ASSESSING
Which phase of the nursing process is when a nurse will ask about potential allergies?
Assessment
What should a nurse do next if a radial pulse is irregular?
Assess the apical pulse for a full minute
What does the guaiac test check?
Blook in the stool
Describe how you would move a patient from a bed to a wheelchair safetly
Lock the wheels on the wheelchair and the bed.
What is the first action to take if an accidental stick of an IM injection occurs to a nurse?
Wash the area of the puncture thoroughly with soap and water.
A nurse discloses medical test results to a daughter of a client. This is a violation of what?
HIPAA
Describe how to conduct a Snellen Eye Chart and a Rosenbaum Chart?
Describe the Weber Test.
Snellen Chart - Hold a white card over one eye and read the smallest possible line.
Rosenbaum Chart - Place the chart about 15 inches from the client's face.
Weber Test - Place a vibrating tuning fork on top of the head and ask the client if the sound is heard the same in both ears.
What would blood-tinged urine indicate in a client?
Bladder infection
What does a Gait belt do?
Helps support the client during ambulation. It keeps the center of gravity stable and helps maintain balance and prevent falls.
What is the earliest and most sensitive indication of altered cerebral function?
Change in level of consciousness
When assessing for cyanosis in a dark-skinned client, the nurse should examine what to identify cyanosis in this client?
Conjunctivae
List four key points when applying wrist restraints to a client.
Secure the restraints using a quick release tie.
Ensure two fingers fit under the restraints.
Removing restraints every 2 hrs.
Secure the restraints to the bedframe that allows repositioning to occur.
How would you examine the ears of a child under 3 years old with an otoscope?
Describe Adduction, Supination and pronation of the wrist, Circumduction, and Dorsiflexion
Pull the auricle down and back
Adduction- Movement of arm in toward the center of the body.
Supination a pronation of the wrist - Rest the left arm on a table and move the lower arm so that the palm of the hand is up and then down.
Circumduction-Shoulder joint moves in circular motion.
Dorsiflexion-Toes are pointing to the ceiling
What is "PERRLA"?
What is Tinnitus?
What does Lethargic mean?
What does scoliosis look like?
Evaluation of the pupils
Ringing of the ears
Drowsy; delayed responses to verbal stimuli: may drift off to sleep during examination
Curvatures of the spine
What is the difference between dizziness and vertigo?
Vertigo the room was spinning around.
Dizziness is off balanced
When creating a discharge plan, the nurse understands when discharge planning should be implemented?
Must begin upon admission of the client to the facility.
What finding would a nurse document if shines a light in the right pupil to test constriction and the left eye also constricts at the same time?
Should a client's pupils dilate when looking toward a distant object?
Document the finding as a positive consensual reaction (Normal).
YES
Describe normal cerebellar function.
How would a nurse test sensory function of a client?
How would a nurse determine if a client's facial cranial nerve (CNVII) is intact?
Client stands with feet together, arms resting at the sides, with eyes open and then eyes closed. The client ways slightly and maintains upright posture with feet together.
Touching the client lightly with a wisp of cotton.
The sides of the mouth are symmetric when the client smiles.
Describe an indicator that a client has an obstruction of the large intestine due to a fecal impaction?
A nurse would recommend which food for a client experiencing constipation?
The client is having small frequent liquid stools
One apple with skin
What should a nurse do if a client is experiencing abdominal cramping while administering a cleansing enema?
Clamp the enema tubing
What should a nurse perform immediately when hearing a client complain of leg pain, swelling and weakness after a fall?
A focused Assessment (OLDCARTS)
What would cause an infection in an indwelling urinary catheter?
Catheter tubing having kinks or twisted.
Where would a nurse palpate while performing a head and neck assessment on a client reporting fatigue and what is the lymph node called?
Occipital lymph node. Back of the head above the neck.
Name the movements on a healthy person when assessing hip range of motion.
Describe an assessment of the ears on a healthy person.
Describe an assessment of the mouth on a healthy adult.
Flexion and extension, Internal and external rotation, Adduction and abduction, and Hyperextension
Cerumen noted in the outer ear canal, Tympanic membrane pearly gray, and whispered words heard accurately.
Lips appear pink, smooth, moist and symmetric, teeth are white, yellow or gray with smooth edges, and slight roughness on the dorsum of the tongue.
Describe what you would find for a client with fluid overload?
Increased heart rate, increased blood pressure, and increased respiratory rate