Which of the following interventions is most important to prevent nosocomial
infections?
Hand hygiene
Standard precautions
are used on every patient because it is not always known whether a patient is infected.
latex allergies
are more common in nurses and in frequently hospitalized patients.
example of inspection
skin pink, visual information
The patient is complaining of abdominal pain. What technique is used to form an
overall impression?
light palpation
tympany is a percussion sound commonly located in the
abdomen
Which organs or body areas does the nurse auscultate as part of the admitting
assessment?
heart, lungs, abdomen
What technique facilitates accurate auscultation?
The chestpiece of the stethoscope is sealed against the skin.
When assessing the child, the nurse makes the following adaptation to the usual
techniques:
A pediatric stethoscope is used for better contact.
The nurse assesses the following vital signs in a 78-year-old man: T 36.6°C,
temporal; P 72 bpm, regular, 2+; R 18 breaths/minute, regular, no use of
accessory muscles; BP 142/92 mm Hg. Which of the findings is abnormal?
BP
four characteristics of respirations
rate, rhythm, depth, quality
The patient's radial pulse is weak and thready. The next action of the nurse is to
compare findings to previous findings and opposite extremity.
The nurse notes an irregular radial pulse in a patient. Further evaluation includes
assessing
for a pulse deficit
Which actions will result in an inaccurate BP reading?
Obtaining a BP immediately after the patient has entered the room;
Using a BP cuff 80% of the arm circumference
Pumping the cuff 10 mm Hg above the palpated systolic BP.
Adult patients may have variations in pulse rates with
exercise
An unconscious 22-year-old man arrives at the hospital after experimenting with
hallucinogenic substances. His vital signs are T 37.2°C, po; P 142 bpm; R 20
breaths/min; BP 100/64 mm Hg. The patient is experiencing
tachycardia
An auscultatory gap is defined as