Vital Signs
Name 3 terms for elevated temperature
100 pt Bonus: What is the normal body temperature in degrees Celsius?
Fever, pyrexia, and febrile
100 pt Bonus: 37 degrees Celsius
The doctor has ordered a CBC w/diff. What is this?
100 pt Bonus: What is the position the patient should be in to be given an enema?
Complete blood count with differential, which is the types and numbers of WBCs
100 pt Bonus: Left Sims; L side-lying with R hip and knee flexed
What position is the patient's bed to be left in for safety?
100 pt Bonus: What must the nurse do first when making an occupied bed?
Low position with wheels locked
100 pt Bonus: Check the order. Get the pt up if bedrest is not ordered
What does ADH stand for?
100 pt Bonus: What does it do?
Anti-diuretic hormone
100 pt Bonus: It tells the kidney to reabsorb water instead of excreting it as urine
What is the normal range for serum pH?
100 pt Bonus: What are the 2 main mechanisms of control for serum pH?
7.35-7.45
100 pt Bonus: The lungs and the urinary system (kidneys)
Name 2 nursing interventions for orthostatic hypotension (postural hypotension)
100 pt Bonus: What is the heart rate for tachycardia?
Have the patient dangle at the bedside before standing; Provide TED hose (compression socks) before standing
100 pt Bonus: Above 100 bpm
Name 2 blood chemistry tests that are performed to determine liver function.
200 pt Bonus: Name 2 blood chemistry tests performed to determine heart function
Bilirubin, AST, ALP, ALT, albumin, and total protein
200 pt Bonus: LDH (lactated dehydrogenase), creatine kinase (CK), and troponins
Name 6 things in the patient's environment that are under the nurse's control
200 pt Bonus: Name the 3 most common factors that predispose a patient to falls
Temperature, odor, noise, humidity, lighting, ventilation, neatness, and privacy
200 pt Bonus: Impaired physical mobility, altered mental status, and sensory and/or motor deficits
What is the best route to deliver hydration to a patient?
200 pt Bonus: Why is this true?
The oral route is best
200 pt Bonus: Because water is more readily available to the cells when given by the oral route than by any other route (like IV)
Your patient is taking opioid medications. Her serum pH is 7.30. She is likely experiencing which acid-base imbalance?
200 pt Bonus: Why do opioid medications lead to this condition?
Respiratory acidosis
200 pt Bonus: Narcotics depress respirations leading to carbon dioxide retention
Name 3 factors that may affect body temperature
200 pt Bonus: Name 5 palpable pulse points
Time of day, environmental temp, pt's age, physical exercise, menstrual cycle and pregnancy, emotional stress, disease conditions, and drugs
200 pt Bonus: Temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis
What does PT/INR stand for?
200 pt Bonus: What does this test measure and why is it done?
Prothrombin time/International normalized ratio
200 pt Bonus: Measures blood clotting time to adjust dosages of coumadin (warfarin)
Name the 4 categories of priority care in triage
200 pt Bonus: What do the categories mean?
Immediate: requires life-saving care
Delayed: requires major care that can be briefly delayed
Minimal: those with minor injuries
Expectant: unlikely to survive even with medical care
Put these patients in order from the greatest amount of body water by weight to the least: obese female, adult male, older adult, infant, adult female
200 pt Bonus: The adult male body contains about ____% of water
Infant, adult male, adult female, obese female, older adult
200 pt Bonus: 60%
Your patient confides in you that he is taking Tums every 2 hrs. He is restless and experiencing muscle twitching. Which acid-base imbalance is he experiencing?
200 pt Bonus: What effect does this condition have on the body if it progresses.
Metabolic alkalosis
200 pt Bonus: Tetany (severe muscle cramps & spasms), seizures, coma
Name 3 changes that occur in vital signs with aging
200 pt Bonus: What is the most accurate noninvasive way to measure body temperature?
A lower normal temp, Fever is less likely to develop, Slightly irregular heart rhythm (HR does not change), Slight increase in respiratory rate, Slight increase in systolic BP
200 pt Bonus: Using a temporal artery thermometer
Patients receiving bowel prep for colonoscopy and/or enemas are at risk for what 2 adverse effects?
200 pt Bonus: What 3 medications must be held prior to colonoscopy
Dehydration and electrolyte imbalance
200 pt Bonus: Iron, aspirin, and anti-inflammatory meds like motrin (ibuprofen)
Name 4 actions that promote safety in the home
100 pt Bonus: How can a nurse avoid alarm fatigue?
Nonskid bath mats, night lights, grab bars in the bathroom, handrails on stairs, remove extension cords, reduce clutter, keep furniture placement constant, use door & bed alarms, avoid napping
100 pt Bonus: Answer alarms promptly
Name 3 ways the body loses fluid
200 pt Bonus: Name the electrolyte
Water follows _____ concentration in the body
Through urine, feces, expired air, perspiration, vomiting, and hemorrhage
200 pt Bonus: Sodium
Name 3 s/sxs of metabolic acidosis
200 pt Bonus: What is the most common cause of metabolic alkalosis?
Kussmaul respirations, headache, confusion, malaise
200 pt Bonus: diuretic administration
What is stroke volume?
100 pt Bonus: What is cardiac output?
The amount of blood pushed into the aorta with each heartbeat
100 pt Bonus: HR X stroke volume; the amt of blood pumped by the L ventricle in 1 minute
Name 2 contraindications for your patient before going to a treadmill stress test
100 pt Bonus: What might a woman be asked to do to prep for an abdominal ultrasound?
No smoking or caffeine 4 hours prior to the test
100 pt Bonus: Drink a liter of water
Name 3 nursing interventions necessary when a patient has a protective device
200 pt Bonus: Name 3 s/sxs of neurovascular compromise when a pt has a protective device
Assess pulses distal q 15-30 min; ensure 2 fingers fit Q 2 hrs offer food, toileting, ROM, reposition Continually eval the need for the device
200 pt Bonus: Skin pallor, coolness, absent distal pulses, increased capillary refill, c/o numbness, or pain, edema, loss of sensation
Your patient has N/V/D. What changes in vital signs can you expect to see?
200 pt Bonus: Which electrolyte levels should the nurse be concerned about?
In dehydration, temperature might be elevated, pulse will increase and become weak, blood pressure will decrease
200 pt Bonus: sodium and potassium
Your patient is admitted with a head injury. He is comatose and breathing rapidly. His pH is 7.37, CO2 is 32 mm Hg. What type of acid-base imbalance is he experiencing?
100 pt Bonus: What is the treatment for hyperventilation?
Respiratory alkalosis
100 pt Bonus: Breathe through a rebreather mask