West Coast University, ATI|NURS 100 Nursing Fundamental Final Study Guide,100% CORRECT
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NURS 100
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NURS 100
West Coast University, ATI|NURS 100 Nursing Fundamental Final Study Guide
WEEK 1
- Medical Asepsis – CLEAN TECHNIQUE
- Surgical asepsis – STERILE TECHNIQUE
- Clean the last soiled areas first to prevent moving more contaminate
- Vital Signs
o BP: Less than 120/80 NORMAL
o NOTE: 120/8...
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West Coast University, ATI|NURS 100 Nursing Fundamental Final Study Guide
WEEK 1
- Medical Asepsis – CLEAN TECHNIQUE
- Surgical asepsis – STERILE TECHNIQUE
- Clean the last soiled areas first to prevent moving more contaminate
- Vital Signs
o BP: Less than 120/80 NORMAL
o NOTE: 120/80 is considered prehypertension
- Oxygen Saturation: 95-100 unless COPD then it is okay to be normal.
o Example – if a patient that has COPD and is on oxygen and their O2 saturation
is 99% that’s a problem since its too damn high for COPD
- Respiratory Rate: 12-20 Breaths/minute
o NORMAL
- Pulse Rate: 60-100 Beats/Minute
o Normal
- Temperature: 96.8-100.4
o Rectal Temp is 0.9F higher than oral and tympanic
o Axillary temp is 0.9F lower than oral and tympanic
o Temporal is 1F higher than oral and 2F higher than axillary
- Know PQRST for assessing patient with pain
o Provocation: What caused it?
o Quality: What does it feel like?
o Radiate:where does it hurt?location?
o Scale:Severity 0-10
o Time-how long has it been hurting
- Prioritizing vital signs; who to assess first(Remember ABC)
o Baby with high fever and diarrhea for three days
o Older patient with diarrhea for days and cant breath.
- Korotkoff Sounds
o Phase 1: Characterized by first appearance of faint; first sound of systolic
o Phase 2: Characterized by muffle/swishing. Sounds may also temporarily
disappear also called auscultatory gap
o Phase 3: Characterized by distinct, loud sound as blood flows relatively free
through an increasingly open artery
o Phase 4: Characterized by distinct, abrupt, muffling sound with sound, blowing
quality. Considered to be the first diastolic pressure
, o Phase 5: The last sound heard before period of continuous silence. Also the second
diastolic pressure
- Communication(therapeutic/non therapeutic)
o Do not ask WHY
o Use open ended questions and
o Touch is therapeutic
▪ Sympathetic touch on a patient who just found out they have cancer
, WEEK 2
- Know Head to toe assessment and know why you’re checking them – BRADEN SCALE
- Skin turgor
o Use to check for dehydration
o Grasp a skin fold on the chest under the clavicle, release it, and note whether it
springs back.
o If you see “tenting” occur, it can mean that patient is dehydrated
o LOOK AT STERNAL BORDER (so CLAVICLE is CLOSEST to STERNUM)
- PERRLA
o P: Pupil clear
o E: Equal and between 3-7 mm in diameter
o R: Round
o RL: Reactive to light
o A: Accommodation
- Abnormal breath Sound
o Crackles: Coarse bubbly sound like rice Krispy; usually with pneumonia, HF,
bronchitis, when there's fluid in the lungs
o Wheezing: High pitched whistling; usually with asthma, tumors or buildup
secretion
o Rhonchi: Coarse, loud, low pitch; snoring/COPD patients
o Absence of breath: from lung collapse of atelectasis (do not hear lung sounds)
o Stridor: Airway obstruction in children; barking sound(choking); is an Emergency
- 5 landmarks for heart (APETM)
o Aortic; Right 2nd intercostal
o Pulmonic; Left 2nd Intercostal
o Erb; left 3rd intercostal
o Tricuspid; left 4th intercostal
o Mitral; Left 5th intercostal; also, site of maximal impulse AKA apical pulse
- Abdomen Assessment:
o Inspect, Auscultate, percuss, palpate (Big on abdomen)
o Auscultate order: Right lower→ Right upper→ Left upper→ Left Lower
- When checking for pulse; you PALPATE
- When checking Capillary refill
o When checking refill, it should refill within 2 seconds
o If it takes 3-4 seconds, it is unexpected finding
o Assess by applying firm pressure to the nail bed to blanch it.
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