Ad lib Correct Answer at liberty (client can move around
freely)
after their reason of care, you collect the Hisotry of Presenting
Illness (HPI) what does this entail? Correct Answer collected
using open ended questions and having the person explain
symptoms
- ask using the eight critical categories (OLD CARTS)
- document in choronological order (first event until present)
- repeat back to client using summary
Onset: When did the syptoms begin? and frequency
Location: specific location, point to where it hurts
Duration: how long do symptoms last?
Characteristics: describe
Aggrevating/alleviating factors: what makes it better/ worse?
Related symptoms: are there other sympomts because of this?
Treatment: what treatments have you tried?
Severity: intensity, scale
- each symptoms goes through this order
are alcohol based hand rubs appropriate as a hand hygiene
method? Correct Answer yes if hands are not visibly soiled
- advantage of taking less time than soap and water, kills more
organisms quickly, and less damaging to the skin
,- use sufficent product, rub hands and fingers together for 20-30
seconds
*** use hand washing when hands are visibly soiled or when
clients are infected with wpore-forming organisms such as C.
diff.
BID Correct Answer twice a day
BK Correct Answer below knee
BP Correct Answer blood pressure
C & S Correct Answer culture and sensitivity
c/o Correct Answer complains of
can clinical judgement and clinical reasoning be delegated?
Correct Answer Not to everyone
- RN and PN are responsible for the portions of client care that
involved clinical reasoning
- AP can collect vital signs, ADL assistance and measurement of
height and weight
Cath Correct Answer catheter
CBC Correct Answer complete blood count
CPR Correct Answer cardiopulmonary resuscitation
CXR Correct Answer chest x-ray
,DNR Correct Answer do not resuscitate
DX Correct Answer diagnosis
Explain factors of a BP assessment Correct Answer - upper
extremiites are preferred, but can be taken from thigh
- uses a sphygmomanometer and stethoscope
- be sure cleitn is relaxed and has not eaten, smokes, or
excerised for 30 min before the measurement (resting for 5 min
before assessing BP)
- put cuff on arm to where is will not fall off and two fingers can
fit underneath
- do not use extremity with a shunt, casts, lesions
Explain inspection during a PA Correct Answer looking
carefully and throughly at a clien, most revealing and provides a
lot of information
- begins the moment you step into client's room
- begin with general survey from head to toe and maintain
organized approach, offers overall impression of a client and
serverity of situation
- sense of smell can provide clues or unusual body odor for
underlying infection, lack of personal hygiene, underlying
condition
- each body system should be assessed but a more thorough
focused examination of a body system is needed if you discover
an unexpected finding
- need visibility of the feet, accessibly from both sides of the
exam table, given gown and privacy
, explain the axillary temperature route Correct Answer - less
accurate and used less frequently, measures surface body
temperature
- safe for infants and children, second preferred in infants/ kids
- when recoring temperatrue write the temperate followed by Ax
so the nurse knows to add one degree
explain the oral temperature route Correct Answer - most
frequently used adn preferred in most situations
- oral sublingual site has a rich blood supply that quickly
respond to changes from the inner core
- cannot measure temperature for clients who are confused,
uncooperative, orally intubated or hisotory of seizures
- not reccomeneded in children 5 and younger
- ensure the client has not smoked, exercised, or had oral intake
recently.. wait 10 to 30 min if so
- document with the tempo reading so the person knows the
route when reading medical record
explain the rectal temperature route Correct Answer - most
accurate reading but should only go this route when necessary
because its invasive and risk for damage of rectal tissue
- preferred for infants under the age of 1 for the most accurate
reading sicne baby temp flucuates
- record the temperature number with the temp follwed by R so
the nurse knows to subtract one degree
explain the temporal artery temperature route Correct Answer -
acruate temperature
- useful for confused or unconscious clients adn children
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