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NUR 216 Final Exam Review – Questions With In Depth Solutions

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NUR 216 Final Exam Review – Questions With In Depth Solutions

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Practice questions for this set


Learn 1 /7 Study using Learn




Bruising, discoloration of the skin resulting from bleeding underneath



Choose an answer



Pulse oximeter alternate locations when
1 General survey components 2
fingers are unavailable



3 Objective data 4 Ecchymosis



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Terms in this set (122)



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 Physical appearance
components 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 Earlobe
fingers are unavailable


Factors that affect HR Exercise (however, marathon runners will have bradycardia for
resting HR)
Fever
Medications
Changing positions
Acute pain
Hyperthyroidism
Anemia
Stress
Shock


Types of pain Visceral - dull crampy, organ pain
Somatic - joint, muscles, ligament pain
Neuropathic - related to nerves, diabetics have this type of
pain
Acute - < 6 months
Chronic - > 6 months


PQRST Provoking - what makes it better or worse?
Quality - what does it feel like?
Region - where is the pain located?
Severity - pain rating
Timing - onset/duration


How to appropriately utilize an interpreter Nurse must provide a trained interpreter
Nurse should speak directly to the client
Nurse should avoid medical jargon just like any client
Interpreter should be used for the entire assessment

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