Techniques & Equipment, Skin, Hair, Nails
Part of stethoscope used for low pitched sounds.
Bell
Where as the diaphragm is for high pitched sounds.
Another name for drainage.
Exudate
What is the formula for cigarette pack years?
Expected finding for arterial pulses.
rhythmic +2 =bilaterally
What abdominal quadrant can you see hepatomegaly in?
RUQ
What is the difference between a bruise (contusion) a laceration and an abrasion.
A bruise (contusion) is the bursting of vessels due to injury or increase pressure. A laceration is a tear (linear). Abrasion is scrapping or scratches.
What does PERRLA stand for?
Pupils equal, round, reactive to light, and accommodation
Which adventitious breath sound should the nurse encourage the patient to cough and then auscultate again?
Rhonchi
What are the pitting edema increments?
1+ 2mm
2+ 4mm
3+ 6mm
4+ 8 mm
What are the 3 abdominal shapes?
Flat, rounded, & distended.
Which one is expected? Flat
What is the formula for BMI and the rounding rules?
(lbs / inches X inches) X 703
If the answer is > 1 round to the nearest tenth.
If the answer is < 1 round to the nearest hundredth.
What is mydriasis?
Pupil dilation, > 5 mm
Three components to a BSE.
Use finger pads, vertical strips, in the shower, & a few days after the start of menstruation.
Identify the 5 heart sound names, locations, S1&S2.
Aortic RSB 2ndICS S2>S1
Pulmonic LSB 2ndICS S2>S1
Erbs LSB 3rdICS S1=S2
Tricuspid LSB 4thICS S1>S2
Mitral LMCL 5thICS S1>S2
Identify the difference between oliguria and anuria.
Oliguria 100-400 mL in 24 hours
Anuria < 100 mL
What does ABCDE stand for with melanoma?
Asymmetrical, borders irregular, color variation, diameter > 6mm, & evolving over time.
What is the difference between the Snellen chart and the Rosenbaum chart?
Snellen is for distant vision (20 feet away, ex. 20/40).
Rosenbaum is for near vision (12-14 inches away).
Both for CN II optic nerve (visual acuity) assessment.
Identify 4 respiratory interventions.
TCDB, raise HOB
IS
Increase Fluids
Suctioning
Medications
Recognize the cues, analyze the cues, prioritize hypotheses, generate solutions, take actions, and evaluate outcomes.
What are the screenings for colorectal cancer vs. prostate cancer?
Colorectal: FOBT, sigmoidoscopy, & colonoscopy
Prostate: PSA, DRE
Describe the six classifications of pressure injuries.
Stage I non-blanchable erythematous lesion (skin intact). Stage II partial thickness loss (parts of the dermis). Stage III full thickness loss (subcutaneous, dead tissue can be present (eschar/slough)). Stage IV full thickness loss (muscle, tendon, or bone) (dead tissue can be present). Unstageable (too much dead tissue). Deep tissue injury (DTI) non-blanchable dk purple maroon lesion (squishy, cool to touch) skin usually intact.
Describe tonsil grading.
0-4+ (increments of 25)
0 absent or tonsillectomy, 1+ is up to 25 %, 2+ is 25 up to 50%, 3+ is 50 up to 75%, 4+ is > 75%
Identify 5 adventitious breath sounds.
Crackles (rales) air flowing by fluid, wheeze air flowing by constricted airways, rhonchi air flowing by thick secretions, stridor severe upper airway obstruction, & pleural friction rub (pleura rubbing *patient hold their breath, need to determine pericardial vs. pleural)
Identify 3 differences with S3 & S4 heart sounds.
S3 happens early in diastole, ventricular gallop, sounds like Kentucky
S4 happens late in diastole, atrial gallop, sounds like Tennessee
What are the abdominal arteries?
Aorta, renal, iliac, & femoral arteries (total of 7).
Use the bell, expectation no bruits