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SOAP modified format - CORRECT ANSWERS Subjective
Objective
Assessment
Plan
What color ink should be used when documenting on paper - CORRECT ANSWERS Permanent
black ink
What is the correct order for vital signs - CORRECT ANSWERS T, P, RR, BP, extremity, pt position,
SPO2
What should be at the top of every page of documentation - CORRECT ANSWERS Patient initials
and date and time of entry
What should be at the end of every documentation entry - CORRECT ANSWERS Interviewers
signature
How do you correct a mistake in documentation - CORRECT ANSWERS 1) Draw a single line
through the incorrect documentation
2) Write error above the entry
3) Initial and date the crossed out entry
Documentation tips - CORRECT ANSWERS 1) Avoid complete sentences
2) Do not use A, an, the
3) Do not put opinion in notes
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4) Avoid use of normal or within normal limits
Normal oral temp range - CORRECT ANSWERS 96.4 - 99.1 F
Febrile - CORRECT ANSWERS With fever
Afebrile - CORRECT ANSWERS Without fever
Hyperthermia symptoms - CORRECT ANSWERS 1) Cessation of shivering
2) Bradycardia
3) Decrease in respiratory minute volume
Most common and easy method of assessing temperature - CORRECT ANSWERS Oral
What methods of assessing temperature reflects core temperature - CORRECT ANSWERS 1) Oral
2) Rectal
3) Tympanic
4) Temporal Artery
What is the least accurate method of assessing temperature - CORRECT ANSWERS axillary
Which patients are contraindicated for rectal temperature readings - CORRECT ANSWERS Patients
with increased HR
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Preferred method of taking infants and small children's temperatures - CORRECT ANSWERS Rectal
Pulse deficit - CORRECT ANSWERS - Difference between apical peripheral pulse
Pulse amplitude scale - CORRECT ANSWERS 0 = no pulse
1 = diminished, weak
2 = normal and expected
3 = full or strong
4 = bounding
Which pulses are assessed during a routine physical assessment? - CORRECT ANSWERS 1) Apical
2) Radial
3) Dorsalis pedis
4) Posterior tibialis
Normal heart rate in resting adult - CORRECT ANSWERS 60 to 100 bpm
Well trained athletes heart rate - CORRECT ANSWERS Heart rate less than 60 bpm
When is it normal for someone to have a rapid heart rate over 100 bpm - CORRECT ANSWERS
Someone with anxiety and right after exercise
Eupnea - CORRECT ANSWERS Normal RR, rhythm and depth
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Normal SPO2 value - CORRECT ANSWERS 95-100%
What level is poor oxygenation - CORRECT ANSWERS below 90%
Systolic BP - CORRECT ANSWERS Maximum pressure on the artery during ventricular contraction
Diastolic BP - CORRECT ANSWERS Resting pressure during ventricular filling
Pulse pressure - CORRECT ANSWERS Difference between systolic and diastolic
Stroke volume - CORRECT ANSWERS Amount of blood ejected with each beat
How does age affect BP - CORRECT ANSWERS BP increases with age
What BP is pre hypertensive? - CORRECT ANSWERS Sustained BP over 120/80
What extremities should you avoid taking a BP in - CORRECT ANSWERS Extremities with IV lines,
invasive lines, history of mastectomy/lymph node issues
Orthostatic hypertension - CORRECT ANSWERS - Decreased BP with change in position
- Drop in SBP of 25 mmHg or DBP of 10 mmHG
- Symptoms
1) Dizziness
2) Weakness