Nursing 113 Exam 1
Normal WBC
3.8 - 10.6
How to put on PPE
Hand hygiene, Gown then mask followed by gloves
How to remove PPE
Gloves, gown, then mask followed by hand hygiene
Norm for Psychosocial Assessment
Behavior is appropriate for situation. Initiates conversation. Makes eye contact. Ask
appropriate questions about hospitalization, procedures/treatments & illness in a
reasonable manner. Anxiety level does not interfere with ability to follow directions.
Expressed religious needs are being met.
objective data
seeing, hearing, smelling something about a patient
subjective data
complaints by the patient such as itching, aching, nausea or pain
initial/background assessment
a patient comes into the ED and a history and physical are done as part of the
admission process
problem focused assessment
A patient is complaining of pain, and we then find that the chief complaint is chest pain
Emergency Assessment
a nurse goes into a patient's room and checks patient for ABC's, finds that they are not
breathing and decides to perform CPR
Ongoing Assessment
everyday per unit standards we are assessing the patient while in the hospital OR we
have a follow up appointment with a patient who had a transplant
supine
laying on back
prone
laying on stomach
dorsal recumbent
lying on back with legs bent and feet flat
lithotomy
examination position in which the client is lying on his or her back with the feet in
stirrups.
direct inspection
a nurse is doing ____ when he or she lifts a patient's sheets to look at their feet
indirect inspection
x-ray, CT scan, use of a stethoscope are all used by the nurse to enhance visualization
Inspection for Adults
looking at a patient from head to toe is typically called
Inspection for Children
looking at a patient from least to most invasive methods is called
palpation
, gentle application of the hands to a specific structure or body area to determine size,
consistency, texture, symmetry, and tenderness of underlying structures
direct auscultation
listening without a stethoscope
indirect auscultation
listening with a stethoscope
light pressure
low pitched sounds
firm pressure
high pitched sounds
what is the order when reporting Vitals
T, P, R, BP, Pain, SPO2
what is the 6th vital sign?
pain
normal temp
36-38 C
most common temp for infants
rectal temp
What is the correct order of Assessment?
Inspection, Auscultation, Palpation
febrile
feverish
femoral pulse
Pulse felt on either side of the groin
popliteal pulse
pulse located behind the knee
posterior tibial pulse
Pulse felt on inside of either ankle
dorsalis pedis pulse
along top of foot between extension tendons or great and first toe. Used to assess
status of circulation in foot
carotid pulse
the pulse felt along the large carotid artery on either side of the neck
character of pulse
rate, rhythm, strength, and equality
newborn pulse
100-170 bpm
infant to 2 years pulse
80-130 bpm
2-6 years pulse
70 - 120 bpm
6-10 years pulse
70-110 bpm
10 - adulthood pulse
60-100 bpm
respiration
Normal WBC
3.8 - 10.6
How to put on PPE
Hand hygiene, Gown then mask followed by gloves
How to remove PPE
Gloves, gown, then mask followed by hand hygiene
Norm for Psychosocial Assessment
Behavior is appropriate for situation. Initiates conversation. Makes eye contact. Ask
appropriate questions about hospitalization, procedures/treatments & illness in a
reasonable manner. Anxiety level does not interfere with ability to follow directions.
Expressed religious needs are being met.
objective data
seeing, hearing, smelling something about a patient
subjective data
complaints by the patient such as itching, aching, nausea or pain
initial/background assessment
a patient comes into the ED and a history and physical are done as part of the
admission process
problem focused assessment
A patient is complaining of pain, and we then find that the chief complaint is chest pain
Emergency Assessment
a nurse goes into a patient's room and checks patient for ABC's, finds that they are not
breathing and decides to perform CPR
Ongoing Assessment
everyday per unit standards we are assessing the patient while in the hospital OR we
have a follow up appointment with a patient who had a transplant
supine
laying on back
prone
laying on stomach
dorsal recumbent
lying on back with legs bent and feet flat
lithotomy
examination position in which the client is lying on his or her back with the feet in
stirrups.
direct inspection
a nurse is doing ____ when he or she lifts a patient's sheets to look at their feet
indirect inspection
x-ray, CT scan, use of a stethoscope are all used by the nurse to enhance visualization
Inspection for Adults
looking at a patient from head to toe is typically called
Inspection for Children
looking at a patient from least to most invasive methods is called
palpation
, gentle application of the hands to a specific structure or body area to determine size,
consistency, texture, symmetry, and tenderness of underlying structures
direct auscultation
listening without a stethoscope
indirect auscultation
listening with a stethoscope
light pressure
low pitched sounds
firm pressure
high pitched sounds
what is the order when reporting Vitals
T, P, R, BP, Pain, SPO2
what is the 6th vital sign?
pain
normal temp
36-38 C
most common temp for infants
rectal temp
What is the correct order of Assessment?
Inspection, Auscultation, Palpation
febrile
feverish
femoral pulse
Pulse felt on either side of the groin
popliteal pulse
pulse located behind the knee
posterior tibial pulse
Pulse felt on inside of either ankle
dorsalis pedis pulse
along top of foot between extension tendons or great and first toe. Used to assess
status of circulation in foot
carotid pulse
the pulse felt along the large carotid artery on either side of the neck
character of pulse
rate, rhythm, strength, and equality
newborn pulse
100-170 bpm
infant to 2 years pulse
80-130 bpm
2-6 years pulse
70 - 120 bpm
6-10 years pulse
70-110 bpm
10 - adulthood pulse
60-100 bpm
respiration
