NUR 216 Final Exam Review UPDATED ACTUAL Questions
and CORRECT Answers
, General survey components A written summary of overall health
Gather information from the first initial encounter with patient, make observations
throughout assessment
Done at first encounter
What is included in the general survey components Physical appearance
Body structure
Mobility
Behavior
Vital signs
First orientation to be lost Time
Subjective data pt report symptoms
Objective data Observed
Precautions Use gloves in situations involving possible contact with blood or bodily fluids,
mucous membranes, non-intact skin (ex. exposed skin that is chapped, abraded or
with dermatitis)
Ranges for RR Normal 12-20
Low >12 = COPD
High <1 = dehydration, respiratory distress, anxiety, fever
Ranges for HR Normal 60 to 100/min
Lower than 60 (bradycardia)
Higher than 100 (tachycardia)
Ranges for BP Normal 120/80
Elevated - 120-129 / <80 (ATI book 141)
HTN Stage 1 - 130--89
HTN Stage 2 - > or = 140 / > or = 90
HTN with 3 separate visits
Hypotension - systolic < 90
Ranges for SpO2 Normal 95-100%
Hypoxia - below 90% (ATI)
Temperature ranges 36 - 38 degrees Celsius
96.8 - 100.4 degrees Fahrenheit
Sodium intake effects on BP Raises BP
Pulse oximeter alternate locations when fingers are Earlobe
unavailable
and CORRECT Answers
, General survey components A written summary of overall health
Gather information from the first initial encounter with patient, make observations
throughout assessment
Done at first encounter
What is included in the general survey components Physical appearance
Body structure
Mobility
Behavior
Vital signs
First orientation to be lost Time
Subjective data pt report symptoms
Objective data Observed
Precautions Use gloves in situations involving possible contact with blood or bodily fluids,
mucous membranes, non-intact skin (ex. exposed skin that is chapped, abraded or
with dermatitis)
Ranges for RR Normal 12-20
Low >12 = COPD
High <1 = dehydration, respiratory distress, anxiety, fever
Ranges for HR Normal 60 to 100/min
Lower than 60 (bradycardia)
Higher than 100 (tachycardia)
Ranges for BP Normal 120/80
Elevated - 120-129 / <80 (ATI book 141)
HTN Stage 1 - 130--89
HTN Stage 2 - > or = 140 / > or = 90
HTN with 3 separate visits
Hypotension - systolic < 90
Ranges for SpO2 Normal 95-100%
Hypoxia - below 90% (ATI)
Temperature ranges 36 - 38 degrees Celsius
96.8 - 100.4 degrees Fahrenheit
Sodium intake effects on BP Raises BP
Pulse oximeter alternate locations when fingers are Earlobe
unavailable
