Essential Nursing TEST PREP RATED A+
Hand Hygiene '5 moments' - Answer - ✔ 1. Before touching patient
2. Before procedure
3. After procedure
4. After touching patient
5. After touching patient surroundings
Vital Signs - Answer - ✔ - Temperature
- Pulse
- Respiratory Rate
- Blood Pressure
- O2 saturation
Vital Signs are assessed: - Answer - ✔ - based upon institutional policy and procedures
- on admission
- change in health status
- before and after surgery
- before and after administering medication
-folllowing an incident/accident
Temperature - Answer - ✔ Balance between the heat produced and heat lost. Average
temperature is 37 degrees.
Factors affecting Temperature - Answer - ✔ - metabolism
- age
-exercise
- hormones
Heat loss - Answer - ✔ - Radiation: heat loss through infrared rays
- Conduction: touch transfer heat
- Convection: movement of air or water across skin
- Evaporation: sweat
Pyrexia/Hypothermia/ Fever - Answer - ✔ Above the normal range
Hyperpyrexia - Answer - ✔ Very high fever e.g. 41 degrees
4 common types of fevers - Answer - ✔ 1. Intermittent
2. Remittent
3. Relapsing
4. Constant fever
How to assess temperature? - Answer - ✔ Oral, forehead, rectal, axillary, tympanic
, Pulse - Answer - ✔ A wave of blood created by contraction of the left ventricle of the
heart. Average is 60-80bpm.
Accessing Pulse - Answer - ✔ Peripheral pulse- located away from the heart
Apical Pulse- located at the apex of the heart
Factors affecting pulse - Answer - ✔ - Age
- Gender
- Exercise
- Fever
- Medications
- Stress
How to assess pulse - Answer - ✔ - Palpation (feeling)
- Auscultation (hearing)
- Middle two or three finger tips
- Apex of heart- stethoscope
Tachycardia - Answer - ✔ >100bpm
Bradycardia - Answer - ✔ <60bpm
Respiration - Answer - ✔ Inhalation or inspiration- breathing in or intake of air into lungs.
Exhalation or expiration- breathing out.
Two types of breathing: - Answer - ✔ - Costal breathing- observed by the movement of
the chest up and down
- Diaphragmatic- observed by the movement of the abdomen
Eupnea - Answer - ✔ Normal respiratory rate
Bradypnea - Answer - ✔ Slow respiratory rate
Tachypnea - Answer - ✔ Fast respiratory rate
Apnea - Answer - ✔ Brief pause in breathing
Dyspnea - Answer - ✔ Difficulty breathing
Factors affecting rate of respirations - Answer - ✔ - increasing: exercise, stress,
increased environmental temperature, lowered oxygen concentration
- decreasing: decreased environmental temp, certain medications, increase intracranial
pressure
Hand Hygiene '5 moments' - Answer - ✔ 1. Before touching patient
2. Before procedure
3. After procedure
4. After touching patient
5. After touching patient surroundings
Vital Signs - Answer - ✔ - Temperature
- Pulse
- Respiratory Rate
- Blood Pressure
- O2 saturation
Vital Signs are assessed: - Answer - ✔ - based upon institutional policy and procedures
- on admission
- change in health status
- before and after surgery
- before and after administering medication
-folllowing an incident/accident
Temperature - Answer - ✔ Balance between the heat produced and heat lost. Average
temperature is 37 degrees.
Factors affecting Temperature - Answer - ✔ - metabolism
- age
-exercise
- hormones
Heat loss - Answer - ✔ - Radiation: heat loss through infrared rays
- Conduction: touch transfer heat
- Convection: movement of air or water across skin
- Evaporation: sweat
Pyrexia/Hypothermia/ Fever - Answer - ✔ Above the normal range
Hyperpyrexia - Answer - ✔ Very high fever e.g. 41 degrees
4 common types of fevers - Answer - ✔ 1. Intermittent
2. Remittent
3. Relapsing
4. Constant fever
How to assess temperature? - Answer - ✔ Oral, forehead, rectal, axillary, tympanic
, Pulse - Answer - ✔ A wave of blood created by contraction of the left ventricle of the
heart. Average is 60-80bpm.
Accessing Pulse - Answer - ✔ Peripheral pulse- located away from the heart
Apical Pulse- located at the apex of the heart
Factors affecting pulse - Answer - ✔ - Age
- Gender
- Exercise
- Fever
- Medications
- Stress
How to assess pulse - Answer - ✔ - Palpation (feeling)
- Auscultation (hearing)
- Middle two or three finger tips
- Apex of heart- stethoscope
Tachycardia - Answer - ✔ >100bpm
Bradycardia - Answer - ✔ <60bpm
Respiration - Answer - ✔ Inhalation or inspiration- breathing in or intake of air into lungs.
Exhalation or expiration- breathing out.
Two types of breathing: - Answer - ✔ - Costal breathing- observed by the movement of
the chest up and down
- Diaphragmatic- observed by the movement of the abdomen
Eupnea - Answer - ✔ Normal respiratory rate
Bradypnea - Answer - ✔ Slow respiratory rate
Tachypnea - Answer - ✔ Fast respiratory rate
Apnea - Answer - ✔ Brief pause in breathing
Dyspnea - Answer - ✔ Difficulty breathing
Factors affecting rate of respirations - Answer - ✔ - increasing: exercise, stress,
increased environmental temperature, lowered oxygen concentration
- decreasing: decreased environmental temp, certain medications, increase intracranial
pressure
