Exam 1 NURS-108 Questions With Complete Solutions
Five Rights of Delegation
Right Task
Right Circumstances
Right Person
Right Direction/Communication
Right Supervision/Evaluation
Responsibilities of a nurse manager
Assist staff in establishing annual goals for the unit and systems
needed to accomplish goals
Monitor professional nursing standards of practice on the unit
Develop an ongoing staff development plan, including one for
new employees
Recruit new employees (interview and hire)
Conduct routine staff evals
Establish self as a role model for positive customer service.
Submit staffing schedules for the unit
Conduct regular patient rounds and problem solve patient or
family complaints
Establish and implement a unit quality improvement plan
Review and recommend new equipment for the unit
Conduct regular staff meetings
Make rounds with health care providers
Establish and support staff and interdisciplinary committees
Guidelines for measuring vital signs
,-The nurse caring for the patient is responsible for measurement
of vital signs
• Ensure that equipment is functional and appropriate for the
size and age of the patient.
• Select equipment based on the patient's condition and
characteristics
• Know the patient's usual range of vital signs.
• Determine the patient's medical history, therapies, and
prescribed medications.
• Control or minimize environmental factors that affect vital
signs.
• Use an organized, systematic approach when taking vital signs.
• Based on the patient's condition, collaborate with health care
providers to decide the frequency of vital sign assessment.
• Use vital sign measurements to determine indications for
medication administration.
• Analyze the results of vital sign measurement.
• Communicate significant changes in vital signs to the patient's
health care provider or the charge nurse. Document findings and
compare with baseline measurements to identify significant
changes. When vital signs appear abnormal, have another nurse
or health care provider repeat the measurement to verify
readings.
Vital Signs: Acceptable Ranges for Adults
Temp: 96.8-100.4
Pulse: 60-100 bpm
Respirations: 12-20
,O2 Saturation: 95-100%
BP: 120/80
Vital Signs: Acceptable Ranges for Adults for SpO2 and
Capnography
Greater than or equal to 95%
Normal is 35-45 mm Hg
When to measure vital signs
-On admission to a health care facility
-When assessing a patient during home car visits
-In a hospital on a routine schedule according to the health care
provider's order or hospital standards of practice before, during,
and after a surgical procedure or invasive diagnostic procedure
-Before, during, and after a transfusion of blood products
-Before, during, and after the administration of medication or
therapies that affect cardiovascular, respiratory, or temperature-
control functions
-When a patient's general physical condition changes (e.g., loss
of consciousness or increased intensity of pain)
-Before, during, and after nursing interventions influencing a
vital sign (e.g., before a patient previously on bedrest ambulates
or before a patient performs range-of-moition exercises)
-When a patient reports nonspecific symptoms of physical
distress (e.g., feeling "funny" or "different")
Sites of temperature measurement
Oral
Rectal
, Axillary
Tympanic membrane (core)
Temporal artery
Esophageal (core)
Pulmonary artery (core)
Bladder (core)
Explain the principles and mechanisms of thermoregulation.
thermoregulation is the internal control of body temperature.
Physiological and behavioral mechanisms regulate the balance
between heat loss and heat produced.
The hypothalamus control body temp- the anternior
hypothalamus controls heat loss (sweating, vasodilation, and
inhibition of heat production).
The posterior hypothalamus senses when body temp is lower
than the setpoint- it initiates heat conservation mechanisms
(Vasoconstriction, voluntary muscle contraction, and shivering.)
Describe nursing measures that promote heat loss and heat
conservation.
Radiation- transfer of heat from the surface of one object to the
surface of another without direct contact betweeen the two.
Nurse should remove clothing and blankets to promote heat loss
OR to decrease heat loss they should cover the body with dark,
closely woven clothing.
Conduction- is the transfer of heat from one object to another
Five Rights of Delegation
Right Task
Right Circumstances
Right Person
Right Direction/Communication
Right Supervision/Evaluation
Responsibilities of a nurse manager
Assist staff in establishing annual goals for the unit and systems
needed to accomplish goals
Monitor professional nursing standards of practice on the unit
Develop an ongoing staff development plan, including one for
new employees
Recruit new employees (interview and hire)
Conduct routine staff evals
Establish self as a role model for positive customer service.
Submit staffing schedules for the unit
Conduct regular patient rounds and problem solve patient or
family complaints
Establish and implement a unit quality improvement plan
Review and recommend new equipment for the unit
Conduct regular staff meetings
Make rounds with health care providers
Establish and support staff and interdisciplinary committees
Guidelines for measuring vital signs
,-The nurse caring for the patient is responsible for measurement
of vital signs
• Ensure that equipment is functional and appropriate for the
size and age of the patient.
• Select equipment based on the patient's condition and
characteristics
• Know the patient's usual range of vital signs.
• Determine the patient's medical history, therapies, and
prescribed medications.
• Control or minimize environmental factors that affect vital
signs.
• Use an organized, systematic approach when taking vital signs.
• Based on the patient's condition, collaborate with health care
providers to decide the frequency of vital sign assessment.
• Use vital sign measurements to determine indications for
medication administration.
• Analyze the results of vital sign measurement.
• Communicate significant changes in vital signs to the patient's
health care provider or the charge nurse. Document findings and
compare with baseline measurements to identify significant
changes. When vital signs appear abnormal, have another nurse
or health care provider repeat the measurement to verify
readings.
Vital Signs: Acceptable Ranges for Adults
Temp: 96.8-100.4
Pulse: 60-100 bpm
Respirations: 12-20
,O2 Saturation: 95-100%
BP: 120/80
Vital Signs: Acceptable Ranges for Adults for SpO2 and
Capnography
Greater than or equal to 95%
Normal is 35-45 mm Hg
When to measure vital signs
-On admission to a health care facility
-When assessing a patient during home car visits
-In a hospital on a routine schedule according to the health care
provider's order or hospital standards of practice before, during,
and after a surgical procedure or invasive diagnostic procedure
-Before, during, and after a transfusion of blood products
-Before, during, and after the administration of medication or
therapies that affect cardiovascular, respiratory, or temperature-
control functions
-When a patient's general physical condition changes (e.g., loss
of consciousness or increased intensity of pain)
-Before, during, and after nursing interventions influencing a
vital sign (e.g., before a patient previously on bedrest ambulates
or before a patient performs range-of-moition exercises)
-When a patient reports nonspecific symptoms of physical
distress (e.g., feeling "funny" or "different")
Sites of temperature measurement
Oral
Rectal
, Axillary
Tympanic membrane (core)
Temporal artery
Esophageal (core)
Pulmonary artery (core)
Bladder (core)
Explain the principles and mechanisms of thermoregulation.
thermoregulation is the internal control of body temperature.
Physiological and behavioral mechanisms regulate the balance
between heat loss and heat produced.
The hypothalamus control body temp- the anternior
hypothalamus controls heat loss (sweating, vasodilation, and
inhibition of heat production).
The posterior hypothalamus senses when body temp is lower
than the setpoint- it initiates heat conservation mechanisms
(Vasoconstriction, voluntary muscle contraction, and shivering.)
Describe nursing measures that promote heat loss and heat
conservation.
Radiation- transfer of heat from the surface of one object to the
surface of another without direct contact betweeen the two.
Nurse should remove clothing and blankets to promote heat loss
OR to decrease heat loss they should cover the body with dark,
closely woven clothing.
Conduction- is the transfer of heat from one object to another
