NURS 301-Final study guide Questions and Correct Answers

What are the steps of the nursing process? ADPIE Assessment - gather information about patient's condition Diagnosis - identify patient's problems Planning - set goals of care and desired outcomes and identify appropriate nursing actions Implementation - perform nursing actions identified in planning Evaluation - determine if goals and expected outcomes are achieved What is the critical thinking approach? while gathering data, you synthesize knowledge and attitudes and use professional standards of practice to direct knowledge from physical, biological, and social sciences to ask relevant questions and collect relevant history What are the four assessment techniques? Inspection Palpation Percussion Auscultation What is the purpose of SBAR? To help improve communication and reduce errors in healthcare What does SBAR stand for and what are the parts of it? Situation - name of patient and their complaints Background - Reason for being seen, medical history, time frame Assessment - Recalls what was observed when checking patient Recommendation - Giving advice for treatment plan What is cultural competency? Respecting patient's health beliefs and understanding the effect of those beliefs on health care delivery Must understand one's own biases and stereotypes (culturally congruent care) Understand medical practices of other cultures What do cultural skills mean? the ability to assess factors that influence patient care and treatment What is pulse pressure? difference between systolic and diastolic pressure Pulse pressure should be in what range? 30-40 mm Hg What is orthostatic hypotension? A drop in blood pressure due to a sudden change of posture. How do we determine if orthostatic hypotension is occurring? take BP lying, sitting and standing What are we listening for when assessing blood pressure? the first and fourth Korotkoff sounds What five factors control blood pressure? age stress ethnicity gender daily variation Blood pressure depends on peripheral vascular resistance (arteries constrict or dilate) What is the normal range for heart rate? 60-100 bpm What is a pulse deficit? difference between apical and radial pulse What is the scale for measuring pulses? What is normal? 0-4 0 = absent 1+ = weak/threaded 2+ = normal 3+ = full 4+ = bounding What can we tell about the pulse if taken at the radial site? the rhythm, strength and symmetry What can we tell about the pulse if taken at the apical site? rate and rhythm only Normal respiration range and description 12-20 bpm deep and regular Temperature is regulated by the hypothalamus What is the normal range for temperature? 96.8-100.4 F 36-38 C The fifth vital sign is pain What questions do we ask about pain? OPQRSTU Onset Provoking Quality Radiation Severity Time U: How does it affect you? ABCDE for pain A: Ask about pain regularly and assess systematically B: Believe the patient and family when pain is reported C: Choose pain control options appropriate for patient D: Deliver interventions in a timely, logical, coordinated way E: Empower patients and their families The normal range for BMI is? Overweight? 18.5-24.9 25-29 = overweight How do you palpate lymph nodes? Easy or difficult? Should they be visible? Palpated with fingers in a circular motion Difficult to palpate and should not be visible Seven lymph nodes to palpate in the head OPPRSSS Occipital Postauricular Preauricular Retropharyngeal Submandibular Submental Supraclavicular