Vital Signs
The normal ranges for pulse, respirations, and blood pressure in adults?
60-100, 12-20, <120/80
Theorized that accepting the person not only as they are now but also as what they may become. Nursing is an interpersonal process.
Jean Watson.
What are the four main concepts of the full spectrum model of nursing?
Thinking, Doing, Caring, and Client Situation
A elderly client is admitted to the hospital with a fever and productive cough, they are later diagnosed with pneumonia. Due to the stress of the illness the client soon develops herpes zoster (shingles).
Identify the primary and secondary infection.
Primary- pneumonia
Secondary- herpes zoster
When the body is overheating it will compensate with
1.Vasodilation
2.Vasoconstriction
Vasodilation.
The diameter of the blood vessels increases. This diverts core-warmed blood to the body's surface where heat can be transferred to the surrounding environment.
In 2011 the Joint Commission mandated what assessment as the fifth major vital sign.
Pain.
The first nurse-scientist. Established a theory that supported the relationship between humans and the environment and the influence on health.
Florence Nightingale
(Select all that apply)
Which of the following are responsibilities of the nurse manager?
A. Budgeting
B. Resolving Conflicts
C. Scheduling
D. Client Safety
E. Hiring
All of the above
Identify 5 reservoirs of infection.
the human body, soil, water, food, environmental surfaces, contaminated water, garbage, fecal matter, or exudate on wound dressings.
The nurse is getting ready to preform tracheostomy care, they have gathered sterile supplies and nonsterile gloves. What level of asepsis is this?
Modified sterile technique
The systolic and diastolic blood pressure is read at what number Korotkoff sound?
Systolic: 1st Korotkoff
Diastolic: 5th Korotkoff
Established the theory that interpersonal communication can improve mental health. Believed that the health of psychiatric patients could be improved if there were more effective ways to communicate with them.
Hildegard Paplau.
The nurse is ambulating a patient the pt states "I feel a little dizzy". The nurse immediately grabs a chair and helps the patient sit down. According to Tanner's Model of Judgement what reasoning skill is this?
Analytical reasoning, Intuitive reasoning, or Narrative reasoning
Intuitive reasoning
Which method of cleaning requires the use of autoclaves, dry heat, ozone, peracetic acid, or low temp hydrogen gas?
Disinfecting, cleaning, or sterilization
BONUS: Which cleaning method can remove prions?
Sterilization is the elimination of all microorganisms (except prions) in or on an object.
B: NONE
Which tool does the nurse use to provide a comprehensive handoff report?
SBAR
PICOT
ADPIE
SOAP
SBAR- Situation, Background, Assessment, and recommendation
A false high BP may be assessed, as the nurse explains to the nurse assistant if:
1.Press the stethoscope too tightly
2.The cuff is too tight
3. Deflate the BP cuff too quickly
4. The cuff is too loose
2. The cuff is too tight.
If the blood pressure cuff is too tight you will get a false high reading and if it is too loose you will get a false low reading.
Theorized that nurses deserve to know what it means to be a nurse. Identified 14 basic needs that are addressed by nursing care.
Virginia Henderson.
Match the knowledge type:
Practical Knowing why. info. facts. principles
Theoretical Understanding oneself,beliefs, & values
Self knowing what and how to do it. intuition
Practical- Knowing what to do and how to do it.
Theoretical- Knowing why. info. facts. principles.
Self- Understand yourself, beliefs, and values.
Which assessment findings should the nurse recognize as a possible sign of infection?
Temp 38.3 C
Tender lymph nodes
Wet mucous membranes
Pulse 107
Diaphoresis
Bradycardia
High Temp
Lymph Nodes
High Pulse
Diaphoresis
Which healthcare setting would be most appropriate for a patient who needs further inpatient therapy after sustaining a stroke?
Nursing home
Assisted Living Center
Independent living facility
Rehabilitation center
Ambulatory care
Rehab- They provide extended care and treatment for clients with physical and mental illness.
A spouse is observed taking a clients blood pressure. The nurse feels additional teaching is needed after the spouse is observed:
1. Deflating the cuff at 2-3 mmHG per second
2. Having the client sit down for the measurement
3. Taking the blood pressure after the client comes back from a walk
4. Taking the BP at the same time each day
3.
The spouse should be educated on waiting an appropriate amount of time after any exercise before taking a BP reading. 30 minutes!
This important theorist was not a nurse. Florence Nightingale, Virginia Henderson, Hildegard Paplau, Patricia Benner, Abraham Maslow, or Madeline Leninger.
Abraham Maslow.
A single father was admitted to the hospital with complaints of blurry vision and unbearable foot pain due to a sore. He is diagnosed with type 2 diabetes and begins receiving treatment. Despite improvements he begins to push for an early discharge after only a few hours have passed. This is an example of?
A. Individual differences
B. Client's Personal Beliefs
C. Client's Roles
D. Previous Experience
Client's roles- A person’s roles influence when, how, and why they seek healthcare. A single parent with young children may ask to be discharged from the hospital early to meet the needs of their family.
Name the 4 parts of secondary defense.
Phagocytosis, Complement cascade, Inflammation, and Fever.
During an appointment at the women’s clinic, a client informs the nurse that her menstrual flow is very heavy and that she experiences severe abdominal cramping during menstruation. The client’s breast examination is normal. When the nurse sees the laboratory results (Pap smear result is normal, but hemoglobin level is low), she suspects that the heavy flow may be causing anemia. According to clinic protocol, birth control pills are prescribed to control the heavy, painful menses and to provide contraception. Ongoing assessment will include visits every 6 months to evaluate the client’s response to hormone therapy and to monitor the anemia. State whether the following data are primary or secondary, subjective or objective:
1. You see in the client’s health record that her breast examination was normal.
2. The client tells the nurse that she experiences cramping with her menstrual cycle.
3. The nurse tells you that the client is experiencing anemia.
4. You check the result of the Pap smear in the electronic health record and see that it is normal.
1. Secondary, Objective
2. Primary, Subjective
3. Secondary, Objective
4. Secondary, Objective