NUR 275 final Exam/90 Q’s and
A’s
things to consider to determine acuity - -A: airway B: breathing C: circulation
D: change in awareness
-what does a general survey include? - -appearance, body structure,
comfortability, position, stated vs appeared age, facial expression, smell. etc.
-how do you verify level of coniosuness? - -person, place, time, event
-what nursing technique does a general survey utilize? - -inspection
-subjective vs objective data - -subjective: what the patient tells you
objective: what you see, smell, hear, observe
-subjective data includes... - -HPI, family history, review of systems, social
history
-objective data includes... - -physical exam, appearance, things you see
about patient
-what is the first step when interact with patient? - -develop trust and
rapport, introduce self, provide privacy, hand hygiene, verify ID of patient
-who typically collects subjective data? - -nurse
-what does a nurse do with a teenager who is experiencing abuse? - -ask
them the origin of the abuse, be kind, tell the charge nurse and report to
DHS and/or parents
-what does ADPIE mean? - -assessment, diagnosis, planning,
implementation, evaluation
-contact precaution equipment - -gloves and gown
-droplet precaution equipment - -gown, mask, protective eyewear, gloves
-airborne precaution equipment - -N95 or respirator, negative pressure air
room
-standard precautions - -wear gloves when contact with bodily fluid may
happen, hand hygiene
, -what is a collaborative problem? - -physiologic problems that are at risk to
occur or have occurred that require both medical and nursing interventions
to treat; collaborate with the patient and may need to collaborate with other
providers too
-nurses response to a collaborative problem by - -reporting to other
providers, following orders, monitoring, working with patient
-why do nurses need to self reflect - -so know own biases and judgements
before enter room
-when do you use diaphragm of stethoscope? - -heart, abdomen, lungs,
high pitched sounds; always compare sides of lungs
-when do you use bell of stethoscope? - -heart (murmurs, bruits), low
pitched sounds
-normal order of assessment - -inspect, percuss, palpate, auscultate
-exception to normal order of assessment - -abdomen: inspect, auscultate,
percuss, palpate
-comprehensive assessment performed when... - -patient first comes into
care
-focused assessment performed when... - -certain area of body part is
complained about, like at a clinic (must have comprehensive baseline)
-partial assessment performed when... - -every time the nurse interacts
with the patient after the comprehensive assessment; focus on what is
wrong and assess that
-emergent assessment performed when... - -emergency situation and only
need vital information; only focus on problem at hand
-central cyanosis vs peripheral cyanosis - -central cyanosis is a result of a
cardiopulmonary problem and peripheral cyanosis is probably a local
problem resulting from vasoconstriction; look for central cyanosis in oral
mucosa; body parts appear blue; peripheral is extremeties
-normal temperature for adults - -96- 99 degrees Fahrenheit orally; lowest
early in morning; tympanic 1 degree higher, axillary 1 degree lower
-normal temperature for elderly - -95- 97.5 degrees Fahrenheit
-normal pulse for adults - -+2, 60-100 bpm
A’s
things to consider to determine acuity - -A: airway B: breathing C: circulation
D: change in awareness
-what does a general survey include? - -appearance, body structure,
comfortability, position, stated vs appeared age, facial expression, smell. etc.
-how do you verify level of coniosuness? - -person, place, time, event
-what nursing technique does a general survey utilize? - -inspection
-subjective vs objective data - -subjective: what the patient tells you
objective: what you see, smell, hear, observe
-subjective data includes... - -HPI, family history, review of systems, social
history
-objective data includes... - -physical exam, appearance, things you see
about patient
-what is the first step when interact with patient? - -develop trust and
rapport, introduce self, provide privacy, hand hygiene, verify ID of patient
-who typically collects subjective data? - -nurse
-what does a nurse do with a teenager who is experiencing abuse? - -ask
them the origin of the abuse, be kind, tell the charge nurse and report to
DHS and/or parents
-what does ADPIE mean? - -assessment, diagnosis, planning,
implementation, evaluation
-contact precaution equipment - -gloves and gown
-droplet precaution equipment - -gown, mask, protective eyewear, gloves
-airborne precaution equipment - -N95 or respirator, negative pressure air
room
-standard precautions - -wear gloves when contact with bodily fluid may
happen, hand hygiene
, -what is a collaborative problem? - -physiologic problems that are at risk to
occur or have occurred that require both medical and nursing interventions
to treat; collaborate with the patient and may need to collaborate with other
providers too
-nurses response to a collaborative problem by - -reporting to other
providers, following orders, monitoring, working with patient
-why do nurses need to self reflect - -so know own biases and judgements
before enter room
-when do you use diaphragm of stethoscope? - -heart, abdomen, lungs,
high pitched sounds; always compare sides of lungs
-when do you use bell of stethoscope? - -heart (murmurs, bruits), low
pitched sounds
-normal order of assessment - -inspect, percuss, palpate, auscultate
-exception to normal order of assessment - -abdomen: inspect, auscultate,
percuss, palpate
-comprehensive assessment performed when... - -patient first comes into
care
-focused assessment performed when... - -certain area of body part is
complained about, like at a clinic (must have comprehensive baseline)
-partial assessment performed when... - -every time the nurse interacts
with the patient after the comprehensive assessment; focus on what is
wrong and assess that
-emergent assessment performed when... - -emergency situation and only
need vital information; only focus on problem at hand
-central cyanosis vs peripheral cyanosis - -central cyanosis is a result of a
cardiopulmonary problem and peripheral cyanosis is probably a local
problem resulting from vasoconstriction; look for central cyanosis in oral
mucosa; body parts appear blue; peripheral is extremeties
-normal temperature for adults - -96- 99 degrees Fahrenheit orally; lowest
early in morning; tympanic 1 degree higher, axillary 1 degree lower
-normal temperature for elderly - -95- 97.5 degrees Fahrenheit
-normal pulse for adults - -+2, 60-100 bpm
