Physical Assessment
The first neurological system assessed when completing a head to toe assessment is_________ and it is done by assessing the patient's?
What is neurological?
What is level of consciousness?
A nurse encounters an unresponsive client in the bathroom, what is the first step the nurse should take?
What is alert emergency response.
Decision-making framework used by nurses to determine the needs of clients
What is the nursing process?
To help reduce hospital-acquired infections (HAIs), the nurse’s first priority is to?
What is handwashing
This type of immobilization device is a firm plastic mold form used to keep a joint or joints from flexing.
What is a splint?
Which sequence of assessment does the nurse apply to correctly assess a client’s abdomen?
What is Inspection, auscultation, and palpation .
Bed lowered & locked, non skid socks, 1 side rail up, clutter free environment, dim lighting at night, call bell within reach.
What is fall precautions.
The PN gathers information by interviewing the client to obtain a health history and reviewing the results of laboratory and diagnostic tests.
What is assessment?
The nurse should hold fingertips above _______ while rinsing hands following a surgical scrub?
What is elbows?
Name an effect of Immobility on the Respiratory System
Group must name at least one:
What is Respiratory muscle weakness? What is Pulmonary emboli? What is Hypostatic pneumonia? What is Atelectasis?
The nurse instructs the patient to "Focus on my penlight and follow it as I move it away from you and then back toward you." The nurse is checking the patients
What is accommodation response
In order to get patient's out of restraints easily they are...?
What is tied in a quick release knot?
The nurse realizes that when setting goals for the patient, the goals must be _________?
What is must be realistic, measurable, and timely.
A nurse wears the following PPE for a patient. Mask, gloves, and gown.
What is droplet precautions?
The nurse finds her patient with a blood pressure of 70/50, the nurse should place the patient in _________
What is trendelenburg?
After receiving a liter of intravenous fluid over 3 hours the nurse describes the characteristics of the patients pulse as...
What is full and bounding?
When assessing a client for falls the nurse uses...
What is a morse fall assessment tool?
ACRONYM for the nursing process.
What is ADPIE?
The nurse is following surgical asepsis if she washes her hands for ____ minutes in preparation for surgery.
What is 6 minutes?
Due to immobility the patient is at risk for thrombosis. To help prevent this the nurse can _____________.
What is assist the patient in active range of motion exercises?
The nurse recognizes that clammy skin, nausea, confusion and headache are all signs of _________
The nurse should intervene in this situation by ____________________?
What is hypoglycemia?
What is give something sweet?
After providing morning care, the nurse forgot to put the bed in the lowest position and left one of the bed rails down causing the client to fall. For which reason could the nurse be reported to the board of nursing?
What is negligence?
A client has been diagnosed with septicemia, a condition in which microorganisms are present and multiplying in the blood.
The PN identifies this is a..?
What is systemic infection?
The nurse notices erythema of intact skin, that will not blanch. The nurse documents this as _________?
What is a Stage 1 pressure wound?