NUR 3065 EXAM 1 QUESTIONS &
ACTUAL CORRECT ANSWERS
PASSED
Subjective Data - CORRECT ANSWER -what patients report about themselves during
history
ex. what they're feeling, family history, health history **pain**
"I have a stomachache" "I have a sore throat", patient reports chronic visual impairment,
reports drinking two gallons of water a day, feels hungry and thirsty
Objective Data - CORRECT ANSWER -what the nurse notes when inspecting,
percussing, palpating, auscultating patient during physical examination
ex. age, level of consciousness, symmetry, height, weight, vital signs
"patient has erythematous pharynx" "left toe has great inflammation", patient appears to
have tremors in fingers, patient is sweaty, agitated, foot inspection reveals _
Patient Database - CORRECT ANSWER -subjective + objective = assessment
-datebase: subjective data + objective data + patients record + lab studies
-database allows nurse to make a clinical judgement or diagnosis about patients health
state
-key is organization of assessment based on complete factually based data
Step 1 of the nursing process - CORRECT ANSWER Assessment
-collect data
Step 2 of the nursing process - CORRECT ANSWER Diagnosis
-interpret data
Step 3 of the nursing process - CORRECT ANSWER Outcome Identification
-expected outcomes
Step 4 of the nursing process - CORRECT ANSWER Planning
-identify and prioritize interventions
Step 5 of the nursing process - CORRECT ANSWER Implementation
-implement plan
Step 6 of the nursing process - CORRECT ANSWER Evaluation
-progress towards outcomes
,Priority levels: first level priority - CORRECT ANSWER Emergent, life threatening,
immediate
ex. ABCs (airway, breathing, circulation)
Priority levels: second level priority - CORRECT ANSWER Next in urgency, requiring
attention so as to avoid further deterioration
ex. mental status change, acute pain, acute urinary elimination problems, untreated
medical problems, abnormal lab values, risk of infection, risk to safety or security)
Priority levels: third level priority - CORRECT ANSWER Important to patients health but
can be addressed after more urgent problems are addressed
ex. long term treatment, collaborative effort between health professionals
Unexpected > expected - CORRECT ANSWER Unexpected problems are more urgent
ex. a patient who receives his first dose of antibiotics complains of painful swallowing
this is unexpected and urgent bc it could be an airway issue (ABCs are first level
priority)
Four types of data - CORRECT ANSWER 1. complete total health database
2. focused or problem centered datebase
3. follow up database
4. emergency database
-treatment and assessment at the same time ex. someone is having a stroke, they may
not be stable enough to provide info later
Vital Signs - CORRECT ANSWER T- temperature
P- pulse
R- respirations
O2- oxygen saturation
BP- blood pressure
Pain
When to take vital signs - CORRECT ANSWER -when patient status could change
-admission
-per unit protocol
-pre/post op
-pre/post invasive procedures
-per pt condition (decline)
-with medications
Temperature normal - CORRECT ANSWER Oral- 98.6 or 37C
Rectal- +1 degree
Axillary- -1 degree
elderly often lower
Pyrexia (fever) - CORRECT ANSWER -raised body temp
, -chills, sweaty, flushing, dehydration, lethargic, confusion, delirium, seizures (kids)
febrile: with fever
afebrile: without fever
Hypothermia - CORRECT ANSWER -less than 96.8F
-caused by exposure to prolonged cold, malnutrition, infection, sepsis, metabolic or
endocrine disorder
-may be medical induced to lower body oxygen requirements during surgeries
(cardiac/vascular/neuro), amputation, post cardiac arrest, GI hemorrhages,
-lowers HR, RR
-temperature conversion F to C: #F-32 x 5/9
C to F: #C x 9/5 + 32
Hyperthermia - CORRECT ANSWER -alterations in body temperature like fever
-greater than 100.4 (so 100.5 is hyperthermia)
-infections, neurologic disorders, trauma, myocardial infarction, stroke, dehydration,
inflammation, cerebral edema, tissue breakdown
-HR and RR will increase
-metabolism increases 13% for every 1 degree C of increase
Check babies/small children temperature - CORRECT ANSWER -tympanic/temporal is
best
-rectal is okay
-temporal is less traumatic and less likely to skew other VS
-for babies check respirations before temp
Pulse - CORRECT ANSWER rate: count for 30 seconds then multiply by two (bpm) if
regular
-if irregular, count for a full minute and take apical (on heart)
-rhythm: if irregular listen for full minute
-symmentry
-tachycardia: >100
-bradycardia: <60
normal: 60-100
-3+ full bounding, 2+ normal, 1+ weak, thready, 0 absent
Pulse rhythm:
Pulse should be ____ and _____
Sinus _______ is common in children and young adults
-_______ up with inspiration, ______ with expiration
Deviations from regular rhythm palpated should be confirmed with ______ at _____ -
CORRECT ANSWER -pulse should be regular and metronomic
-sinus arrhythmia is common in children and young adults
-speeds up with inspiration and slows with expiration
-Deviations from regular rhythm palpated should be confirmed with auscultations at PMI
ACTUAL CORRECT ANSWERS
PASSED
Subjective Data - CORRECT ANSWER -what patients report about themselves during
history
ex. what they're feeling, family history, health history **pain**
"I have a stomachache" "I have a sore throat", patient reports chronic visual impairment,
reports drinking two gallons of water a day, feels hungry and thirsty
Objective Data - CORRECT ANSWER -what the nurse notes when inspecting,
percussing, palpating, auscultating patient during physical examination
ex. age, level of consciousness, symmetry, height, weight, vital signs
"patient has erythematous pharynx" "left toe has great inflammation", patient appears to
have tremors in fingers, patient is sweaty, agitated, foot inspection reveals _
Patient Database - CORRECT ANSWER -subjective + objective = assessment
-datebase: subjective data + objective data + patients record + lab studies
-database allows nurse to make a clinical judgement or diagnosis about patients health
state
-key is organization of assessment based on complete factually based data
Step 1 of the nursing process - CORRECT ANSWER Assessment
-collect data
Step 2 of the nursing process - CORRECT ANSWER Diagnosis
-interpret data
Step 3 of the nursing process - CORRECT ANSWER Outcome Identification
-expected outcomes
Step 4 of the nursing process - CORRECT ANSWER Planning
-identify and prioritize interventions
Step 5 of the nursing process - CORRECT ANSWER Implementation
-implement plan
Step 6 of the nursing process - CORRECT ANSWER Evaluation
-progress towards outcomes
,Priority levels: first level priority - CORRECT ANSWER Emergent, life threatening,
immediate
ex. ABCs (airway, breathing, circulation)
Priority levels: second level priority - CORRECT ANSWER Next in urgency, requiring
attention so as to avoid further deterioration
ex. mental status change, acute pain, acute urinary elimination problems, untreated
medical problems, abnormal lab values, risk of infection, risk to safety or security)
Priority levels: third level priority - CORRECT ANSWER Important to patients health but
can be addressed after more urgent problems are addressed
ex. long term treatment, collaborative effort between health professionals
Unexpected > expected - CORRECT ANSWER Unexpected problems are more urgent
ex. a patient who receives his first dose of antibiotics complains of painful swallowing
this is unexpected and urgent bc it could be an airway issue (ABCs are first level
priority)
Four types of data - CORRECT ANSWER 1. complete total health database
2. focused or problem centered datebase
3. follow up database
4. emergency database
-treatment and assessment at the same time ex. someone is having a stroke, they may
not be stable enough to provide info later
Vital Signs - CORRECT ANSWER T- temperature
P- pulse
R- respirations
O2- oxygen saturation
BP- blood pressure
Pain
When to take vital signs - CORRECT ANSWER -when patient status could change
-admission
-per unit protocol
-pre/post op
-pre/post invasive procedures
-per pt condition (decline)
-with medications
Temperature normal - CORRECT ANSWER Oral- 98.6 or 37C
Rectal- +1 degree
Axillary- -1 degree
elderly often lower
Pyrexia (fever) - CORRECT ANSWER -raised body temp
, -chills, sweaty, flushing, dehydration, lethargic, confusion, delirium, seizures (kids)
febrile: with fever
afebrile: without fever
Hypothermia - CORRECT ANSWER -less than 96.8F
-caused by exposure to prolonged cold, malnutrition, infection, sepsis, metabolic or
endocrine disorder
-may be medical induced to lower body oxygen requirements during surgeries
(cardiac/vascular/neuro), amputation, post cardiac arrest, GI hemorrhages,
-lowers HR, RR
-temperature conversion F to C: #F-32 x 5/9
C to F: #C x 9/5 + 32
Hyperthermia - CORRECT ANSWER -alterations in body temperature like fever
-greater than 100.4 (so 100.5 is hyperthermia)
-infections, neurologic disorders, trauma, myocardial infarction, stroke, dehydration,
inflammation, cerebral edema, tissue breakdown
-HR and RR will increase
-metabolism increases 13% for every 1 degree C of increase
Check babies/small children temperature - CORRECT ANSWER -tympanic/temporal is
best
-rectal is okay
-temporal is less traumatic and less likely to skew other VS
-for babies check respirations before temp
Pulse - CORRECT ANSWER rate: count for 30 seconds then multiply by two (bpm) if
regular
-if irregular, count for a full minute and take apical (on heart)
-rhythm: if irregular listen for full minute
-symmentry
-tachycardia: >100
-bradycardia: <60
normal: 60-100
-3+ full bounding, 2+ normal, 1+ weak, thready, 0 absent
Pulse rhythm:
Pulse should be ____ and _____
Sinus _______ is common in children and young adults
-_______ up with inspiration, ______ with expiration
Deviations from regular rhythm palpated should be confirmed with ______ at _____ -
CORRECT ANSWER -pulse should be regular and metronomic
-sinus arrhythmia is common in children and young adults
-speeds up with inspiration and slows with expiration
-Deviations from regular rhythm palpated should be confirmed with auscultations at PMI
