Vitals (basics)

Question 1

Normal temperature

Answer 1

36.5°-37.5°C or 97.6°-99.6°F

Question 2

Adult pulse

Answer 2

60 to 100 beats/min

Question 3

Newborn pulse

Answer 3

130-160 bpm

Question 4

Adult respirations

Answer 4

12-20 breaths/min

Question 5

Newborn respirations

Answer 5

40-60 breaths/min

Question 6

Adult blood pressure

Answer 6

120/80

Question 7

O2 saturation normal level

Answer 7

Above 94

Question 8

Blood pressure (BP) measured during ventricular contraction is known as

Answer 8

Systolic pressure

Question 9

Blood pressure measured during ventricular relaxation is known as

Answer 9

Diastolic pressure

Question 10

Formula for Pulse Pressure

Answer 10

Pulse Pressure = Systolic BP – Diastolic BP

Question 11

What is the Auscultatory gap

Answer 11

Period of silence/reduced intensity of Korotkoff sounds during BP measurement
Maximum inflation

Question 12

What are Body mechanics?

Answer 12

Coordinated efforts of M/A and nervous systems to maintain balance, posture, and body alignment during lifting, bending, moving, and performing ADL’s

Question 13

What are the 2 Nursing Interventions

Answer 13

Positioning and Turning

Question 14

Purpose of footboard/splints

Answer 14

To prevent irreversible foot drop

Question 15

Purpose of abduction pillow

Answer 15

Keeps patients spread while laying down or on their side

Question 16

Purpose of a trapeze

Answer 16

Allows paraplegic patient to assist you.
Can hold onto the bar and pull themselves up in bed, encourages upper body strength and independence

Question 17

What is a pulse?

Answer 17

A wave created by expansion and contraction of blood in aorta that travels along blood vessels

Question 18

What are the characteristics of a pulse?

Answer 18

Pulsation can be felt as a throb or a tap in a peripheral artery

Question 19

Orthostatic hypotension

Answer 19

BP drop with change in position drop in systolic BP >20 mmHg or diastolic BP >10 mmHg when getting up from lying down.

Question 20

What is Eupnea

Answer 20

Normal breathing

Question 21

Your patient had surgery 1 week ago and has been on bedrest. They decide that they want to get up and walk around the unit today, but when they do, they get dizzy and stumble. What are your priorities?

a) Take their blood pressure
b) Help them continue to walk around the unit
c) Take their temperature
d) Help the patient return to bed

Answer 21

a) Take their blood pressure
d) Help the patient return to bed

Question 22

What is a HERO?

Answer 22

Hopkins Event Reporting Online

Report adverse event, like a medical error or a fall.

Question 23

When is SBAR used?

Answer 23

When there is a change in the pt’s state.

Question 24

Sentinel Event

Answer 24

An event that’s life threatening or life-changing

Question 25

What are some NON-pharmacological things nurses can do to treat pain?

Answer 25

Heat/cold, Massage, Positioning, Hygiene: wash their face/hair, Ensure comfortable environment: lighting, music, cleanliness of room, Distraction, guided imagery, meditation etc.

Question 26

What other reasons would you take an apical pulse on a patient?

Answer 26

If the pulse is difficult to palpate If the pulse is weak. If the patient was an infant

Question 27

Effects of Immobility on Musculoskeletal System

Answer 27

Osteoporosis, Atrophy, Contractures/spasticity, Decubitus Ulcer

Question 28

Effects of Immobility on Nutrition and Metabolism

Answer 28

Decreased BMR Negative nitrogen balance (Protein breakdown → Body eating itself) Calcium loss from bone

Question 29

Effects of Immobility on Elimination

Answer 29

Urinary stasis UTI Renal calculi (From calcium loss from bones) Constipation

Question 30

List some methods to prevent thrombus formation

Answer 30

Anticoagulants (Heparin, Lovenox) Pt must continue these until completely d/ced TED (Thrombo-Embolic-Deterrent) stockings Calf pumping exercises Sequential Compression Device Sleeves that are pumped with air to help push blood

Question 31

Effects of Immobility on Cardiovascular System

Answer 31

Orthostatic hypotension Increased workload of heart due to decrease in venous return to heart Risk for thrombus (blood clot) Part of it can break off and become an embolus Necrosis or DVT (Deep vein thrombosis) can occur from poor circulation

Question 32

Effects of Immobility on the Respiratory System

Answer 32

Decreased activity → Decreased BMR → Decreased CO2 production → Decreased stimulation to breathe → Slower, more shallow respirations

Question 33

___% of cardiopulmonary arrest potentially avoidable

Answer 33

84% of cardiopulmonary arrest potentially avoidable

Question 34

Evisceration

Answer 34

Organs pop back out

Question 35

Korotkoff sounds

Answer 35

sounds heard when a blood pressure cuff is deflated, which indicate blood pressure

Question 36

Dehiscence

Answer 36

The separation or opening of a previously closed structure, such as a wound, incision, or fruit capsule.

Question 37

Pressure ulcer prevention/interventions

Answer 37

Turning patients Q2 (laying), turn a sitting patient every 15 minute

Question 38

How often do you have to check on patients with restraints

Answer 38

Once the order is done, check pt an hour after and then after 2 hours

Question 39

What makes an elderly person a fall risk (aside from age and fragility)

Answer 39

Confused patients, patients who can use the bathroom or on diuretic medication

Question 40

Pannis

Answer 40

Skin folds for obese pts