Head to Toe Assessment
Sterile Dressing Change
Catheter Care
Cardiac
Grab Bag
100
How many different subjective assessment questions do I need to ask my patient?
7 (related to the system)
100
How do you clean a wound?
Top to bottom / center to outside
100
What position should the patient be in for a catheter insertion?
Dorsal recumbent
100
What are the five auscultation points of the heart (that you need to listen to on your head to toe)?
Aortic, pulmonic, Erb's, tricuspid, mitral
100
How do you auscultate the abdomen?
Start in the RLQ, go clockwise through all 4 quadrants
200
How many minutes do you have to do both parts of the head to toe?
20 minutes for the assessment, 25 for the write up
200
When cleaning your wound, when do you need to get a new piece of gauze?
With each swipe over the wound
200
Before you open the catheter tray, after explaining the procedure, what should you verbalize that you would do?
Perineal care
200
What does jugular venous distension indicate?
Heart failure
200
If I had significant swaying during my Romberg test, was it positive or negative?
Positive
300
How should you document the patient's chief complaint?
In quotation and in the patient's own words
"I have a headache"
"My tummy hurts"
300
What supplies do you need on your sterile field?
Basin, sterile water in basin, 4x4s, abd pad, gauze for cleaning
300
How far in should you put the catheter?
Until you get urine, and then an inch or two more
300
Name 3 symptoms of arterial ulcers
Pain, cool to cold skin, dry/shiny skin, pale skin when legs are elevated, delayed cap refill, loss of hair, thick and ridged nails
300
Where are the DP and PT pulses / what do DP and PT stand for?
(Don't feel through socks)
400
In regards to the lungs, what must you assess on your patient?
Lung sounds (anterior posterior and lateral), respiratory rate, rhythm, and effort
400
What is the last thing you need to do before you lower the bed down and do your active learning template?
Label the dressing with your initials, the date and the time
400
What are potential complications of insertion of a urinary catheter?
____ ? this is on your active learning template
400
Name 3 symptoms of venous insufficiency
Thick and tough leathery skin, reddish-blue or brown skin, edema, aching and cramping, varicose veins,
400
What 4 questions can you ask to assess LOC?
Person - What's your name?
Place - Where are you?
Time - What day is it?
Situation - What brought you into the hospital?
500
When you have your patient stand during the assessment, what will you assess for?
Gait, balance, and Romberg
500
What are the things that you are inspecting the wound for / doing to the wound when you take off the old dressing?
Inspect the wound/incision site for size, color, appearance, temperature & drainage. Inspect and lightly palpate the peri-wound
500
How do you clean your patient with the sterile swabs?
For a male, in circles around the meatus and then the last swab directly over the meatus
For a female, clean the labial fold top to bottom left of the meatus, then the right, and then the last one goes directly over the meatus
500
Name 3 interventions to prevent DVTs
Ted hose, SCDs, heparin, ROM exercises, hydration, turns in bed
500
What does COLDSPA stand for?
C: characteristics
O:Onset
L: Location
D:Duration
S: Severity
P: Pattern
A:Associated Factors