Exam 1 Topics Notes

Question 1

MAR

Answer 1

Where data are charted

Question 2

Assess this pulse site prior to giving a cardiac medication

Answer 2

Apical pulse: check for rhythm (irregular or regular), rate (60-100 bpm), strength (no pulse, weak, moderate, bounding/strong), equality-(distal pulses), count and assess for full 60 seconds

Question 3

Name of the chest/endpiece of the stethoscope used to auscultate high pitch sounds.

Answer 3

Diaphragm: high pitch sound. Ex: bowel (GI) sounds, respiratory sounds, PMI (point of maximal impulse- where the apex of the heart is)
Bell: Low pitch sound. Ex: bruits, korotkoff

Question 4

Older age, stress, ethnicity, post menopausal, elevated BMI, cigarette smoking and time of day are factors affecting this VS.

Answer 4

Blood pressure: amount of blood exerted on walls of capillaries

Question 5

Used to obtain an oxygen saturation.

Answer 5

Pulse oximeter: device that can be used to clip on fingers, toes, earlobes to know the oxygen saturation level (current O2 bind to hemoglobin compared to unbounded hemoglobin)

Question 6

Used when counting a RR or HR.

Answer 6

Lapel watch

Question 7

Used to auscultate Korotkoff’s sounds?

Answer 7

Stethoscope (bell side, but can use diaphragm as well)

Question 8

This is the name for the waveform on the pulse oximeter indicating reliability.

Answer 8

Plethysmograph

Question 9

Used to assess a pulse that is not palpable.

Answer 9

Doppler ultrasound

Question 10

Normal BPM

Answer 10

60-100 beats per minute (normal resting HR adult)

Question 11

> 95% on room air

Answer 11

Normal oxygen saturation level (lower for CO2 retainer patients and patients have problems with respiratory disorder - 92%)

Question 12

12-20 breaths/min

Answer 12

Normal adult respiratory rate

Question 13

96.8-99.5 (36C-37.5)

Answer 13

Normal adult body temp (for younger patients- more than 104 (40C) considers fever, or 101 (38.3)

Question 14

SBP + 2(DBP)/3

Answer 14

Mean arterial pressure

Question 15

Administer acetaminophen/Tylenol and use cooling measures.

Answer 15

Treatment of fever (febrile)

Question 16

Keep skin clean and linens dry, give warm fluids and blanket from warmer, cover head.

Answer 16

Treating hypothermia (Uncontrolled shivering temp less than 96F [35.5C], HR and RR also decrease. Vasodilation occurs with warming – monitor for hypotension)

Question 17

What to do for decrease resp rate or increase oxygen saturation pts?

Answer 17

Verbally calm, breathe with the patient, position for maximal lung expansion, decrease lights, use a fan.

Question 18

How to treat tachycardia (fast heart beat)?

Answer 18

Administer a beta blocker i.e. metoprolol/Lopressor, treat pain and anxiety and give IV fluids.

Question 19

When to give IV fluids?

Answer 19

Heart rate:Healthcare providers should consider fluid administration when the heart rate exceeds 90 bpm. Tachycardia may indicate a compensatory physiological response to preserve perfusion in hypovolemia and can manifest as an early sign of compensated hypovolemic shock. Nonetheless, tachycardia can have various other causes, including pain, fever, and anxiety.

Blood pressure:Healthcare providers should contemplate fluid administration when the systolic blood pressure falls below 100 mm Hg. A declining blood pressure is an ominous finding often linked with tachycardia. Hypotension and tachycardia indicate that the cardiovascular system can no longer compensate for hypovolemia effectively. Conversely, elevated blood pressure is typically associated with hypervolemia.

Orthostatic vital signs:These signs involve a reduction of at least 20 mm Hg in systolic blood pressure or 10 mm Hg in diastolic blood pressure within 2 to 5 minutes of standing quietly after 5 minutes of supine rest, which signifies the presence of orthostatic hypotension.[6]These findings may be evident in dehydrated or older patients who have experienced reduced sensitivity in the baroreceptors of their blood vessels.

Respiratory rate:Healthcare providers should contemplate fluid administration when the patient’s respiratory rate exceeds 20 breaths per minute. An elevated respiratory rate suggests a compensatory response to metabolic acidosis resulting from lactic acidosis due to inadequate tissue perfusion.

Urine output:In clinical practice, healthcare providers should anticipate a minimum urine output of 1.5 mL/kg/h in children and more than 1 mL/kg/h in adults. Specific clinical scenarios may necessitate higher urine output thresholds to minimize the risk of renal toxicity, especially when administering nephrotoxic medicationssuch asacyclovir.

Question 20

Treatment for hypertension pt?

Answer 20

Regular exercise, heart healthy diet, BMI 18.5-24.9 kg/m², <2.3gm/D of Na and manage stress.

Question 21

Susceptible host/immunocompromised patients

Answer 21

Taking steroids or chemo, splenectomy, Hx of poorly controlled diabetes mellitus and older age.

Question 22

10% of hospitalized patients with a Foley (urethral) catheter will develop this acronym.

Answer 22

CAUTI (Central line associated Urinary Tract Infection)- follow guidlines from CAUTI bundle

Question 23

SIRS (Systemic Inflammatory Response Syndrome) symptoms/signs

Answer 23

Body temperature less than 36 or more than 38. Where white blood cells count is lower than 4k or more than 12k. Heart rate is more than 90 beats per minute. And respiratory rate is more than 20 breaths per minute.

Question 24

QSOFA (Sepsis) criteria

Answer 24

GCS less than 13. Respiratory rate more than or equal to 22 breaths/min. Systolic blood pressure less than or equal to 100 mm/Hg

Question 25

This is the location the RN wastes unused medications.

Answer 25

the pharmaceutical waste bin: Usually blue and white

Question 26

Isolation used for all patient care.

Answer 26

Standard precautions (HIV, every other patients). Might have to use PPE as needed for fluid exposure

Question 27

Minimum PPE to wear for contact precautions.

Answer 27

Gowns and gloves

Question 28

Minimum PPE to wear for airborne precautions.

Answer 28

Gowns, gloves, N-95 masks or PAPR (powered air-purifying respirator)? COVID, TB, measles varicella,

Question 29

May not be used for hand hygiene after working with a patient positive for C. diff.

Answer 29

alcohol based hand cleansers

Question 30

Used to decrease the microbial load in a patient’s environment at least once per shift.

Answer 30

wipe with Sani wipes or equivalent? Use at nurses’ station, med carts, etc. Bleach one which is yellow color that can be used for C.diff patients.

Question 31

Ischemic stroke vs hemorrhage stroke

Answer 31

Ischemic stroke: stroke that can be either caused by plaque- thrombosis (atherosclerosis) or blood causes emboli. Because of the emboli, not enough blood or no blood can come to the area of needed like brain and this obstruction causes lack of supply of blood/oxygen needed. Treatment: We want high BP, around 160-180 is fine, so enough blood flow can be given to areas of needed oxygen/blood supply.
Hemmorrhage stroke: stroke that is caused by long time hypertension, and can cause bleeding in the cerebral arteries and blood filled in the brain which is seriously emergency case. We want BP to be low because we don’t want no more bleeding
Might need coronary artery bypass graft surgery.

Question 32

Pain assess scales use explain

Answer 32

1. Numeric scale: number scales to assess pain level for patient severity where 0 is no pain and 10 is the most pain ever imagined. Can use picture to demonstrate from facility. Use for patients who can follow directions
2. PQRST: A combined pain assessment with numeric scale. More details and used for general patients who understand and comprehend language/conscious mind
   P – Provocation or Palliation: This refers to what provokes or alleviates the pain. Healthcare providers may ask patients what triggers their pain or makes it worse and what makes it feel better. For example, the patient may report that certain activities or movements worsen their pain, or that it is alleviated by rest or medication.
   Q – Quality refers to the pain’s nature or quality. Healthcare providers may ask patients to describe their pain in their own words. For example, the patient may describe their pain as sharp, dull, throbbing, or burning.
   R – Region or Radiation: This letter refers to where the pain is located and if it radiates to other body areas. Healthcare providers may ask patients to point to where the pain is located and if it spreads to other areas. For example, a patient may report pain in their left arm that radiates up to their shoulder.
   S – Severity: This letter refers to the intensity of the pain. Healthcare providers may ask patients to rate their pain on a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable. This rating can help healthcare providers understand how severe the pain is and how it impacts the patient’s daily life.
   T – Timing: This letter refers to when the pain occurs and how long it lasts. Healthcare providers may ask patients how long they have been experiencing pain, if it is constant or intermittent, and if it occurs at a certain time of day or in response to certain activities.
3. FLACC: Used for patients who understand the process but can’t verbalize back.
   0 is the least point and 10 is the maximum point can have. Face (angry, happy, frowning/grumpy). Leg (is patient normal position/relaxed or uneasy or kicking), activity (is pt lying quietly or moving back and forth or patient is stiff, jerking or rigid), cry (is patient have no expression, or moan or crying steadily), consoling (relaxed or patient needs hug/touch/talking/distraction or these don’t help at all)
4. PAINAD: basically the same as FLACC scale but used for advanced dementia patients.
   0 is the least and 10 is the maximum point can get. Need to see for breathing as extra with FLACC (is patient breathing normally, rapid or hyperventilate/presenting Cheyne’s stokes breathing)

Question 33

CO2 retainers patients

Answer 33

Patient can have low O2 levels. Be mindful that the O2 supplemental therapy should not be high where titrate fio2 should be from 88-92% because too much O2 makes patient loss the drive to breath.
CO2 retention is known as hypercapnia or hypercarbia. Hypercapnia is often caused by hypoventilation or failure to remove excess CO2 and may be diagnosed by an arterial or venous blood gas. Elevations of CO2 in the bloodstream can lead to respiratory acidosis. Normal respiratory drive, and thus CO2 exhalation, is primarily maintained by the chemoreceptor reflex. The chemoreceptor reflex is important in allowing the body to respond to changes in pO2, pCO2, and pH. Chemoreceptors can be categorized as peripheral or central. Peripheral chemoreceptors are located in the carotid and aortic bodies. The carotid body is the principal sensor of increased pCO2, decreased pO2, and overall decreased pH. The glomus cells of the carotid body relay changes in peripheral arterial pH to the central nervous system via the glossopharyngeal nerve. [1]

Central chemoreceptors are located near the ventrolateral surfaces of the medulla. While peripheral chemoreceptors are primarily sensitive to changes O2 and CO2, central chemoreceptors are responsive to changes in pCO2 and pH. Central chemoreceptors are able to rapidly detect changes in PCO2. The blood-brain barrier is permeable to CO2, thus allowing chemosensitive cells within the medulla to respond to elevations in blood CO2, and the subsequently lowered pH. The decrease in pH of the cerebrospinal fluid ultimately increases minute ventilation, defined by the product of respiratory rate and tidal volume. Interestingly, central chemoreceptors have shown a greater response to hypercapnic acidosis rather than isocapnic acidosis, in part likely due to the impermeability of the blood-brain barrier to H+ ions. As a result, the sympathetic outflow to the vasculature is increased, and efforts are made to increase the respiratory rate.

Question 34

How to identify stroke

Answer 34

BEFAST:
1. Balance: signs for dizziness, stumble to stand/loss of balance
2. Eyes: blurred vision
2. Face: one side drooling. Ask patient to smile and see if still symmetry
3. Arms: one side weakness (arm or leg). Ask patients to raise both arms and see if one drift downward
4. Speech: speech dificulty, slurred speech. Ask patient to say something and is it strange
5. Time: call 911

Question 35

Different settings for frequency of vital signs assessment

Answer 35

ICU: Q1H
Telemetry: Q4H
Medical-surgical: Q8H
However, each patient is different. Whenever there is a change in condition, or when patient complains about their condition, or when patient need to do surgery either pre or postoperative, or when upon administration, specific orders and according to the rules of each facility.

Question 36

Body temp notes

Answer 36

Sites of surface temperatures route: oral, axillary, temporal (scanning infrared)
Sites of core temperatures route: rectal, tympanic (infrared)
Can be lower in the morning and more at afternoon. Can increase when there’s increase in cells metabolic rate like ovulation, hormones like estrogen excretion, hyperthyroidism, etc.

Question 37

Hypothermia

Answer 37

Early rise in BP, HR, and RR. However, if can not control, overtime, body can experience low BP, undetectable pulse and RR (low RR and low HR). As body loses control where mostly body would vasoconstriction to keep heat, but because of this, vasodilations cause loss of heat and people can sweat more when hypothermia so make sure give towels to dry skin otherwise colder after sweating. Make sure patient having enough hydration (offer warm fluids, warm heated blankets, bair hugger after or before surgery).

Question 38

Fever noticeable notes

Answer 38

If patient is experiencing fever, we can adjust the temperature and if patient have thick blankets, then take off. If patient asks for it, bring lightweight blankets. Monitor skin and other vital signs (might have to blood lab values). Can bring in fan to have more air. Can give antipyretic (if have liver problems like liver cirrhosis, then can ibuprofen, or aspirin). We don’t want shivers, don’t want activity that can increase metabolic rate.

Question 39

When assess the pulse, what to notice

Answer 39

Rate (60-100 bpm), rhythm (irregular or regular) strength (0,1,2,3) , equality (is both sides lateral)

Question 40

Important notes

Answer 40

In men, increase respiratory rate increase in total peripheral pressure and cause decrease in heart rate and decrease in cardiac output. There is no correlation shown in women.

Question 41

Perfusion

Answer 41

Blood flow distribution to every part of the heart. If poor perfusion and circulation, this can take increase in capillary refill time (>3s). Weak palpated pulse and pale/cyanosis skin, etc

Question 42

5 rights of delegation

Answer 42

1. The right task
2. Under the right circumstances
3. Right person
4. Right directions and communication
5. Right supervision and evaluation

Question 43

Types of Maslow’s hierarchy

Answer 43

Basic needs from physiological (food, drink, oxygen), safety, love/belonging, esteem, to self-actualization

Question 44

2 types of aphasia mentioned

Answer 44

Damage on Broca’s area: can’t speak full sentences while understanding
Damage on Wernicke’s aphasia: fluency speaking but people speaking feels foreign to them (don’t understand language)
Global aphasia: both broca’s and wernicke’s area

Question 45

Who is at risk for VTE

Answer 45

Immobile patients/ ICU patients, active cancer patients, hormone therapy replacement, birth control taking, etc
Might need Ted, SCDs or PCDs

Question 46

MORSE fall scale

Answer 46

Fall risk scale:
0-24: no risk, 25 to 50: low risk, more than equal to 51: high risk. Can get total of 125 points
1. History falling
2. Secondary diagnosis
3. Assistive device
4. IV/heparin lock
5. Gait/transferring
6. Mental status

Question 47

Skin bundle

Answer 47

Surface, keep turning, incontinent, nutrition
- Specialty Mattress
Heels off of bed
TEDs & SCDs to be removed every shift
- Reposition at least Q2H
- Perineal care Q8H
Moisture barrier
Avoid diapers except for excessive soiling
- Dietary consult for nutritional deficits
Glycemic management

Question 48

Risk for hygiene problems

Answer 48

Oral cavity: dehydration, NPO, NGT, O2
skin impairment (immobile, decrease sensation, moisture, vascular insufficient, external devices)
vision impairment
Upper/lower extremity weakness

Question 49

Daily bath

Answer 49

Use of readybath personal cleaning cloth/ medline readyflush protect personal cleaning cloth for 1. Face and head (avoid the eye area)
Use of 2% CHG wipes (can be microwave): 2. Left arm and hand, 3. Right arm and hand, 4. Neck and chest area, 5. Left leg and foot, 6. Right leg and foot, 7. Back and buttocks (avoid the anus area/don’t use CHG wipes to clean private parts or use for incontinent cleaning)
Use of ready bath/ medline readyflush protect personal cleaning cloth for 8. Perineum
CHG wipes might not be compatible with lotions and other skin products. Compatible with remedy hydrating cleansing foam- can use on intact, irritated or denuded skin and has dimethicone skin protectant (check do not use for pts have allergy to green tea, soy, blue or green algae).