NUR 216 FINAL EXAM REVIEW QUESTIONS
General survey components - Answers - A written summary of overall health
Gather information from the first initial encounter with patient, make observations
throughout assessment
Done at first encounter
What is included in the general survey components - Answers - Physical appearance
Body structure
Mobility
Behavior
Vital signs
First orientation to be lost - Answers - Time
Subjective data - Answers - pt report symptoms
Objective data - Answers - Observed
Precautions - Answers - Use gloves in situations involving possible contact with blood or
bodily fluids, mucous membranes, non-intact skin (ex. exposed skin that is chapped,
abraded or with dermatitis)
Ranges for RR - Answers - Normal 12-20
Low >12 = COPD
High <1 = dehydration, respiratory distress, anxiety, fever
Ranges for HR - Answers - Normal 60 to 100/min
Lower than 60 (bradycardia)
Higher than 100 (tachycardia)
Ranges for BP - Answers - Normal 120/80
Elevated - 120-129 / <80 (ATI book 141)
HTN Stage 1 - 130--89
HTN Stage 2 - > or = 140 / > or = 90
HTN with 3 separate visits
Hypotension - systolic < 90
Ranges for SpO2 - Answers - Normal 95-100%
Hypoxia - below 90% (ATI)
Temperature ranges - Answers - 36 - 38 degrees Celsius
96.8 - 100.4 degrees Fahrenheit
, Sodium intake effects on BP - Answers - Raises BP
Pulse oximeter alternate locations when fingers are unavailable - Answers - Earlobe
Factors that affect HR - Answers - Exercise (however, marathon runners will have
bradycardia for resting HR)
Fever
Medications
Changing positions
Acute pain
Hyperthyroidism
Anemia
Stress
Shock
Types of pain - Answers - Visceral - dull crampy, organ pain
Somatic - joint, muscles, ligament pain
Neuropathic - related to nerves, diabetics have this type of pain
Acute - < 6 months
Chronic - > 6 months
PQRST - Answers - Provoking - what makes it better or worse?
Quality - what does it feel like?
Region - where is the pain located?
Severity - pain rating
Timing - onset/duration
How to appropriately utilize an interpreter - Answers - Nurse must provide a trained
interpreter
Nurse should speak directly to the client
Nurse should avoid medical jargon just like any client
Interpreter should be used for the entire assessment
Appropriate actions to delegate to the UAP - Answers - Ambulation
Recording intake
Recording output
Taking vitals
Hygiene
ADPIE - Answers - Assessment
Diagnosis
Planning
Interventions
Evaluation
Ethical principles - Answers - Autonomy
General survey components - Answers - A written summary of overall health
Gather information from the first initial encounter with patient, make observations
throughout assessment
Done at first encounter
What is included in the general survey components - Answers - Physical appearance
Body structure
Mobility
Behavior
Vital signs
First orientation to be lost - Answers - Time
Subjective data - Answers - pt report symptoms
Objective data - Answers - Observed
Precautions - Answers - Use gloves in situations involving possible contact with blood or
bodily fluids, mucous membranes, non-intact skin (ex. exposed skin that is chapped,
abraded or with dermatitis)
Ranges for RR - Answers - Normal 12-20
Low >12 = COPD
High <1 = dehydration, respiratory distress, anxiety, fever
Ranges for HR - Answers - Normal 60 to 100/min
Lower than 60 (bradycardia)
Higher than 100 (tachycardia)
Ranges for BP - Answers - Normal 120/80
Elevated - 120-129 / <80 (ATI book 141)
HTN Stage 1 - 130--89
HTN Stage 2 - > or = 140 / > or = 90
HTN with 3 separate visits
Hypotension - systolic < 90
Ranges for SpO2 - Answers - Normal 95-100%
Hypoxia - below 90% (ATI)
Temperature ranges - Answers - 36 - 38 degrees Celsius
96.8 - 100.4 degrees Fahrenheit
, Sodium intake effects on BP - Answers - Raises BP
Pulse oximeter alternate locations when fingers are unavailable - Answers - Earlobe
Factors that affect HR - Answers - Exercise (however, marathon runners will have
bradycardia for resting HR)
Fever
Medications
Changing positions
Acute pain
Hyperthyroidism
Anemia
Stress
Shock
Types of pain - Answers - Visceral - dull crampy, organ pain
Somatic - joint, muscles, ligament pain
Neuropathic - related to nerves, diabetics have this type of pain
Acute - < 6 months
Chronic - > 6 months
PQRST - Answers - Provoking - what makes it better or worse?
Quality - what does it feel like?
Region - where is the pain located?
Severity - pain rating
Timing - onset/duration
How to appropriately utilize an interpreter - Answers - Nurse must provide a trained
interpreter
Nurse should speak directly to the client
Nurse should avoid medical jargon just like any client
Interpreter should be used for the entire assessment
Appropriate actions to delegate to the UAP - Answers - Ambulation
Recording intake
Recording output
Taking vitals
Hygiene
ADPIE - Answers - Assessment
Diagnosis
Planning
Interventions
Evaluation
Ethical principles - Answers - Autonomy
