study guide
EXAM 1 Study Guide
The exam will be 60 questions (multiple choice, drag and drop, select all that apply, and a
calculation). All questions are worth 2.5 points. 1st exam worth 150 points and it will cover
units 1 and 2. Here are a few areas that you can expect to see on your exam.
Unit 1 – Ch 1, 2, 3, 4, 5, 29
Unit 2 – Ch 8, 9, 10, 11
THE PROCEDURE
o Pt doesn’t need a complete head to toe physical every 24 hr stay
o Initial Assessment 1 – note anything that needs continuous monitoring
o Initial Assessment 2 – basic reassess for adults in med, surg, cardiac stepdown care areas
Then specialized to each adult
o Health Hist Sequence 1
Verify markers/flags on way to room – isolations, allergies, fall precaution
Once inside room introduce, wash hands, make eye contact & ask how theyre
feeling/any pain or discomfort/how they spent previous shif
o Health Hist Seq 2
Refer to what u heard from previous shif
Offer water as courtesy (if pt is not NPO) – indicates pt is able to hear, follow
directions, ability to swallow, etc
General appearance, verify name band
o Vitals: Temperature, Pulse, Respiration, BP, pulse oximetry, pain level (1-10), if pain med
given then note response in 15 mins for IV admin to 1 hr for oral admin
o THINGS TO DO (activity)
If pt is on bed rest HOB should greater than 15 degs as pt at risk for skin
breakdown
If SCD(Sequential compression device)s ordered then note that & follow
protocol
If ambulatory assist to sitting level and move to chair
Not any resistance needed & ability to transfer
Assess need for aid or equipment
Complete standardized scales per protocol to quantify fall risk
Complete documentation
SKILLS performed one at a time
o Inspection
o Palpation (sense of touch) – assessing texture, temp, moisture, organ location/size,
swelling/vibration/pulsation, rigidity or spasticity, crepitation, presence of lumps or
masses, presence of tenderness or pain
o Percussion – mapping location/size of organs, density, superficial abnormal mass
(vibrations penetrate about 5cm deep & deeper mass would give no change), eliciting
pain/deep tendon reflex
o Auscultation (listening to sounds produced by body) – heart, bowel, lung, abnormal
vascular sounds
General Survey
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, o Physical Appearance – Age, Sex, LOC, Skin color, facial features, overall appearance
o Signs of Acute distress
o Body Structure & Mobility
o Behavior – facial expressions, mood/affect, speech pattern, dress, personal hygiene
o Initial Measurements – ht, wt, BMI
o Vital signs – temp, pulse, BP, respirations, pain
o Ethical & Legal Implications
Vital signs- know the ranges, causes of abnormalities and variations, when to report
the findings and when to reassess
o Vitals: Temperature, Pulse, Respiration, BP, pulse oximetry, pain level (1-10), if pain med
given then note response in 15 mins for IV admin to 1 hr for oral admin
o THESE REQUIRE IMMEDIATE ASSISTANCE
Systolic BP > 160 or <90
Normal 120/80 (syst/diast)
Systolic maximum pressure felt on artery during lef ventricular
contraction
Diastolic resting; pressure that blood exerts constantly bw each
contraction
Temperature <= 97 or >=100 F
Normal 98.6F
Fever can cause rise in temp
Rectal temp – not for those who have bleeding disorders
Heart rate <= 60 or >= 90 beats/min
Lower heart rate can imply more efficient heart function & better
cardiovascular fitness aka athlete who has 40bts/min
Bradycardia low HR
Tachycardia -> high HR
Radial abnormal check apical
Pulse defecit = apical – radial
Respirations <=12 or >=28 /min
Normal is 12-20
Aging affects respiratory rates
o Newborns – 30-40
o Adolescents – 12-20
o Adults – 10-20
Abnormal blood cell function (sickle cell) reduces ability of hemoglobin
to carry O2 inc resp rate & depth
O2 saturation <=92%
Normal 95-100
Urine output <30 or <240ml/8hrs
Normal for 24 hr urine 800-2000ml
Dark amber or bloody urine (*urology pts)
Postop nausea or vomiting
Surgical pain not controlled w/ medication and/or chest pain
Bleeding
This study source was downloaded by 100000830772748 from CourseHero.com on 02-17-2022 06:38:02 GMT -06:00
https://www.coursehero.com/file/33756926/EXAM-1-Study-Guidedocx/
EXAM 1 Study Guide
The exam will be 60 questions (multiple choice, drag and drop, select all that apply, and a
calculation). All questions are worth 2.5 points. 1st exam worth 150 points and it will cover
units 1 and 2. Here are a few areas that you can expect to see on your exam.
Unit 1 – Ch 1, 2, 3, 4, 5, 29
Unit 2 – Ch 8, 9, 10, 11
THE PROCEDURE
o Pt doesn’t need a complete head to toe physical every 24 hr stay
o Initial Assessment 1 – note anything that needs continuous monitoring
o Initial Assessment 2 – basic reassess for adults in med, surg, cardiac stepdown care areas
Then specialized to each adult
o Health Hist Sequence 1
Verify markers/flags on way to room – isolations, allergies, fall precaution
Once inside room introduce, wash hands, make eye contact & ask how theyre
feeling/any pain or discomfort/how they spent previous shif
o Health Hist Seq 2
Refer to what u heard from previous shif
Offer water as courtesy (if pt is not NPO) – indicates pt is able to hear, follow
directions, ability to swallow, etc
General appearance, verify name band
o Vitals: Temperature, Pulse, Respiration, BP, pulse oximetry, pain level (1-10), if pain med
given then note response in 15 mins for IV admin to 1 hr for oral admin
o THINGS TO DO (activity)
If pt is on bed rest HOB should greater than 15 degs as pt at risk for skin
breakdown
If SCD(Sequential compression device)s ordered then note that & follow
protocol
If ambulatory assist to sitting level and move to chair
Not any resistance needed & ability to transfer
Assess need for aid or equipment
Complete standardized scales per protocol to quantify fall risk
Complete documentation
SKILLS performed one at a time
o Inspection
o Palpation (sense of touch) – assessing texture, temp, moisture, organ location/size,
swelling/vibration/pulsation, rigidity or spasticity, crepitation, presence of lumps or
masses, presence of tenderness or pain
o Percussion – mapping location/size of organs, density, superficial abnormal mass
(vibrations penetrate about 5cm deep & deeper mass would give no change), eliciting
pain/deep tendon reflex
o Auscultation (listening to sounds produced by body) – heart, bowel, lung, abnormal
vascular sounds
General Survey
This study source was downloaded by 100000830772748 from CourseHero.com on 02-17-2022 06:38:02 GMT -06:00
https://www.coursehero.com/file/33756926/EXAM-1-Study-Guidedocx/
, o Physical Appearance – Age, Sex, LOC, Skin color, facial features, overall appearance
o Signs of Acute distress
o Body Structure & Mobility
o Behavior – facial expressions, mood/affect, speech pattern, dress, personal hygiene
o Initial Measurements – ht, wt, BMI
o Vital signs – temp, pulse, BP, respirations, pain
o Ethical & Legal Implications
Vital signs- know the ranges, causes of abnormalities and variations, when to report
the findings and when to reassess
o Vitals: Temperature, Pulse, Respiration, BP, pulse oximetry, pain level (1-10), if pain med
given then note response in 15 mins for IV admin to 1 hr for oral admin
o THESE REQUIRE IMMEDIATE ASSISTANCE
Systolic BP > 160 or <90
Normal 120/80 (syst/diast)
Systolic maximum pressure felt on artery during lef ventricular
contraction
Diastolic resting; pressure that blood exerts constantly bw each
contraction
Temperature <= 97 or >=100 F
Normal 98.6F
Fever can cause rise in temp
Rectal temp – not for those who have bleeding disorders
Heart rate <= 60 or >= 90 beats/min
Lower heart rate can imply more efficient heart function & better
cardiovascular fitness aka athlete who has 40bts/min
Bradycardia low HR
Tachycardia -> high HR
Radial abnormal check apical
Pulse defecit = apical – radial
Respirations <=12 or >=28 /min
Normal is 12-20
Aging affects respiratory rates
o Newborns – 30-40
o Adolescents – 12-20
o Adults – 10-20
Abnormal blood cell function (sickle cell) reduces ability of hemoglobin
to carry O2 inc resp rate & depth
O2 saturation <=92%
Normal 95-100
Urine output <30 or <240ml/8hrs
Normal for 24 hr urine 800-2000ml
Dark amber or bloody urine (*urology pts)
Postop nausea or vomiting
Surgical pain not controlled w/ medication and/or chest pain
Bleeding
This study source was downloaded by 100000830772748 from CourseHero.com on 02-17-2022 06:38:02 GMT -06:00
https://www.coursehero.com/file/33756926/EXAM-1-Study-Guidedocx/
