NSG 312 – Nursing Assessment Final Exam Comprehensive Review and Study
Guide
What are universal fall precautions? - correct answer ✔✔Universal fall precautions are called
"universal" because they apply to all patients regardless of fall risk. Universal fall precautions
revolve around keeping the patient's environment safe and comfortable.
-Familiarize the patient with the environment.
-Have the patient demonstrate call light use.
-Maintain call light within reach.
-Keep the patient's personal possessions within patient safe reach.
-Have sturdy handrails in patient bathrooms, room, and hallway.
-Place the hospital bed in low position when a patient is resting in bed; raise bed to a
comfortable height when the patient is transferring out of bed.
-Keep hospital bed brakes locked.
-Keep wheelchair wheel locks in "locked" position when stationary.
-Keep nonslip, comfortable, well-fitting footwear on the patient.
-Use night lights or supplemental lighting.
-Keep floor surfaces clean and dry. Clean up all spills promptly.
-Keep patient care areas uncluttered.
-Follow safe patient handling practices.
Possible causes of chest pain - correct answer ✔✔-Cardiac
-Aortic
-Musculoskeletal
-Pleural
-Gastrointestinal
,-Pulmonary
-Psychoneurotic
-Rule out cardiac before other options
-Chest pain in children and adolescents is seldom due to a cardiac problem.
-In assessment of chest pain in adults - assume cardiac until proven otherwise
Where should you start counting intercostal spaces? - correct answer ✔✔The angle of Louis
(also called the sternal angle)
is a useful place to start counting ribs.
If you find the sternal notch,
walk your fingers down the manubrium
a few centimeters until you feel
a distinct bony ridge. This is the sternal angle.
The 2nd rib is continuous with the sternal angle;
slide your finger down to localize the 2nd intercostal space.
The angle of Louis also marks the site of bifurcation
of the trachea into the right and left main bronchi
and corresponds with the upper border of the atria of the heart
Where do you palpate on the chest? - correct answer ✔✔Palpate the base, left sternal border
and apex
Mid-clavicular line, 5th intercostal space, palpate PMI with one finger (located under breast
tissue in women)
, assess location of PMI
(point of maximal impulse or apical impulse)
Order of auscultation of the heart. - correct answer ✔✔A- aortic
P - pulmonic
T - tricuspid
E - erbs point
M - mitral
22345
Second ICS R of sternum
Second ICS L of sternum
Third ICS L of sternum
Fourth ICS L of sternum
Fifth ICS mid clavicular
Use of the Stethoscope:
-diaphragm
-bell - correct answer ✔✔Diaphragm
-High pitched sounds
-Best for hearing S1 and S2
-(bowel, breath, normal cardiac)
Bell
-Low pitched sounds
Guide
What are universal fall precautions? - correct answer ✔✔Universal fall precautions are called
"universal" because they apply to all patients regardless of fall risk. Universal fall precautions
revolve around keeping the patient's environment safe and comfortable.
-Familiarize the patient with the environment.
-Have the patient demonstrate call light use.
-Maintain call light within reach.
-Keep the patient's personal possessions within patient safe reach.
-Have sturdy handrails in patient bathrooms, room, and hallway.
-Place the hospital bed in low position when a patient is resting in bed; raise bed to a
comfortable height when the patient is transferring out of bed.
-Keep hospital bed brakes locked.
-Keep wheelchair wheel locks in "locked" position when stationary.
-Keep nonslip, comfortable, well-fitting footwear on the patient.
-Use night lights or supplemental lighting.
-Keep floor surfaces clean and dry. Clean up all spills promptly.
-Keep patient care areas uncluttered.
-Follow safe patient handling practices.
Possible causes of chest pain - correct answer ✔✔-Cardiac
-Aortic
-Musculoskeletal
-Pleural
-Gastrointestinal
,-Pulmonary
-Psychoneurotic
-Rule out cardiac before other options
-Chest pain in children and adolescents is seldom due to a cardiac problem.
-In assessment of chest pain in adults - assume cardiac until proven otherwise
Where should you start counting intercostal spaces? - correct answer ✔✔The angle of Louis
(also called the sternal angle)
is a useful place to start counting ribs.
If you find the sternal notch,
walk your fingers down the manubrium
a few centimeters until you feel
a distinct bony ridge. This is the sternal angle.
The 2nd rib is continuous with the sternal angle;
slide your finger down to localize the 2nd intercostal space.
The angle of Louis also marks the site of bifurcation
of the trachea into the right and left main bronchi
and corresponds with the upper border of the atria of the heart
Where do you palpate on the chest? - correct answer ✔✔Palpate the base, left sternal border
and apex
Mid-clavicular line, 5th intercostal space, palpate PMI with one finger (located under breast
tissue in women)
, assess location of PMI
(point of maximal impulse or apical impulse)
Order of auscultation of the heart. - correct answer ✔✔A- aortic
P - pulmonic
T - tricuspid
E - erbs point
M - mitral
22345
Second ICS R of sternum
Second ICS L of sternum
Third ICS L of sternum
Fourth ICS L of sternum
Fifth ICS mid clavicular
Use of the Stethoscope:
-diaphragm
-bell - correct answer ✔✔Diaphragm
-High pitched sounds
-Best for hearing S1 and S2
-(bowel, breath, normal cardiac)
Bell
-Low pitched sounds
