NR224 Fundamentals Skills Final Exam Review UPDATED ACTUAL
Questions and CORRECT Answers
A heart rate that exceeds the normal resting rate, often defined as a heart rate over
Tachycardia
100 beats per minute.
A slower than normal heart rate, typically defined as a heart rate below 60 beats per
Bradycardia
minute.
Factors causing tachycardia Exercise, Fever/heat, Anxiety, Loss of blood, Positive chronotropic drugs.
, Hypothermia, Long-term exercise (athletes), Unrelieved severe pain, Negative
Factors causing bradycardia
chronotropic drugs, Lying down.
Blood pressure assessment questions Have you had AV fistulas or a mastectomy?
Cuff selection for blood pressure Based on the size of the client's arm.
Cuff placement for blood pressure Align cuff artery mark with brachial artery.
Importance of proper cuff placement Ensures that proper pressure is applied during inflation.
Blood pressure reading action Return in 30 minutes and retake the blood pressure.
Priority instruction for UAP with low Avoid rectal temperatures.
platelet count
Client to see first based on vital signs 88-year-old male client admitted with pneumonia, RR 28, SPo2 89%.
Client admitted with several rib fractures, Woman who is 9 months pregnant, A 3
Clients at risk for tachypnea
pack per day smoker with pneumonia.
-Very thin and very obese people
-Age related changes
-Fluid loss during illness
Risk Factors for Pressure Ulcer
-Moisture/fluids/stool against the skin
Development
-Diseases of the skin
-Immobility
-Comorbidities
-Color
-Odor
-Consistency
Skin assessment
-Amount
-Measurements(Length x width x depth)
-Type of tissue(granulation, eschar, slough)
Primary Intention: Wound that is closed
Healing process Secondary Intention: Wound edges not approximated
Tertiary Intention: Wound that is left open for several days; then wo approximated
Desiccation drying out
Maceration Softening or breaking down the skin due to exposure to moisture
Pressure "pressure" areas of the skin that are more at risk for breakdown
Trauma caused by physical harm to the area
Edema swelling
Necrosis tissue death in area slows other tissue healing
-bleeding
Hemorrhage -May be seen externally, or may be internal and careful assessment needed to
assess
Dehiscence Incision fails to heal properly, or tissues separate
Evisceration Protrusion of visceral organs through a surgical wo
Questions and CORRECT Answers
A heart rate that exceeds the normal resting rate, often defined as a heart rate over
Tachycardia
100 beats per minute.
A slower than normal heart rate, typically defined as a heart rate below 60 beats per
Bradycardia
minute.
Factors causing tachycardia Exercise, Fever/heat, Anxiety, Loss of blood, Positive chronotropic drugs.
, Hypothermia, Long-term exercise (athletes), Unrelieved severe pain, Negative
Factors causing bradycardia
chronotropic drugs, Lying down.
Blood pressure assessment questions Have you had AV fistulas or a mastectomy?
Cuff selection for blood pressure Based on the size of the client's arm.
Cuff placement for blood pressure Align cuff artery mark with brachial artery.
Importance of proper cuff placement Ensures that proper pressure is applied during inflation.
Blood pressure reading action Return in 30 minutes and retake the blood pressure.
Priority instruction for UAP with low Avoid rectal temperatures.
platelet count
Client to see first based on vital signs 88-year-old male client admitted with pneumonia, RR 28, SPo2 89%.
Client admitted with several rib fractures, Woman who is 9 months pregnant, A 3
Clients at risk for tachypnea
pack per day smoker with pneumonia.
-Very thin and very obese people
-Age related changes
-Fluid loss during illness
Risk Factors for Pressure Ulcer
-Moisture/fluids/stool against the skin
Development
-Diseases of the skin
-Immobility
-Comorbidities
-Color
-Odor
-Consistency
Skin assessment
-Amount
-Measurements(Length x width x depth)
-Type of tissue(granulation, eschar, slough)
Primary Intention: Wound that is closed
Healing process Secondary Intention: Wound edges not approximated
Tertiary Intention: Wound that is left open for several days; then wo approximated
Desiccation drying out
Maceration Softening or breaking down the skin due to exposure to moisture
Pressure "pressure" areas of the skin that are more at risk for breakdown
Trauma caused by physical harm to the area
Edema swelling
Necrosis tissue death in area slows other tissue healing
-bleeding
Hemorrhage -May be seen externally, or may be internal and careful assessment needed to
assess
Dehiscence Incision fails to heal properly, or tissues separate
Evisceration Protrusion of visceral organs through a surgical wo
