A Nurse is caring for a clients on the med-surg unit. Which client is most at risk to develop a
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nosocomial infection?
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A- client with alcohol abuse admitted for detox
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B- Client with Type I diabetes and peripheral neuropathy
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C- Client recovering from a cholecystectomy
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D- Client with full thickness burns, an NG tube and a Foley <CORRECT ANSWER>D- Full
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thickness burn, NG tube and Foley
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Think immunosuppression and avenues for infection
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Adult vital signs <CORRECT ANSWER>Temp: 97.5 99.5F
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HR: 60-100 bb bb
BP: Systolic 90/140 Diastolic 60/80
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Resp: 12-20 bb
o2 95%-100%bb
Celsius to Fahrenheit <CORRECT ANSWER>(C x 1.8) + 32
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Fahrenheit to Celsius <CORRECT ANSWER>(F-32)/1.8 bb bb bb bb
grading scale for pulses <CORRECT ANSWER>4+ = strong and bounding
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3+ = full pulse, increased
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2+ = normal, easily palpable
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1+ = weak, barely palpable
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0 = absent, not palpable
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,NUR 2811 Module 1 Exam
What type of information is Pain? <CORRECT ANSWER>Subjective
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When measuring an apical pulse you should count for a... <CORRECT ANSWER>A full minute
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Heart rate slows with ______, ________. _____________. and body temperature will ______
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the heart rate <CORRECT ANSWER>1. age
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2. emotions
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3. pain
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4. Increase
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What is all included in a set of vital signs? <CORRECT ANSWER>Heart rate, Blood pressure,
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Respiration rate, Oxygen saturation, Temperature, And pain
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What is sodium level? <CORRECT ANSWER>135-145
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What is potassium level? <CORRECT ANSWER>3.5-5
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What is digoxin level? <CORRECT ANSWER>0.5-2
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What is magnesium level? <CORRECT ANSWER>1.5-2.5 mEq/L
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What is calcium level? <CORRECT ANSWER>9-10.5
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What is phosphorus level? <CORRECT ANSWER>3.5-4.5
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,NUR 2811 Module 1 Exam
What is the normal WBC range? <CORRECT ANSWER>5,000-10,000/mm3
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What is the normal platelet range? <CORRECT ANSWER>150,000-400,000/mm3
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What is the normal Hemoglobin range? (male and female) <CORRECT ANSWER>Male- 14-18
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Female- 12-16 bb
What is the normal hematocrit range? (male and female)
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(always get male wrong) <CORRECT ANSWER>Male- 45-52%
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Female- 37-47% bb
what is the normal creatinine range? <CORRECT ANSWER>0.5-1.2 mg/dl
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What is the normal BUN range? <CORRECT ANSWER>10-20 mg/dL
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Cardiac Labs <CORRECT ANSWER>CK
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LDH = 140 - 280 (signifies MI
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Myoglobin = <90 (elevation could indicate MI)
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Troponin T: <0.2 (↑ = MI) bb bb bb bb bb
What is the normal APTT, PT, INR <CORRECT ANSWER>APTT- 30-60 seconds
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PT- 11-12.5 seconds
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INR 0.81-1.20
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What does the HgbA1c test for? <CORRECT ANSWER>3 months average blood sugar
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, NUR 2811 Module 1 Exam
Signs and Symptoms of Metabolic Acidosis <CORRECT ANSWER>- headache
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- decreased BP
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- *hyperkalemia*
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- *muscle twitching*
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- warm, flushed skin (vasodilation)
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- nausea, vomiting, diarrhea
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- *Kussmal respirations (compensatory hyperventilation)*
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Respiratory Alkalosis Signs/Sx <CORRECT ANSWER>-seizures
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-deep, rapid breathing
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-hyperventilation
-tachycardia
-hypokalemia
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Metabolic Alkalosis Signs and Symptoms <CORRECT ANSWER>-dysrhythmias (tachycardia)
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-hypoventilation
-nausea/vomiting/diarrhea
-tremors, muscle cramps bb bb
-hypokalemia
Normal PH level? <CORRECT ANSWER>7.35-7.45
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Normal PaCO2 <CORRECT ANSWER>35-45
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