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NR 302 final reviewerythema - correct answer ✔✔white skin is redness of the skin produced by capillary congestion
objective data - correct answer ✔✔measurable data, for example vital signs
after completing an initial assessment on a pt, the nurse charts, vital signs as temp of 100.1 oral, apical
HR 98 irregular, RR 24 shallow, B/P 128/90, pulse ox of 90% on RA, what are you worried about - correct
answer ✔✔oxygenation, infection, activity intolerance, capillary refill greater than 3 seconds
during assessment of the lower extremities of a male patient the nurse is unable to palpate the dorsalis
pedis pulse, what action should the nurse take first - correct answer ✔✔reposition the fingers and assess
again
what is a Doppler? - correct answer ✔✔is a test that uses high frequency sound waves (ultrasound) to
measure the amount of blood flow through your arteries and veins, usually those that supply blood to
your arms and legs
an example of objective data obtained during the physical assessment includes - correct answer
✔✔audible and auscultated inspiratory wheeze, 2x2 cm stage 1 pressure ulcer on right ankle, crackles
that clear with cough
audible vs. ausculated - correct answer ✔✔auscultated is hearing through stethoscope while audible is
heard within the room
what does clears with cough mean - correct answer ✔✔hear normal sounds after patient coughs
level of consciousness - correct answer ✔✔objective data, alert, lethargic, stuporons, and comatose
orientation x 4 - correct answer ✔✔person, place, time, situation
, a mother is at the clinic with her 2 year old son, "he wont go to sleep at night and during the day he has
several fits" I get so upset when this happens, the nurses best verbal response would be - correct answer
✔✔to clarify and get more information, fits?, tell me what you mean by this
what are non-therapeutic communcation - correct answer ✔✔asking closed ended questions, medical
jargon, talking too much, asking why questions
which of the following statements illustrates the use of open-ended questions - correct answer
✔✔builds and enhances rapport, used when narrative information is needed
therapeutic communication techniques - correct answer ✔✔assists the narrative, open-ended questions,
repeating what patient says for clarification
a patients reason for seeking care is shortness of breath, when obtaining a health history, which of these
questions by the nurse would obtain the most helpful information - correct answer ✔✔will you please
describe the activities that cause you to be short of breath
components of a health history - correct answer ✔✔biographical data, review of systems, functional
assessment, activities of daily living
the nurse is collecting data about a patients smoking history, the patient admits to smoking 1.5
packs/day for the last 10 years, the nurse documents the patient has a smoking history of how many
pack-years - correct answer ✔✔15 pack years
what is the relationship between sleep and smoking? - correct answer ✔✔decreases sleep by
interrupting the latency cycle which is the time of complete wakefulness to the lightest REM (rapid eye
movement) sleep
pack year formula - correct answer ✔✔number of cigarettes times the years divided by 20
during an exam the nurse notices the patient has round, flat red lesions on the skin of the forearm, the
nurse suspects - correct answer ✔✔petechiae which is bleeds under the skin that confluence
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