological complaints your patient may report?
Headache
Dizzy
Numbness/Tingling
Generalized Weakness
Where are the 2 best areas on the body to test hydration?
Collarbone area & back of hand
Whenever bathing patients, how often should this be done and what kind of soap should we use?
Daily and antimicrobial (CHG)
What is normal heart rate in an adult?
60-100 BPM
If a patient is complaining about SOB what is the most basic intervention you can do first?
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
Your patient reports chest pain upon assessment, what further questions do you want to ask?
Describe the pain.
When did it start?
does anything make it worse or better?
does it radiate?
What is the term for painful urination?
dysuria
What are the characteristics we are assessing with respirations
Rate, rhythm, & depth
What does PERRLA stand for?
Pupils Equal Round Reactive 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
What does FAST stand for in relation to stroke?
F-Face- uneven
A-Arm- weakness
S- Speech- slur
T- Time- Call 911
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 with swabs and brush teeth
What are the 2 types of edema?
Pitting- Push down on skin and leaves impression
Non-pitting- push down and "bounces" back
Upon entering your patient's room, they are diaphoretic and anxious, you check their VS and their pulse is 189. After alerting the MD, what test or lab can you expect to be ordered for this patient?
EKG and troponin
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 are the 5 lobes we are listening to for breath sounds?
RUL, LUL, LLL, RML, RLL
How can you assess a patient's EOMs?
Have them follow your finger or pen light
What does oliguria and anuria mean?
Oliguria- low urine output
Anuria- No urine output
How do you grade edema?
1+ 2mm indentation
2+ 4mm
3+ 6mm
4+ 8mm
A patient reporting decreased sensation in extremities can be a sign of what? Example: Patient reports n/t to RLE.
poor blood flow/perfusion to that extremity
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
Your patient reports a cough, what other information do you want know about the cough?
wet/moist
dry/harsh
Productive/Nonproductive- if productive, characteristics.