Vital Signs
Where should the arm be placed when checking the BP?
at the level of the heart
A laceration which has edges that do not approximate must heal by:
Secondary intention
A nurse needs to turn/reposition a very heavy patient. What is the best action to prevent injury?
Ask for help!
What lab will be draw for patients who are on warfarin (coumadin)?
PT/INR
reorientation therapy
What part of the sterile field is considered contaminated or dirty?
The 1 inch border
Tip: You can touch any part of the 1 inch border with 'dirty hands' and once you don sterile gloves you can not touch that 1 inch border
The 6 rights must be verified how many times?
3
A patient has a bp reading of 130/80. What stage of hypertension is this considered?
pre-hypertension
A blood pressure reading of 124/84 mm Hg places this client in the prehypertension category. This includes a systolic pressure of 120 to130 mm Hg and a diastolic pressure of 80 to 89 mm Hg.
cough and deep breathe
(sometimes this can clear the fluid)
This stage pressure injury can be described as a shallow open ulcer.
stage II
What is the 1st intervention the nurse should do if a patient complains of difficulty breathing?
What might a WBC of 15 indicate?
Infection
The sharing of life stories & memories in a group of elderly patients is a behavioral approach to dementia known as:
reminiscence
What type of precautions are required for VRE +/- MRSA of a wound?
contact
hives
The carotid pulse indicates circulation to which organ?
Brain
What is the term for a respiratory pattern that goes from faster, to slower, to periods of apnea?
Cheyne Stotkes
A full thickness skin loss with a 'crater' but no visible bone or muscle is what stage PI?
Stage III
Safety hazzards in the elderly patient's environment include:
scatter rugs
cords
A patient has bloody stools. What lab does the nurse expect will be drawn?
CBC
TIP: this contains hgb&hct, plateletes = all should be assessed when bleeding is suspected
occult blood
Airborne precautions such as for TB requires the use of what type of mask?
N95
Tip: and negative pressure room for the pt; also use gown gloves and eye protection
The first thing the nurse should offer the patient when trying to determine ability to swallow for a med pass is what?
a sip of water
A pulse felt over the just posterior to the ankle bone on the inner aspect of the ankle
posterior tibial
When a patient is dehydrated, what does the nurse expect the USG level to be?
How does the nurse treat a wound evisceration?
Cover with NSS soaked gauze
The nurse notes a urine output of 180 in an 8hr shift and performs a bladder scan which also shows 180 ml. What should the nurse expect when calling the provider?
possibly an order for IV fluids (to rehydrate if that is the issue) & an order for labs like a BMP to assess kidney function
Tip: remember, normal urine output is ___ml per hour
A patient's INR is 4.0.
What will the nurse assess?
Signs of bleeding such as bloody stools, melena, bleeding gums, distended abdomen, hematuria
Order: 300,000 units of drug X; available is 100,000 units of drug X per 2 ml. How many ml would you give? Round to nearest 10th.
6 ml
Droplet precautions such as for the flu requires what type of mask?
surgical mask
Tip: also requires gown, gloves & eye protection
The pinna are pulled "_&_" when giving ear drops to an adult.
up and back
What will the BP and HR do when a patient is in shock?
Heart rate up, bp down
When the nurse pinches an area of skin over the clavicle and it doesn't bounce back quickly this is known as?
skin tenting
Tip: a sign of dehydration but not 100% accurate- it is only 1 clue that must be examined
What type of dressing is recommended for a stage I pressure injury?
either no dressing or a transparent (clear) dressing
this is a dressing that will protect from shearing. This dressing will also allow the nurse to visualize the area for assessment purposes.
DO NOT RECAP! Place the used needle in a sharps container immediately
A 24 hour urine specimen is collected in a specific manner. When should the specimen collection begin?
After the pt discards the first urine of the day (the 1st urination after awakening)
Order: 1 L NSS to infuse over 8 hours. How many mls/hr would the nurse administer?
125 mls/hr
Remember the formulas!
What type of precautions are required for pertussis?
Droplet
Prior to administering meds that effect the heart rate, the nurse must assess what and for what time frame?
apical, 1 full minute