Download NRSG 2220 Final Exam Review: Vital Signs and Respiratory Assessment and more Exams Nursing in PDF only on Docsity!
NRSG 2220 NEW FINAL EXAM 100% VERIFIED
Taking Blood Pressure - Answer Locate Brachial artery, Line artery marking on cuff with brachial artery Palpate artery while inflating When you feel no pulse deflate After 15 seconds reinflate cuff to 30 above palpated pressure. Deflate cuff at 2-3 mm per second If retake wait 2 min.
Blood pressure definition - Answer the force of the moving blood against arterial walls
Blood pressure numbers-Adults - Answer Normal- less than 120 over less the 80 Prehypertension- 120-139 over 80- High blood pressure Stage 1- 140-159 over 90- High blood pressure Stage 2-greater than 160 over greater 100
Factors causing blood pressure variations in healthy people - Answer Age- older adult has decreased elasticity of the arteries, which increases peripheral resistance. Circadium rhythm- Normal fluctuations occur during the day. Usually lowest when first getting up. Gender- women usually have lower BP than men until menopause Food Intake- Blood pressure increases after eating. Exercise- systolic pressure rises during exercise Weight- Higher in obese people Emotional state- Anger, fear, excitement, pain can cause BP to rise, but goes back to normal afterward
Body position- Lower when prone or supine, than when sitting or standing Race- More prevalent in African american men and women Drugs-Oral contraceptives cause a mild increase
BP false low readings- Response Hearing deficit, Noise in environment, Viewing meniscus above eye level, applying a too wide cuff, using stethoscope incorrectly, cracked or kinked tubing, Releasing valve to quickly, Misplacing the bell, Failing to pump cuff 20 to 30 above pulse disappearance.
BP false high readings Using manometer not calibrated at zero, taking right after exercise,Viewing meniscus below eye level, cuff to narrow, releasing valve too slowly, Reinflating bladder during auscultation
Kortokoff sounds series of sounds that correspond to changes in blood flow through an artery as pressure is released.
Normal Body temperature 35.9 to 38C, 96.7 to 100.5F depending on route
Primary source of heat - Answer Metabolism
Primary source of Heat loss - Answer Skin
Factors affecting Body temperature - Answer Circadium rhythms, Age and gender, Physical activity, State of health, Environmental temp.
Normal temperatures at different sites - Answer Oral: 37.0C-98.6F Rectal: 37.5C-99.5F Axillary: 36.5C- 97.7F Tympanic: 37.5C-99.5F Temporal Artery: 37C- 98.6F
Fever - A nswer Elevation in normal body temperature. Occurs as a result of an upward displacement of the thermoregulatory set point in the hypothalamus. Caused by bacteria, microorganisms, viruses or by chemicals produced to respond to tissue injury.
Respiratory diseases- Anemia-decrease in oxygen carrying hemoglobin Meds- narcotics, sedatives Acute pain-increases resp. rate
Tachypnea - Answer increased respiratory rate caused by fever, anxiety, exercise.
Bradypnea - Answer decreased respiratory rate caused by depression of respiratory center, meds, brain damage
Hyperventilation - Answer Increased rate and depth, caused by extreme exercise, fear, diabetic ketoacidosis.
Hypoventilation - Answer decreased rate and depth caused by, overdose of narcotics or anesthetics
Cheyne-Stokes - Answer Alternating periods of deep, rapid breathing followed by apnea caused by, drug overdose, heart failure, increased intracranial pressure, renal failure
Biot's respirations - Ansewer irregular depth's and rate of breathing and apnea caused by meningitis, severe brain damage.
Pulse pressure - Ansewer Difference between systolic and diastolic reading; Determined by stroke volume and aortic artery compliance
Orthostatic hypertension - Ansewer temporary fall in BP when standing up.
Pain assessment - Patients description of pain, Duration of pain, Location of pain, Quantity and intensity of pain, Quality of pain, scale of 1 to 10, Chronology of pain, Aggravating factors, Alleviating factors, Physiologic indicators of the pain, Effect of pain on activities and lifestyle.
When assessing pain - Patients self report, Report of family member, Non verbal behaviors, Physiologic measures
Pulse oximetry - Answer measures the arterial oxyhemoglobin saturation of arterial blood 95% to 100% are normal. under 90 abnormal
Hypoxia - Answer inadequate amount of oxygen available to the cells. Treatment get more oxygen into the cells.
Oxygen Nasal cannula - Answer Bring equipment to bedside or table Hand Hygiene Identify patient Close curtains Explain what you are going to do and reason Connect cannula to oxygen Place prongs in patients nostrils Adjust the fit snug not tight Encourage patients to breathe through nose Reassess respiratory status rate, effort, lung sounds. 24% to 44% oxygen
Oxygen by Simple Mask - Answer Bring equipment to bedside or table Hand Hygiene Identify patient Close curtains Explain what you are going to do and reason Attach face mask to oxygen source
coughing, Classified by coarseness: fine, medium, coarse. Assoc, with Pneumonia, Pulmonary edema
Wheeze - Answer High-pitched, continuous, Musical, squeaking, Louder on expiration. Assoc. with Asthma
Stridor - Answer High-pitched crowing sound on inspiration. Assoc. with upper airway obstruction and croup
Rhonchi - Answer Low-pitched continuous, Snoring or rumbling, Heard at inspiration and expiration, May clear with coughing. air bubbling past secretions in large airways
Pleural Friction rub- Answer Low-pitched, dry grating sound, Caused by rubbing or inflamed pleural surfaces. Heard in inspiration and expiration.
Pleurisy- Answer Inflammation of lining of lungs, deeper breath cause more pain. every breath hurts
Pleural effusion- Answer Diminished or absent breath sounds over affected area.
Pneumothorax- Answer Collapsed lung, no breath sounds
Respiratory interventions- Answer Chest Physiotherapy- Clear mucous, Postural drainage- morning, promotes drainage, Clapping Rx for pneumonia, cystic fibrosis, COPD
Respiratory interventions 2 - Answer Chest X-ray, Fluid or air in pleural space Collapsed or underinfalted lung, Position of catheters/tubes, Response to therapy.
Peak Flow - Answer Measures peak forced expiratory flow rate (L/min) Inexpensive, Monitors pulmonary function in asthmatics. Do it three times
Incentive spirometer - Answer Measures maximum inhalation slowly count of three in mL, Patient motivation, Encourage patients to take nice deep breaths. 8/10 times an hour Stop collapsed lungs.
Aerosol Therapy - Answer Small volume nebulizers- Steady stream of meds, adds moisture to O2 delivery, Hydrates thick sputum (moisture deep in lungs, Administer bronchodilaters
Sputum Culture - Answer Suctioned, Coughed up, Lab test Gram stain C&S
Respiratory Interventions - Answer Hydration- Water Position changes-every 2 hrs. Shifts mucous Progressive ambulation after surgery Coughing and deep breathing-Cough pillow Leg exercises Purse-lip breathing in 2 out 4 Oxygen admin.
Venturi Mask - Answer 24% to 50%
Pressure Ulcers Risk factors - Answer Immobility, Nutrition, Hydration, skin moisture, mental status, and age. Compromised with these also cause Pressure Ulcers Incontinence, Skin hygiene, Diabetes Mellitus, Diminished pain awareness, Fractures, Corticosteroid use, Immunosuppression, Multisystem trauma, Poor circulation, Obesity or thinness.
Stages of Pressure Ulcers-Answer Stage 1-an area of intact skin with nonblanchable redness over a bony prominence
Skin assessment - Answer observe for cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity and lesions. Go head to toe, look for symmetry. Identify any problems such as skin problems, deficient self care, immobility, malnutrition, decreased hydration, decreased sensation, sun exposure, presence of irritants.
Skin Care - Answer Dry skin- drink more water, showers short, warm not hot water Acne- no squeezing, gently wash face 2 times a day, oil free water based moisturizers Skin rashes- wash throughly with mild cleansing agent, Use moisturizing lotion,
At risk for skin issues - Answer younger that 2 yrs, skin is thinner can be easily injured, Very thin and obese people are more susceptible to skin injury, Older people subcutaneous tissue becomes thin,
Sterile technique- wound care - Answer Always face sterile field Sterile items must be always be above waist or on top of field. Edges of field are considered contaminated Sterile only comes in contact with sterile Keep movements controlled to avoid contaminating the air with pathogens Water = contamination
Wound care - Answer Physical and aesthetic comfort Protect from further injury Prevent or control infection Absorb drainage Protect skin surrounding wound Maintain moist wound environment Remove necrotic tissue
Communication - Answer Be forthright and honest, interested and respectful. Do not give too many details, just the basics Ask if the pt. has any questions Be a cheerleader for the pt. Avoid lecturing. Use simple words. Vary your tone of voice. Keep the message straightforward and simple. Listen without interrupting when the pt. speaks. Make sure the environment is conducive to learning and free from interruptions. Be sensitive to timing of teaching sessions. A younger child may require a shorter session, while an adult may need to find an opportune time to learn new information.
Non-verbal communication - Respond to Touch Eye contact Facial expressions Posture Gait Gestures General physical appearance Mode of dress and grooming Sounds Silence
Therapeutic communication - Answer Positive regard Genuineness Empathy Concreteness
cultural context. Urinalysis - Answr sterile specimen not req Collect urine in clean bedpan, urinal or receptacle. Using aseptic tech. pour urine into container Label with patients name, date and time of collection. Stool specimen - Answr Void first Defecate into requird container Dont place toilet tissue in container Notify the nurse when specimen is available so it can be collected and taken to lab. When placing a specimen in a container and use two clean tongue blades. Usually 1 inch(2.5cm) of formed stool is enough Send to lab immediately
Hemoccult and Guiac - Answer Chemical tests to determine occult blood in the stool. Blue=positive
SBAR - Answer Situation- calling about concerned about VS are Background- pt. mental status, skin is Assessment-what the problem is, pt is unstable Recommendation-from Dr., tests needed, change in treatment
Abdominal assessment-Inspection - Answer Inspection-Note skin color and character Cyanosis-hypoxia, Jaundice-bilirubin, Glistening, taut-fluid accumulation Note abdominal symmetry and position of umbilicus Note for Striae, bulging, lesions Scars Fat excess
Fluid excess Feces Flatus Full Bladder Presence of vascular lesions- petechiae, ecchymosis Surface movement- peristalsis, pulsations, respirations Abdominal contour- flat, scaphoid, rounded, protuberant
Abdominal assessment- Auscultation - Answer Bowel sounds, clockwise start at 9 listen for clicks and gurgles. Increased bowel sounds- Gasteroenteritis, Hunger, Early obstruction Decreased bowels sounds- Peritonitis Absent bowel sounds- Paralytic ileus Bowel sounds Irregular- high-pitched clicks, gurgling Borborygmi-loud prolonged gurgles heard with hunger. Bruit- a blowing whistle sound produced by blood moving through a narrow vessel Abdominal arteries- Renal, Abdominal aorta, iliac, femoral
Abdominal assessment-Percussion - Answer Percuss in all four quadrants Tympany- normal over most of abdomen Dullness- organs, masses, stool, and distended bladder Costovertebral tenderness-use ulnar surface of closed fist and strike pt. firmly over angle Pt. should feel a thud not pain or tenderness
Abdominal assessment- Palpation - Answer Palpate clockwise in all quadrants Begin with light palpation and proceed to deeper Observe facial expression and voluntary/involuntary guarding
Foley urine - Answer THere should however, be a port along the tubing that you would swab with alcohol and aspirate the urine from with a needle/syringe, after clamping for a time.
Diets - Answer Variety of vegetables Fruits; especially whole fruit Grains; 50% are whole grains Fat free or low fat dairy and/or fortified soy beverages Lean meats and other protein foods Oils from plants Also nuts, seeds, seafood, olives, and avocado Saturated Fats <10% total kcal Avoid trans fat Sodium <2,300 mg Added Sugars <10% total kcal Alcohol up to 1 drink women* / 2 drinks men* daily Potassium Fiber Choline •Magnesium •Calcium •Vitamins A, D, E and C And for women 19 -iron
Clear liquid diet - Answer Only clear liquids or foods at body temp. Requires minimal digestion, Includes clear broth, coffee, tea, clear fruit juices(apple, cranberry,grape) gelatin, popsicles, clear liquid supplements
Full liquid diets - Answer all items on clear liquid diet, and milk and milk drinks, puddings, custards, plain frozen deserts, pasteurized eggs, cereal gruel's, veggie juices, milk and egg sub.
Nasogastric tube - Answer Inserted through the nose and into the stomach, risk for aspiration(the tube feeding solution into the lungs) Patients with dysfunctional gag reflex, nasal injuries,gastric stress, reflux not candidate. Use x-ray length markings, pH testing, and aspirate characteristics. Nutritional assessment - Answer Usual dietary intake Food allergies or intolerances Food prep. and storage Type of dietary practices Eating disorder patterns Height and weight BMI and waist circumference Barriers to eating (Dysphagia) Lab tests- blood and urine levels, body vitamins, minerals and trace elements Hemoglobin, protein Blood glucose, cholesterol, triglycerides Hygiene- Factors that affect - Answer Culture, Socioeconomic class, spiritual practices, developmental status, Health state, personal preferences.
Bed baths - Answer provide pt. with stuff needs for bathing Place items so they can be seen provide privacy remove top linens and replace with bath blanket
Don't use unmarked containers aware of cloudiness changes in liquids sediment presence dates of expiration no lapses recheck and double check all calculations Never crush SR or EC meds Oral meds - Answer Identify pt. 2 forms can swallow GI motility Body system assessment Vital signs Document immediately upon administration Oral routes - Answer Mouth- Sublingual-under the tongue, do not swallow until after pill has dissolved Buccal-to the side of the mouth under upper lip Vial - Answer Multi dose two vials Pull up multi dose first and then pull up single dose
Ampule - Answer Single dose use a filter needle
Syringe selection Standard - Answer 3ml for SC IM 5mL or 10mL
Syringe selection Insulin - Answer Units non detachable needles 25-30 gauge
1/2 of 5/8 needle
Intradermal - Answer use Tb syringe bevel up 5 to 15 degrees inner forearm
Subcutaneous - Answer Into connective tissue Small doses (0.5 -1.0mL) 25-28 gauge needle outside of arms, thigh, stomach, upper back Insertion 45 to 90 degrees
Intramuscular - Answer Into muscle layer 3ml to 5mL syringe 19-25 gauge needle 5/8 to 3" needle No more that 3 ml in one injection 90 degree angle Z track Deltoid, vastus lateralis and ventrogluteal
peak - Answer highest plasma level concentration level of a drug. measured when absorption is complete. measure therapeutic range
trough - Answer the point when a drug is at its lowest concentration. Indicates rate of elimination
Medical asepsis - Answer Clean technique, hand washing, PPE, always be aware of transfer of pathogens. Condition free from germs, infection and forms of life.
