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Nursing Skills 1105 Exam 3 Flashcards 2025 Latest Update Graded A+, Exams of Nursing

Imperial College LondonNursing

Nursing Skills 1105 Exam 3 Flashcards 2025 Latest Update Graded A+ Nursing Skills 1105 Exam 3 Flashcards 2025 Latest Update Graded A+

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2024/2025

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Nursing Skills 1105 Exam 3 Flashcards 2025 Latest Update
Graded A+
Vital signs include - ANSWERS-1. temperature (T)
2. pulse (P)
3. respiration rate (RR)
4. blood pressure (BP)
5. Puls oximatry (PsO2)
Change in vital signs indicates - ANSWERS-A change in condition
When is a pt baselines vital signs obtained? - ANSWERS-on initial contact with pt (compared to trends
from previous shifts)
Why is a pt basline vital signs important? - ANSWERS-1. to help evaluate: circulatory, pulmonary,
endocrine and neurological functioning.
2. For comparison with subsequent measurments to detect changes and or abnormal findings
If there are any significants changes in the vital signs what should you do? - ANSWERS-1. repeat to verify
accuracy
2. get a 2nd health care provider to confirm vital signs
How often do we assess vital signs? - ANSWERS-1. Upon admission and transfer from one unit to another
2. Any time there is a change in a pt condition
3. Before and after procedures that reqauire anesthesia/sedation
4. Before and after administering medications that affect cardiovascular or respiratory function or pain
level
5. Before and after any activity that causes them to change
6. As ordered by the HCP, Unity policy, Transfer of Care
Normal body temp range for children: - ANSWERS-98.6 -99.6 F
Normal body temp range for adults: - ANSWERS-96.8 - 100.4 F
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Download Nursing Skills 1105 Exam 3 Flashcards 2025 Latest Update Graded A+ and more Exams Nursing in PDF only on Docsity!

Nursing Skills 1105 Exam 3 Flashcards 2025 Latest Update

Graded A+

Vital signs include - ANSWERS-1. temperature (T)

  1. pulse (P)
  2. respiration rate (RR)
  3. blood pressure (BP)
  4. Puls oximatry (PsO2) Change in vital signs indicates - ANSWERS-A change in condition When is a pt baselines vital signs obtained? - ANSWERS-on initial contact with pt (compared to trends from previous shifts) Why is a pt basline vital signs important? - ANSWERS-1. to help evaluate: circulatory, pulmonary, endocrine and neurological functioning.
  5. For comparison with subsequent measurments to detect changes and or abnormal findings If there are any significants changes in the vital signs what should you do? - ANSWERS-1. repeat to verify accuracy
  6. get a 2nd health care provider to confirm vital signs How often do we assess vital signs? - ANSWERS-1. Upon admission and transfer from one unit to another
  7. Any time there is a change in a pt condition
  8. Before and after procedures that reqauire anesthesia/sedation
  9. Before and after administering medications that affect cardiovascular or respiratory function or pain level
  10. Before and after any activity that causes them to change
  11. As ordered by the HCP, Unity policy, Transfer of Care Normal body temp range for children: - ANSWERS-98.6 -99.6 F Normal body temp range for adults: - ANSWERS-96.8 - 100.4 F

Normal body temp range for elderly - ANSWERS-96.6 - 98.6 F Rectal temp is - ANSWERS-1 degree higher than oral Axillary temp is - ANSWERS-1 degree lower than oral Body temperature is regulated by - ANSWERS-hypothalamus Factors that affect temperature - ANSWERS-1. Age

  1. Activity/ Excerscise
  2. Sleep
  3. Hormones
  4. Stress
  5. Enviornment
  6. Medication
  7. Illness Sensory input from the skin and major organs initate - ANSWERS-body response to decrease heat reduction and increase heat loss Primary source of heat production is - ANSWERS-metabolism Primary site of heat loss is - ANSWERS-through the skin (vasodilation) 4 mechanisms of heat loss - ANSWERS-Convection Radiation Evaporation Conduction Convection - ANSWERS-The transfer of heat by the movement of a fluid Conduction - ANSWERS-The direct transfer of heat from one substance to another substance that it is touching. Radiation - ANSWERS-heat transfered from the body to a cooler source Evaporation - ANSWERS-transfer of heat when a liquid is changed into a gas Consideraiton for assesing oral temp - ANSWERS-Probe / thermometer placed

placed in the center of the DRY armpit and arm adducted. When is an axillary temp used? - ANSWERS-Used for newborns to avoid perforating the wall of the rectum. Febrile (pyrexia) Hyperthermia - ANSWERS-elevated body temp. > 100.4F Heat Stroke - ANSWERS-very high fever: >104 F Afebrile - ANSWERS-without fever, temp. normal Hypothermia - ANSWERS-body temp. < 97 F When assesing heart rate/ pulse - ANSWERS-Count pressure or pulse waves heart rate (pulse) - ANSWERS-Regulated by Autonomic Nervous System which stimulates the SA node to increase or decrease rate of heart beat (contractions). sympathetic - ANSWERS-increases heart rate Parasympathetic - ANSWERS-decreases heart rate Left Ventricular Contraction - ANSWERS-(squeeze / Systole) Left Ventricular Relaxation - ANSWERS-resting or filling phase / Diastole Right Ventricle - ANSWERS-Pumps blood through the Lung arteries Stroke volume - ANSWERS-volume of blood that enters the arteries with each ventricular contraction. Heart rate (Pulse) - ANSWERS-Palpated or Auscultated number of beats in a minute Cardiac Output (CO) - ANSWERS-HR x SV Assessing the Heart Rate (Pulse) Palpatation - ANSWERS-To Feel:

  1. Middle two - three fingers are placed over the radial artery on the

thumb / palm side of the wrist

  1. Pads of fingers are most sensitive areas for detecting a pulse Assessing the Heart Rate (Pulse) Ascultation - ANSWERS-To Hear:
  2. Stethoscope used for auscultating an apical pulse Assessing the Heart Rate (Pulse) Doppler Ultrasound - ANSWERS-Used to auscultate peripheral pulses that you are unable to palpate. What is the most acurate measure of heart rate in the presence of a dysrhythmia (irregular HR) - ANSWERS-Apical Pulse How to take an apical pulse - ANSWERS-1. Place the stethoscope on the diaphragm: on the midclavicular line (about 3 in. left of the midsternal line)
  3. in between the 5th and 6th ribs (5th intercostal space) Peripheral pulse locations - ANSWERS-Carotid, Brachial, Radial, Popliteal, PT, & DP. Factors that Increase Pulse Tachycardia in an adult - >100 beats/min - ANSWERS-1. Bleeding - increase in pulse when there inadequate oxygen delivered to the tissues and organs. By the negative mechanism these receptors send the signals to the brain and thus stimulate heart to pump faster.
  4. Activity - the heart's compensatory ability attempts to meet the need for increase blood circulation.
  1. Accessory muscles used? Chemoreceptors in the carotid arteries and aorta sense - ANSWERS-O2 (oxygen) / CO2 (carbon Dioxide) / pH (hydrogen ion concentration or Acidosis vs. Alkalosis) levels O2 (oxygen) / CO2 (carbon Dioxide) / pH (hydrogen ion concentration or Acidosis vs. Alkalosis) levels control - ANSWERS-Respiratory rate and depth Respiratory centers of the brain - ANSWERS-brain stem brain stem - ANSWERS-midbrain, pons, medulla oblongata Factors that Increase RR Tachypnea in an adult is a RR > than 24 breaths/min. - ANSWERS-1. Age - A newborn RR ranges from 30- breaths/min
  2. Activity - The RR increases due to the increased energy demands placed upon the body. The rate increases to keep up with these energy demands
  3. Anemia - Decrease in hemoglobin, which carries O2, may increase RR.
  4. Medications - Cocaine and amphetamines, known as "uppers," may increase rate and depth.
  5. Pain - acute pain may increase rate but decrease respiratory depth
  6. Smoking - alters the pulmonary airways causing increased RR, even at rest Factors that Decrease RR

Bradypnea in an adult is a RR < 10 breaths/min. - ANSWERS-1. Age - An older adult has a lower baseline RR. An adult's normal range of RR is 12- breaths / min.

  1. Activity - slower in trained athletes
  2. Medications - Narcotics, sedatives and general anesthetics slow rate and depth
  3. Pain - acute pain may increase rate but decrease respiratory depth Most common and convienent site for assessing blood pressure - ANSWERS-brachial site Alternative sites for assesing blood pressure is - ANSWERS-cuff on thigh and listen to popliteal artery behind knee blood pressure is - ANSWERS-a measure of the pressure exerted by the blood on the walls of the arteries systolic pressure - ANSWERS-(squeeze) maximum pressure exerted on atrial walls with ventricular contraction diastolic pressure - ANSWERS-(ventricular resting) minimum or residual pressure in the arteries and ventricles. Resting phase Normal BP - ANSWERS-less than 120/80 mmHg Prehypertension BP - ANSWERS-120-139/80- Hypertension BP - ANSWERS-140/90 or higher stethoscope - ANSWERS-1. Diaphragm: for blood pressure and lung sounds
  4. Bell: bowl sounds and heart murmurs
  5. Cuff if cuff is too large - ANSWERS-false low BP if cuff is too small - ANSWERS-false high BbP Syphygmomanometer - ANSWERS-blood pressure cuff

Men vs. Women tend to - ANSWERS-have higher BP women BP - ANSWERS-increases after menopause During exercise BP tends to - ANSWERS-increase unless trained athelet BP is higher in people that are - ANSWERS-obese BP is higher in - ANSWERS-in black people Pulse Oximetry (SpO2) used to monitor for - ANSWERS-1. O2 stat intermittent or continous

  1. Hypoxia
  2. With Anesthesia or Sedation
  3. Effectivnes of O2 therapy Normal O2 saturation - ANSWERS-95-100% life-threatening O2 saturation is - ANSWERS-90 and below If O2 stat is low what should you do - ANSWERS-1. Assess and intervene
  4. Tell pt to take deep brath
  5. Reposition up in bed and raise head to high fowlers
  6. Check position of sensor probe
  7. CHeck oxygen supply
  8. check proper placement of nasal canula
  9. check meter flow setting Shallow breathing only fills - ANSWERS-The top part of the lungs Deep breathing fills - ANSWERS-the lungs fully atelectasis - ANSWERS-a complete or partial collapsed of the lung or lobe of the lung atelectasis occurs when - ANSWERS-the tiny air sacs (aveoli) within the lung become deflated What is one of the most common respiratory complications post surgery? - ANSWERS-Atelectasis symptoms of atelectasis - ANSWERS-difficulty breathing (dyspnea) coughing

low grade fever Rapid, shallow breathign (tachypnea) Dyspnea - ANSWERS-difficulty breathing Tachypnea - ANSWERS-rapid shallow breathing Risk factors for atelectasis - ANSWERS-1. Dysphagia

  1. bedrest
  2. abdominal or chest surgery
  3. recent anesthesia
  4. pain
  5. obesity Promoting Proper Breathing - ANSWERS-Turn cough deep breath q2h How do breathing exercises support respiratory function - ANSWERS-1. loosens and mobilizes secretion
  6. Improves pulmonary ventilation
  7. counteracts the effects of anesthesia/ hypoventilation
  8. Expands collapsed alveoli how to teach proper breathing - ANSWERS-1. splint abdomen
  9. take 3 deep breaths :in 2,3,4 out:2,3,
  10. Take deep breath and hold 3 sec then Hack X quick breath through the mouth then cough if a pt is post abdominal incision and it hurts to breath deeply so he is hypoventilating what strategies would you teach - ANSWERS-1. Assess pain level
  11. Elevate head of bed or dangle on side of bed

pursed lip breathing can help releive - ANSWERS-shortness of breath Pursed lip breathing can promote - ANSWERS-general relaxation In pursed lip breathing airway stays open longer which - ANSWERS-decreases the work of breathing Benefits of frequent position change - ANSWERS-1. promotes drainaged of secretions of all areas of the lungs

  1. Stimulates cough reflex
  2. Reduces pain and discomfort
  3. maintains pt airway Use of incentive spirometer - ANSWERS--improve pulmonary ventilation -counteract effects of anesthesia or hypoventilation -loosen respiratory secretions -facilitate respiratory gaseous exchange -expand collapsed alveoli When instructing on using incentive spirometer - ANSWERS-1. inhale slowley like suckign a straw
  4. Hold breath for several seconds before exhaling how does an incentive spirometer encourage deep breathing exercise - ANSWERS-1. Allows pt to watch their progress
  5. provides positive reinforcement for effort hypoxemia - ANSWERS-deficient amount of oxygen in the blood O2 delivery systems - ANSWERS-Nasal canula face mask Benefits of nasal cannula - ANSWERS-1. low flow oxygen can be delivered by the nasal prongs
  6. Does not interfer with speaking or eating/drinking Nursing considerations for nasal canula - ANSWERS-1. easily disloged
  7. can cause drying of the mucosa
  8. can cause irritation over the ear from the strap
  1. if pt is mouth breather it is hard to determine if O2 is being recieved Benefits of face mask - ANSWERS-More precise delivery of a certain percentage of oxygen Nursing Considerations for face mask - ANSWERS-1. Can cause anxiety/ feelings of confinement/ claustrophobia
  2. interferes with eating/drinking
  3. Condensation build up inside mask why would you use a humidify - ANSWERS-1. drying of nasal mucosa
  4. High flow oxygen
  5. Rebreather and Venti masks who can order oxygen therapy - ANSWERS-the HCP because it is considered a med (order will contain the flow rate and method) chest physiotherapy - ANSWERS-a series of maneuvers including percussion, vibration, and postural drainage designed to promote clearance of excessive respiratory secretions. Saftey precautions for O2 - ANSWERS-1. Aviod open flame
  6. No smoking
  7. Maintain electrical devices to prevent sparks
  8. aviod materials that produce static electricity
  9. Aviod using oils Preparing the pt to eat - ANSWERS-1. Check pt diet prior to enterting room
  10. assemble needed supplies
  11. offer pt hand hygeine and toleting
  12. place in comfortable position
  13. provide oral hygien
  14. Provide with clothing protectors
  15. Provide with dentures Saftey precaustions when feeding a pt - ANSWERS-1. Check swallowing and gag reflex first
  16. Check food temperature (do not burn pt)
  1. Soups
  2. No meat Soft mechanical diet - ANSWERS-1. transition to regular diet
  3. pt with difficulty earting
  4. designed for minimal chewing
  5. minimal fiber
  6. Chpped, grounded or puree
  7. cooked veggies Soft mechanical diet does not include - ANSWERS-strong: grains/bran, veggies or raw fruit Regular diet - ANSWERS-1. about 2500
  8. low calorie
  9. low protien
  10. low salt
  11. low fat Homeostasis - ANSWERS-state of equilibrium in the body homeostasis is maintained by - ANSWERS-adaptive responses Body fluids and electrolytes are maintained within - ANSWERS-narrow limits Monitoring intake and output for deficits and surplus = - ANSWERS-monitoring homeostasis/ identifying balances Factors that affect fluid and electrolyte imbalance - ANSWERS-1. dependenc on others for nutrition and fluid
  12. pre op and post op pt
  13. NPO
  14. IV contrast
  15. Nausea and vomiting
  16. Chronic Disease
  1. Aspiration risk 8.Sever trauma
  2. Burns
  3. Wound
  4. Nasogastric suction HCP may order strick I & O on a critical pt where - ANSWERS-fluid overload is a high risk (renal pt, cardiac pt) We record for I&O: - ANSWERS-foley cath IV infusion surgical drains NG tube When do nurses initiate I&O as a nursing order - ANSWERS-when pt status indicates imbalance or spuspected Fluid intake and output is measured in - ANSWERS-ml 1 cup - ANSWERS-8 oz 8oz - ANSWERS-240mL 1oz - ANSWERS-30mL 1000mL - ANSWERS-1L 1GM - ANSWERS-1ml 1l - ANSWERS-1kg What is measured as oral intake - ANSWERS-oral fluids: beverage and water taken with meds Ice chips: recorded as 1/2 the orifinal amount Any food that is liquid at room temp What is measured as non oral intake - ANSWERS-Tube feeding

I&O is evaluated every - ANSWERS-24 hr Identify deficits - ANSWERS-early to prevent sever imbalances Monitoring I&O is an ongoing evaluation of the pt - ANSWERS-hydration status Neurological symptoms of over hydration - ANSWERS-1. change in loss of contious

  1. confusion
  2. headache
  3. seizures Respiratory symptoms of over hydration - ANSWERS-Pulminary congestion Cardiovascular symptoms of over hydration - ANSWERS-tachycardia GI symptoms of over hydration - ANSWERS-Anorexia nausea Overhydration can cause - ANSWERS-dependent pitting edema function of large intestine - ANSWERS-water absorption formation of feces expultion of feces through perastalsis factors that affect Elimination - ANSWERS-1. developmental stage
  4. daily patterns
  5. fluid food intake 4.level of activity
  6. lifestlye
  7. emotional state
  8. Pathologic process
  9. medication
  10. Diagnstic and surgery Factors that affect constipation - ANSWERS-bedrest

constipating meds reduced fluids or bulk diet depression CNS disease Lesions Hypotonic solution enema (Tap wate) - ANSWERS-500ml-1000ml flow of water is out of bowl to mucosa low to high swells mucos to stilulate paritslis Adverse effects of hypotonic solution enema - ANSWERS-water toxicity circulatory overload fluid and electrolyte embalance Hypotonic enema should not be repeated more than - ANSWERS-3 times Isotonic enema ( .9 Saline) - ANSWERS-large or small volume equal concentration on both sides safest adverse effects of isotonic enema - ANSWERS-fluid and electrolyte embalance sodium retention In an isotonic enema never repate more than - ANSWERS-3 times hypertonic solution enema - ANSWERS-70-130 ml small volume water out of the mucosa into the bowl higher to lower concentration irritates mucosa and distends bobwl to cause paristalis adverse effects of hypertonic solution enema - ANSWERS-sodium retention Hypertonic enema can only be done - ANSWERS-1 time