NUR 155 exam 1
-pnea - ✅✅-breathing
(Lung sounds) Rales are - ✅✅-short 'crackly' sounds/ high pitched
(Lung sounds) rhonchi are - ✅✅-low/ deep pitched, snoring sounds
(Lung sounds) Stridor is - ✅✅-a harsh, high pitched sound
(Lung sounds) wheezes are - ✅✅-high pitched, 'squeaky' sounds
5 RIGHTs of Delegation - ✅✅-1. RIGHT task
2.RIGHT circumstance
3. RIGHT person
4. RIGHT direction/communication
5. RIGHT supervision/education
✅✅-without/ missing
a- -
Abduction - ✅✅-Movement away from the midline of the body: legs, arms,
fingers
Abnormal skin disorder: - ✅✅-Jaundice, Cyanosis, Erythema, vitiligo, edema,
etc.
Aduction - ✅✅-movement toward the midline: legs, arms, fingers
Afebrile - ✅✅-without fever
normal temp: 96.8-99.5
Apical Pulse - ✅✅ -a central pulse located at the apex of the heart
listen for 1 minute
PMI
Apnea - ✅✅-not breathing
,Arrhythmia/ Dysrhythmia -✅✅-Irregular/ Abnormal heart rhythm
Assertive communication: - ✅✅--communication that takes a listener's feelings
and rights into account
-telling patient what you/they will be doing
-"I" statements
Assess: - ✅✅-collect data, collect patient's chief complaint
Atrophy - ✅✅-wrinkles
Bacteremia - ✅✅-presence of bacteria in the blood / reveals microorganisms
Bathing process: - ✅✅-- No soap on face
-Face: start inward from inner canthus to outer canthus
-Hot spots:
change towel after each one
move/get under fat rolls/breasts/under neck
-vagina: front to back & spread labia ( use wipes not towels)
-penis: uncircumcised, pull down foreskin & wipe, wipe shaft & scrotum
-keep areas covered/ conservative/ warm as you move about body
-change linens after
✅✅-slow
brady- -
Bradycardia - ✅✅-Adult: <60
slow heart rate
bradypnea - ✅✅-slow breathing
<12
✅✅-Anterior over trachea, minimal sound
bronchial -
Broncho-vesicular - ✅✅-At 1st/2nd Intercostal space, moderate sound, normal
breath sounds heard over the upper anterior chest and intercostal area
C-Diff specifics - ✅✅-- not killed by alcohol
, - wash hands (soap & water)
- contact PPE
- endospores
-patient in contact isolation
-private room
✅✅-pertaining to the heart
cardio- -
Charting by Exception: - ✅✅--use of predetermined standards and norms to
record only significant/abnormal assessment data
-involves check marks or initials
-shorthand method
Circumduction - ✅✅-circular movement of a limb at the far end: head,
arms/shoulders, fingers, legs, feet
Communication Methods - ✅✅-Assertive, non assertive, & therapeutic
Correct way to assess abdomen: - ✅✅-Inspect (Look)
Auscultate (Listen)
Palpate (feel) RLQ then clockwise
Critical Thinking - ✅✅-Problem Solving
Decision Making
Delegation
✅✅-scabs
crust -
D A R - ✅✅-Document
Action
Response
Diagnosis formulated:
PED- ✅✅-Problem ; Etiology ; Defining Characteristics
-pnea - ✅✅-breathing
(Lung sounds) Rales are - ✅✅-short 'crackly' sounds/ high pitched
(Lung sounds) rhonchi are - ✅✅-low/ deep pitched, snoring sounds
(Lung sounds) Stridor is - ✅✅-a harsh, high pitched sound
(Lung sounds) wheezes are - ✅✅-high pitched, 'squeaky' sounds
5 RIGHTs of Delegation - ✅✅-1. RIGHT task
2.RIGHT circumstance
3. RIGHT person
4. RIGHT direction/communication
5. RIGHT supervision/education
✅✅-without/ missing
a- -
Abduction - ✅✅-Movement away from the midline of the body: legs, arms,
fingers
Abnormal skin disorder: - ✅✅-Jaundice, Cyanosis, Erythema, vitiligo, edema,
etc.
Aduction - ✅✅-movement toward the midline: legs, arms, fingers
Afebrile - ✅✅-without fever
normal temp: 96.8-99.5
Apical Pulse - ✅✅ -a central pulse located at the apex of the heart
listen for 1 minute
PMI
Apnea - ✅✅-not breathing
,Arrhythmia/ Dysrhythmia -✅✅-Irregular/ Abnormal heart rhythm
Assertive communication: - ✅✅--communication that takes a listener's feelings
and rights into account
-telling patient what you/they will be doing
-"I" statements
Assess: - ✅✅-collect data, collect patient's chief complaint
Atrophy - ✅✅-wrinkles
Bacteremia - ✅✅-presence of bacteria in the blood / reveals microorganisms
Bathing process: - ✅✅-- No soap on face
-Face: start inward from inner canthus to outer canthus
-Hot spots:
change towel after each one
move/get under fat rolls/breasts/under neck
-vagina: front to back & spread labia ( use wipes not towels)
-penis: uncircumcised, pull down foreskin & wipe, wipe shaft & scrotum
-keep areas covered/ conservative/ warm as you move about body
-change linens after
✅✅-slow
brady- -
Bradycardia - ✅✅-Adult: <60
slow heart rate
bradypnea - ✅✅-slow breathing
<12
✅✅-Anterior over trachea, minimal sound
bronchial -
Broncho-vesicular - ✅✅-At 1st/2nd Intercostal space, moderate sound, normal
breath sounds heard over the upper anterior chest and intercostal area
C-Diff specifics - ✅✅-- not killed by alcohol
, - wash hands (soap & water)
- contact PPE
- endospores
-patient in contact isolation
-private room
✅✅-pertaining to the heart
cardio- -
Charting by Exception: - ✅✅--use of predetermined standards and norms to
record only significant/abnormal assessment data
-involves check marks or initials
-shorthand method
Circumduction - ✅✅-circular movement of a limb at the far end: head,
arms/shoulders, fingers, legs, feet
Communication Methods - ✅✅-Assertive, non assertive, & therapeutic
Correct way to assess abdomen: - ✅✅-Inspect (Look)
Auscultate (Listen)
Palpate (feel) RLQ then clockwise
Critical Thinking - ✅✅-Problem Solving
Decision Making
Delegation
✅✅-scabs
crust -
D A R - ✅✅-Document
Action
Response
Diagnosis formulated:
PED- ✅✅-Problem ; Etiology ; Defining Characteristics
