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Vital Signs
Documentation
Safety
Infection Control
Nursing STUFF!
100
The normal range for a healthy adult's heart rate is:
Between 60-100
100
What is subjective data?
The patient's statements. Document the patient’s exact words within quotation marks whenever possible
100
What does the acronym R.A.C.E., stand for?
Fires: “RACE” Rescue patients. Activate alarm. Confine fire. Extinguish.
100
What is the most important technique to use in preventing and controlling transmission of infection?
Hand hygiene. Gel in and out! Wash hands with warm water and soap for 15-20 seconds.
100
A postoperative patient arrives at an ambulatory care center and states, “I am not feeling good.” Upon assessment, you note an elevated temperature. An indication that the wound is infected would be A. It has no odor. B. A culture is negative. C. The edges reveal the presence of fluid. D. It shows purulent drainage coming from the incision site.
D. It shows purulent drainage coming from the incision site.
200
What is the best way to count a patient's respirations?
When the patient is not aware that you are counting respirations, otherwise patient may try to control breathing rate. While taking radial pulse watch chest rise and fall, use a watch with a second hand and count breaths for 60 seconds.
200

What is objective data?

An objective description is the result of direct observation and measurement. For example, “B/P 80/50, patient diaphoretic, heart rate 102 and regular.”

200
What does the acronym PASS stand for?
pull, aim, squeeze and sweep
200
It is okay not to wear gloves while starting an IV if you know the patient does not have an infectious disease. T/F
False, always wear PPE when exposure to bodily fluids is a possibility!
200
1. When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true? A. Chronic pain is psychological in nature. B. Patients are the best judges of their pain. C. Regular use of narcotic analgesics leads to drug addiction. D. Amount of pain is reflective of actual tissue damage.
B. Patients are the best judges of their pain.
300
Which of the following vital signs would you report immediately? BP 130/89 HR 146 RR 18 Pulse Ox: 93% on RA
Heart rate of 146
300
What does SBAR stand for?
Situation-background-assessment-recommendation
300
. A newly admitted patient was found wandering the hallways for the past two nights. The most appropriate nursing interventions to prevent a fall for this patient would include A. Raise all four side rails when darkness falls. B. Use an electronic bed monitoring device. C. Place the patient in a room close to the nursing station. D. Use a loose-fitting vest-type jacket restraint.
B. Use an electronic bed monitoring device.
300
A bottle containing a sterile solution is sterile and therefore can be placed within the sterile field. T/F
FALSE: A bottle containing a sterile solution is sterile on the inside and contaminated on the outside; the neck of the bottle is also contaminated, but the inside of the bottle cap is considered sterile.
300
What are the four techniques used in a physical examination?
The four techniques used in a physical examination are inspection, palpation, percussion, and auscultation.
400
What are the six vital signs?
Blood pressure, Temperature, heart rate, respiratory rate, pulse ox, PAIN.
400
A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of A. PIE documentation. B. SOAP documentation. C. Narrative charting. D. Charting by exception.
C. Narrative Charting Narrative documentation uses a story-like format. Weaknesses of the narrative format include repetition, length, and disorganization.
400
What are the six rights of medication administration?
Right patient, drug, route, time, dose, documentation.
400
Describe the following types of exudate: 1. Serous 2. Sanguineous 3. Purulent
Exudate may be 1.serous (clear, like plasma) 2. sanguineous (containing red blood cells) 3.purulent (containing WBCs and bacteria).
400
List the order you would conduct during an abdominal assessment: A. Auscultation. B. Inspection. C. Palpation. D. Percussion.
Inspect, Auscultate, Palpate, Percuss
500
What medical terminology would you use to describe the following vital signs? 1. BP 170/85 2. HR 145 3. RR 36 4. Temp: 100.8
1. Hypertensive 2. Tachycardia 3. Tachyneic 4. Febrile
500
In order to keep up on your charting, it is okay to document ahead of time.
FALSE
500
In cases of "never events", the hospital will still be reimbursed by Centers for Medicare and Medicaid Services. T/F
FALSE The Centers for Medicare and Medicaid Services (CMS) now denies hospitals higher payments resulting from or complicated by a “never event.”
500
Name 2 common causes of Hospital Associated Infections.
Surgical wounds traumatic wounds Urinary tracts (foley catheter) Respiratory PNA
500

The correct order for offing PPE is

What is Glove, Goggles, Gown, Mask, Hand hygiene