Assessments
Heart rate, blood pressure, capillary refill, warmth and pallor make up the data collected for this assessment.
What is a cardiovascular assessment.
Removing medications from the cart and comparing them to the patient's MAR.
What is the second medication check.
81 mg daily is a typical dose for prevention of thrombus formation in patients at risk for myocardial infarction.
What is aspirin?
12 - 20 and >95% are values associated with this assessment.
What is a respiratory assessment?
When a healing wound is pulled apart.
What is dehiscence?
This is where I put my stethoscope to assess an apical pulse.
What is the left side, mid-clavicular line, 5th intercostal space.
Your patient has been receiving digoxin (Lanoxin)125 mcg every morning. Today his doctor writes a new order: Digoxin 0.25 mg PO Q AM start now. How many 125 mcg tablets will you administer?
tab=1tab/125mcgx1000mcg/1mgx0.25mg/1
250/125= 2 tabs
Name the five steps of the nursing process.
What are Assessment, Diagnosis, Planning, Implementation and Evaluation?
We ask these questions when assessing if we should administer a flu vaccine.
What is do you have any allergies to vaccines? Have you ever had an allergic reaction to the flu vaccine? Do you have a history of Guillain-Barre syndrome?
3 ml, 22 gauge, 1.5" are attributes of this type of medication delivery.
What is an intramuscular injection?
325-650 mg every four to six hours.
What is the typical dose range and time for acetaminophen?
Contraction of the ventricles refers to this phase of the cardiac cycle.
What is systole?
Heels, ankles, hips, sacrum, elbows, occiput and pinna.
What are bony prominences? What are anatomical sites we assess for skin breakdown?
First, I need to palpate the iliac crest and place my palm over the greater trochanter.
What is locating the ventrogluteal site.
Your 4 year old pediatric patient weighs 40 pounds. She is febrile. You need to administer acetaminophen (Tylenol)15mg/kg. How many mg will you administer? Round to the nearest whole number.
mg=15mg/kgx1kg/2.2x40lbs/1
272.7, 273mg
We collect subjective and objective data to make this determination.
What is a nursing diagnosis?
We ask these questions to determine our patient's baseline orientation.
What are "tell me your name," "do you know where you are?" "do you know why you're here?" and "do you know the date/time?"
Cloudy to clear, clear to cloudy.
Its onset of action is 30-60 minutes, and its peak time of action is 2-5 hours.
What is regular insulin.
Heart rates below 60 BPM and above 100 BPM are referred to with these medical terms.
What are bradycardia and tachycardia?
Redness, warmth, swelling, exudate.
What are signs of infection.
Placing my stethoscope in these areas would make it hard to perform an accurate assessment of lung sounds.
What is over the clavicle, sternum, spine and scapulae.
Your patient weighs 250lbs and is prescribed a medication for 2.5mg/kg/day, 3 doses per day. How many mg would you administer per dose? Round to the nearest whole number.
mg= 2.5mg/1kg x 1kg/2.2lb x 250lb/1
625/2.2 = 284/3 = 95 mg/dose
The letters in the SMART goal writing format refer to these words.
What are specific, measurable, achievable, relevant and time-bound?
Provocative/palliation, quality, radiation, severity and timing form the mnemonic device for assessment of this fifth vital sign.
What is a PQRST pain assessment?
Patient, medication, dose, route, time.
What are the five rights of medication administration?
This antibiotic would be contraindicated in a patient with a penicillin allergy.
What is amoxicillin?
When blood glucose is assessed below 70 mg/dl, the patient is considered to be in this state.
What is hypoglycemic?
These dressing types absorb moisture while these others add moisture.
Anterior thigh, abdomen and posterior upper arm.
What are common subcutaneous injection sites.
You need to calculate intake in ml for your patient. For lunch they had: 8 oz apple juice 7 tsp of chicken broth and 1 cup of jello. How much intake did your patient have in ml?
8oz = 240ml
7tsp = 35ml
1 cup = 240 ml
240 + 35 + 240 = 515ml
These are the three parts of an acute nursing diagnosis.
What are diagnostic label, etiology and supporting data?
Sensory perception, moisture, activity, mobility, nutrition, friction and shear are elements of this focused assessment.
What is the Braden Scale?
We have successfully administered this test when we form a bleb or wheal at the injection site.
What is a PPD test?
Naloxone and acetylcysteine are antidotes to these medications.
What are opiates and acetaminophen?
Above 99 F or above 37.2 C.
What is febrile?
Red, non-blanchable skin; Blistered and/or red, exposed dermis.
What are stages one and two pressure ulcers.
These are parts I pull or expose to administer eye and ear drops.
What are the pinnae and conjunctivae?
Your patient weighs 99lbs and is prescribed a medication for 3mg/kg/dose. It is available in your formulary at a concentration of 2mg/0.5ml. What volume will you give the patient? Round to the nearest 100th.
ml=0.5ml/2mgx3mg/1kgx1kg/2.2lbx99lb/1
148.5/4.4= 33.75 ml
Critical thinking in nursing allows us to make these important patient care decisions.
What are clinical judgements?