NURS 301 Health Assessment Exam 2 Review –
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Terms in this set (55)
How long should you count RR or HR 1 full minute
if they are abnormal?
How long should you count HR if the 1 full minute
patient is about to receive a beta
blocker?
What is the expected SpO2 (Oxygen 95-100%
Saturation) -range for a normal
person?
What is the expected SpO2 for a Low 90s
patient with COPD?
What causes pallor (pale) skin? ♥ Anemia
♥ shock
♥ local arterial insufficiency
What causes cyanosis (blue skin)? Hypoxia (deoxygenated hemoglobin)
What causes erythema (red skin)? ♥ Inflammation
♥ polycythemia (increased amount of RBCs in blood)
♥ fever
♥ alcohol intake
♥ rash
♥ sunburn
What causes jaundice (yellow skin)? ♥ Hepatic dysfunction
♥ RBC destruction
, What causes brown discoloration of ♥ Addison's disease (bronze appearance)
skin? ♥ Venous stasis dermatitis
What consideration should you keep Alterations is skin color may be less obvious
in mind when assessing skin color of Assess nail beds, mucus membranes, and the sclera
patients with darker skin? of the eyes for discoloration
What is the difference between Pitting edema is when an indentation remains after
"pitting" and "non-pitting" edema? pressure is applied to the edematous area.
Non-pitting edema does not do this
How do you assess for pitting edema? Use the index finger to press firmly for 5 seconds
over a bony prominence in the edematous area (like
the tibia, or medial malleolus).
A depression left in the skin indicates edema.
Document based on depth of indentation.
How would you document pitting 0 = no pitting edema
edema? 1+ = Slight pitting, 2mm depth
2+ = Moderate pitting, 4mm depth
3+ = Deep pitting, 6mm depth
4+ = Very deep pitting, 8mm depth
Divide the pit depth in mm by 2 to get the pitting
level!
What are you assessing when 1. Inspect size, shape, thickness, and cleanliness
conducting a nail assessment? 2. Assess angle between nail plate and skin
(expected is an angle less than or equal to 160 deg -
assessing for clubbing)
3. Assess capillary refill (expected is less than or
equal 2 seconds)
Questions With Trusted Solutions
Save
Terms in this set (55)
How long should you count RR or HR 1 full minute
if they are abnormal?
How long should you count HR if the 1 full minute
patient is about to receive a beta
blocker?
What is the expected SpO2 (Oxygen 95-100%
Saturation) -range for a normal
person?
What is the expected SpO2 for a Low 90s
patient with COPD?
What causes pallor (pale) skin? ♥ Anemia
♥ shock
♥ local arterial insufficiency
What causes cyanosis (blue skin)? Hypoxia (deoxygenated hemoglobin)
What causes erythema (red skin)? ♥ Inflammation
♥ polycythemia (increased amount of RBCs in blood)
♥ fever
♥ alcohol intake
♥ rash
♥ sunburn
What causes jaundice (yellow skin)? ♥ Hepatic dysfunction
♥ RBC destruction
, What causes brown discoloration of ♥ Addison's disease (bronze appearance)
skin? ♥ Venous stasis dermatitis
What consideration should you keep Alterations is skin color may be less obvious
in mind when assessing skin color of Assess nail beds, mucus membranes, and the sclera
patients with darker skin? of the eyes for discoloration
What is the difference between Pitting edema is when an indentation remains after
"pitting" and "non-pitting" edema? pressure is applied to the edematous area.
Non-pitting edema does not do this
How do you assess for pitting edema? Use the index finger to press firmly for 5 seconds
over a bony prominence in the edematous area (like
the tibia, or medial malleolus).
A depression left in the skin indicates edema.
Document based on depth of indentation.
How would you document pitting 0 = no pitting edema
edema? 1+ = Slight pitting, 2mm depth
2+ = Moderate pitting, 4mm depth
3+ = Deep pitting, 6mm depth
4+ = Very deep pitting, 8mm depth
Divide the pit depth in mm by 2 to get the pitting
level!
What are you assessing when 1. Inspect size, shape, thickness, and cleanliness
conducting a nail assessment? 2. Assess angle between nail plate and skin
(expected is an angle less than or equal to 160 deg -
assessing for clubbing)
3. Assess capillary refill (expected is less than or
equal 2 seconds)
