Nursing 113 Exam 1

Nursing 113 Exam 1 Normal WBC 3.8 - 10.6 How to put on PPE Hand hygiene, Gown then mask followed by gloves How to remove PPE Gloves, gown, then mask followed by hand hygiene Norm for Psychosocial Assessment Behavior is appropriate for situation. Initiates conversation. Makes eye contact. Ask appropriate questions about hospitalization, procedures/treatments & illness in a reasonable manner. Anxiety level does not interfere with ability to follow directions. Expressed religious needs are being met. objective data seeing, hearing, smelling something about a patient subjective data complaints by the patient such as itching, aching, nausea or pain initial/background assessment a patient comes into the ED and a history and physical are done as part of the admission process problem focused assessment A patient is complaining of pain, and we then find that the chief complaint is chest pain Emergency Assessment a nurse goes into a patient's room and checks patient for ABC's, finds that they are not breathing and decides to perform CPR Ongoing Assessment everyday per unit standards we are assessing the patient while in the hospital OR we have a follow up appointment with a patient who had a transplant supine laying on back prone laying on stomach dorsal recumbent lying on back with legs bent and feet flat lithotomy examination position in which the client is lying on his or her back with the feet in stirrups. direct inspection a nurse is doing ____ when he or she lifts a patient's sheets to look at their feet indirect inspection x-ray, CT scan, use of a stethoscope are all used by the nurse to enhance visualization Inspection for Adults looking at a patient from head to toe is typically called Inspection for Children looking at a patient from least to most invasive methods is called palpation gentle application of the hands to a specific structure or body area to determine size, consistency, texture, symmetry, and tenderness of underlying structures direct auscultation listening without a stethoscope indirect auscultation listening with a stethoscope light pressure low pitched sounds firm pressure high pitched sounds what is the order when reporting Vitals T, P, R, BP, Pain, SPO2 what is the 6th vital sign? pain normal temp 36-38 C most common temp for infants rectal temp What is the correct order of Assessment? Inspection, Auscultation, Palpation febrile feverish femoral pulse Pulse felt on either side of the groin popliteal pulse pulse located behind the knee posterior tibial pulse Pulse felt on inside of either ankle dorsalis pedis pulse along top of foot between extension tendons or great and first toe. Used to assess status of circulation in foot carotid pulse the pulse felt along the large carotid artery on either side of the neck character of pulse rate, rhythm, strength, and equality newborn pulse 100-170 bpm infant to 2 years pulse 80-130 bpm 2-6 years pulse 70 - 120 bpm 6-10 years pulse 70-110 bpm 10 - adulthood pulse 60-100 bpm respiration