Vital Signs/ Assessment
Give 3 examples of objective data
vital signs, bowel sounds, lung sounds, etc
List 4 abnormal breath sounds
Crackles, Wheezing, Rhonci, Stridor
Name the different isolations and 2 examples of each
Contact-
Droplet-
Airborne-
Protective-
A nurse is preparing to administer codeine 20mg PO every 6 hours for PRN pain. Available is codeine oral solution 10mg/5ml. How many ml should the nurse administer per dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
10ml
Describe interventions to assess for and decrease risk of aspiration for PO and Enteral feedings
stroke, neurological, weakness, positioning, confusion
po- diet consistency, fluid consistency, positioning
enteral- 30 degree continuous, high fowlers for bolus
What would you expect vitals signs to be with fluid volume excess?
hypertension, tachycardia, tachypnea, no change in temp, possibly decrease in O2 sat
The nurse is auscultating a patient’s heart sounds. Which area is best for hearing the sound of the aortic valve?
2nd intercostal space, right of the sternum
Describe 5 things that can delay wound healing
Diabetes, smoking, obesity, malnutrition, presence of infection, immunocompromised, Cardiovascular disease
The doctor writes an order to infuse a solution. The order reads: "Infuse 300ml over 6 hours". What is the hourly rate (ml/hr)?
a. 50ml/hr
b. 100ml/hr
c. 1800 ml/hr
d. 90 ml/hr
a. 50 ml/hr
What are the 3 things an NG tube is used for?
Describe what they are.
Gavage, lavage, decompression
When assessing a clients radial pulse, you find the pulse to be irregular. What are your next steps? (Include pulse deficit)
Auscultate apical pulse for a full 60 sec
Pulse deficit- 2 RNs, 1 watch, start at same time, counting apical and radial pulse for 60 sec. Apical-radial = pulse deficit
Describe atelectasis and provide patient education
Collapsing of the alveoli
Incentive Spirometer- 10 x an hour
List the different types of pressure injuries and describe each one
Stage 1, 2, 3, 4
unstageable, deep pressure injury
The doctor writes an order to infuse a solution. The order reads: "Infuse 1500 ml/hr over 12 hours". The drip factor is 15 gtt/ml. How many drops per min (gtts/min) will be administered?
a. 95 gtt/min
b. 32 gtt/min
c. 31 gtt/min
d. 15 gtt/min
c. 31 gtt/min
Describe how you educate the patient.
List 3 factors that can affect each of the following:
Tachycardia, Hypotension, Increased Temperature
tachy- pain, increased temp, exercise, fluid volume deficit
hypotension- fluid volume deficit, vasodilation, sepsis, position changes
increased temp- infection, exercise, environmental, dehydration
Your patient has a murmur, how and where do you assess for this? And How do you know it's a murmur?
APETM
auscultation, whooshing sound
Describe concepts of setting up and maintaining a sterile field
examples
A nurse is preparing to administer meperidine 75mg IM stat. Available is meperidine injection 100mg/ml. How many ml should the nurse administer?
(Round to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero).
0.75 ml
Describe the process of giving an enema, include precautions
explain
Describe what the OPQRST is and provide a question you would ask you client with each?
O- Onset
P- Palliative
Q- Quality
R- radiation
S- Severity
T- Timing
Describe what is included in a Cardiovascular assessment.
Color of skin
BP, HR, Heart sounds, pulses, JVD, thrills and bruits, capillary refill, edema
Complications of wound healing
List each one and describe who is at risk and 2 interventions for each
Hematoma
Dehiscence
Evisceration
The doctor writes an order to infuse a solution. The order reads: "Infuse 500 ml bag at 20 gtt/min". The drip factor is 10 gtt/ml. You start the IV infusion at 0500. At what time will the infusion be complete?
a. 0630
b. 0853
c. 2210
d. 0910
d. 0910
Describe the process of initiating an Enteral feeding.
explain