Exam 1 outline

Question 1

SBAR definition?

Answer 1

To standardize communication across the board

Question 2

SBAR stands for:

Answer 2

o Situation: introducing yourself, where you’re calling from
o Background: relevant background information
o Assessment: vitals, lung sounds, heart sounds, skin assessment
o Recommendations: what do I think we should do?

Question 3

ABCs stand for:

Answer 3

Airway, Breathing, Circulation, Safety, Prevention

Question 4

HAI stand for:

Answer 4

Hospital acquired infection

Question 5

Examples of HAI:

Answer 5

UTI, Pneumonia, Surgical site infections

Question 6

How to prevent HAI?

Answer 6

Hand washing, PPE

Question 7

5 ways to prevent UTI?

Answer 7

o Keep foley bag below bladder level
o Empty foley more than once a shift
o Foley care as needed plus regularly
o Do not let drainage valve touch inside of container when
emptying

Question 8

Orthostatic BP definition?

Answer 8

You stand and your BP drops

Question 9

For Orthostatic BP how much does systolic drop?

Answer 9

20 mmHg

Question 10

For Orthostatic BP how much does diastolic drop?

Answer 10

10 mmHg

Question 10

For Orthostatic BP how much does pulse rate drop?

Answer 10

30

Question 11

How to take Orthostatic BP?

Answer 11

Lying to Sitting to Standing (2 minutes after each position
change take the BP and pulse)

Question 12

Symptoms of Orthostatic BP:

Answer 12

Dizziness, fainting, lightheadedness

Question 13

Verbal communication examples

Answer 13

Hello I am Kyristen

Question 14

Nonverbal communication examples:

Answer 14

Eye contact, posture, pointing, gestures, tone

Question 14

What Nonverbal communication can be unreliable because of cultural differences?

Answer 14

Eye contact

Question 15

Edema

Answer 15

o Excess fluid –> heart failure
patients
o Can be pitting or nonpitting

Question 16

Inflammation characteristics?

Answer 16

Redness, warm, swelling, pain

Question 17

When should you be Washing Hands?

Answer 17

Preform hand hygiene before and after procedures

Question 18

What should you do with visibly soiled hands?

Answer 18

wash hands

Question 19

What should you do with not visibly soiled hands?

Answer 19

Hand hygiene (sanitizer) or wash hands

Question 20

UAP stands for:

Answer 20

Unlicensed assistive personnel

Question 21

What can UAP do?

Answer 21

o Take vitals
o Help with bathing and positioning
o Report findings to the nurse

Question 22

What can UAP not do?

Answer 22

o Pass meds
o Assess patients
o Procedures

Question 23

If a UAP reports abnormal findings to a nurse, what should the nurse always do?

Answer 23

Always the nurses responsibility to double check any abnormal findings from the UAP.

Question 24

Physical Exam Technique:

Answer 24

o Inspect- looking at the body o Palpate- feeling the body with fingers or hands o Percuss- producing sounds, usually by tapping on specific areas of the body o Auscultate- listening to sounds, usually with a stethoscope

Question 25

Stethoscope Bell used to hear?

Answer 25

Low-pitched, abnormal heart sounds

Question 25

Stethoscope Diaphragm used to hear?

Answer 25

o High-pitched o Normal heart sounds o Lungs sounds o Bowel sounds

Question 26

Ambulation definition?

Answer 26

The ability to walk or stand around independently of with the help of a device.

Question 26

Post-surgical ambulation, what does is it do?

Answer 26

o Keeps patient mobile o Prevents muscle atrophy (Wasting)

Question 26

How to use Crutches:

Answer 26

o 2-3 fingers down from the axilla o 15-30 degrees for elbows o 2 inches lateral 4-6 inches in front

Question 26

Psychosocial aspects are ______ while physical aspects are ________.

Answer 26

Mental, Physical

Question 27

Braden scale:

Answer 27

o Risk of skin breakdown ( 6 categories of Braden scale) o A tool used to assess a patients risk of developing pressure ulcers, or sores.

Question 28

Repositioning:

Answer 28

o Helps to avoid skin breakdown o Nonpharmacological intervention

Question 29

Sims (Position):

Answer 29

o left lying o left leg straight o right leg bent

Question 30

Vesicles:

Answer 30

o A type of skin lesion o small, fluid- sacs or blisters

Question 31

Papule:

Answer 31

o A type of skin lesion o Oil-filled inflamed bump

Question 32

Varicella (chicken pox) is what type of skin lesion?

Answer 32

Vesicles

Question 33

A patient has Nerve damage in feet. What will they experience?

Answer 33

Altered sensory

Question 34

SpO2 is: What does O2 stand for?

Answer 34

o SpO2 is the amount of oxygen saturation in blood o O2 means oxygen

Question 35

what is the mnemonic OLD CARTS used for?

Answer 35

o To guide nurses interview of a patient while documenting a history of present illness. o Used to assess pain

Question 36

What does OLD CARTS stand for: AR can be linked together.

Answer 36

o Onset- Gradual or acute o Location- Where is the pain located? o Duration- How long has the pain Been present o Characteristics- How patient describes the pain o Alleviating or aggravating factors- what makes the pain worse? o Radiating or relieving factors - What makes the pain better? o Timing - does it occur e.g. after certain situations? o Severity- 1-10 scale or subjective grading.

Question 37

Pain can be felt with in what 2 ways?

Answer 37

Pharmacological and nonpharmacological

Question 38

What can occur if the BP cuff is to tight?

Answer 38

Too tight = false low reading

Question 39

What can occur if the BP cuff is too loose?

Answer 39

Too loose = false high reading

Question 40

Mobility

Answer 40

The ability to move or be moved freely and easily.

Question 41

ADLS stand for:

Answer 41

Activities of daily life

Question 42

What are normal changes in older adults?

Answer 42

o Body slows down o Slower wound healing o Lower body temp o Less collagen, slower skin turgor

Question 43

What are not normal changes in older adults?

Answer 43

Confusion

Question 44

Passive ROM (Range of motion) helps patients with?

Answer 44

Joint mobility

Question 45

Active ROM (Range of Motion) helps patients with?

Answer 45

Muscle strengthening

Question 46

How to use Canes:

Answer 46

o Keep on stronger side o Greater trochanter to the floor

Question 47

Sterile (surgical) vs medical asepsis (clean):

Answer 47

o Sterile gloves, keep sterile, strict o Clean- physical exam, less strict

Question 48

SpO2 stands for:

Answer 48

(O2) Oxygen saturation in blood

Question 49

What is a resting (SpO2) oxygen saturation level?

Answer 49

95%-100%

Question 50

Immobility

Answer 50

Inability to move or be moved