Vital Signs
Lists 3 factors that can increase respiratory rate
Exercise
Anxiety
Fever
Low hemoglobin
What is dysphagia?
Difficulty swallowing
What is the Point of Maximal Impulse (PMI)?
The location at which the cardiac impulse can be best palpated on the chest wall
"Angio/o"
Blood vessel
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature?
A. Rectal
B. Tympanic
C. Oral
D. Temporal
D. Temporal
Rationale: The temporal artery route, while not as accurate as the rectal route for obtaining a precise body temperature, is noninvasive and can be used to obtain the temperature of a toddler who might have an ear infection and who is having diarrhea. The nurse should place the probe behind the ear is the client is diaphoretic, but should avoid placing it over an area covered with hair.
What are the 6 locations at which temperature can be measured?
Tympanic
Temporal
Oral
Axillary
Rectal
Skin
What are the two forms of digestion?
Mechanical (i.e chewing)
Chemical (i.e enzymes/saliva)
Which cranial nerve is responsible for equilibrium and hearing (number and name)?
CN VIII - Vestibulocochlear
"Thorac/o-, Thoracico-"
Chest
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following action should the nurse plan to take?
A. Place the client supine
B. Keep both side rails up
C. Raise the level of the bed
D. Inspect the client's mouth using a finger sweep
Rationale: The nurse should raise the bed to allow for the use of proper body mechanics and reduce the risk of self-injury
What part of the brain controls breathing?
Medulla
What does NPO mean?
"Nil per os" = Nothing by mouth
Which cranial nerve is responsible for salivation/swallowing (number and name)?
CN IX - Glossopharyngeal
"Gastr/o"
Stomach
A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39C (102.6F), heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?
A. Heart rate 105/min
B. Soft, nontender abdomen
C. Temperature
D. Overdue menses
C. Temperature
Rationale: Elevated temperature is an emergent physiological need, which requires priority intervention by the nurse. The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's hierarchy of needs, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. However, it is important for the nurse to consider all contributing factors, as higher levels of the pyramid can compete with those at the lower levels depending on the situation.
How would decreased blood volume influence your ability to palpate a pulse?
Pulse is often weaker and more difficult to palpate
List 3 common reasons a therapeutic diet may be ordered
Maintain, restore, and correct nutritional status
Decrease calories for weight control
Increase calories for weight gain (ex: supplements, nourishments, “at hour of sleep” snacks)
Balance amounts of macromolecules (carbs, lipids, etc)
Increase the amount of protein
Decrease sodium intake
Exclude foods due to allergies or intolerance
Provide texture modification due to problems with chewing and/or swallowing
What is tidal volume?
The amount of air that moves in and out of the lungs with each breath
"Gloss-"
Tongue
A nurse is receiving a patient from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the patient from the stretcher to the bed?
A. Lock the wheels on the bed and stretcher
B. Instruct the client to raise his arms above head
C. Elevate the stretcher 2.5cm (1in) above the height of the bed
D. Log roll the client
A. Lock the wheels on the bed and stretcher
Rationale: Locking the wheels prevents the patient from falling to the floor by not allowing the cart or bed to move apart or away from the client
How is pulse pressure calculated?
systolic - diastolic values
What are the 4 stages of digestion?
Which cranial nerve is responsible for pupillary response (number and name)?
CN III - Oculomotor
"-scopy"
Examine
A nurse is caring for a patient who requires a chest x-ray. Prior to the patient being transported for the procedure, which of the following actions should the nurse take first?
A. Explain the x-ray procedure to the patient
B. Help the patient into a wheelchair before the transporter arrives
C. Ask if the patient has any questions
D. Identify the patient using two identifiers
D. Identify the patient using two identifiers
Rationale: The nurse should identify the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Once the client's identity is determined, the nurse can then proceed with the other options. This action is the priority action because it provides for the safety of the client. It is a nursing responsibility to be certain that each client receives only what has been prescribed. The nurse must assure that the correct client is being transported for a chest x-ray.