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NURS3303 Exam 1 With
Complete Solution
What do you do if a patient has a seizure? - ANSWER Let patient haveseizure, clear area -after seizure is over place in supine position-place on side and give oxygen STAY. SAFE. SIDE What is the normal blood pressure for newborns? - ANSWER 40 (mean)What is the normal blood pressure for a 1 year old? - ANSWER 95/ What is the normal blood pressure for a 6 year old? - ANSWER 105/ What is the normal adolescent blood pressure? 10-13 - ANSWER 110/ What is a teenagers normal blood pressure? 14-17 - ANSWER 119/75What is normal blood pressure? - ANSWER 120/ What is the normal pulse for an adult? - ANSWER 60-100 bpm What is the normal pulse of an adolescent? - ANSWER 60-90What is the normal pulse of a school aged child? - ANSWER 75- What is the normal pulse of a preschooler? - ANSWER 80- What is the normal pulse of a toddler - ANSWER 90-
What is the normal pulse of an infant? - ANSWER 120-160What is the normal respiration of an infant? - ANSWER 30- 30-60 for newborn What is the normal respiration of a preschooler? - ANSWER 25-32What is the normal respiration of a child? - ANSWER 20- What is the normal respiration of an adolescent? - ANSWER 16- what is the normal respiration of an adult? - ANSWER 12- What is the average temperature range for adults? - ANSWER 36-38 celsius96.8 to 100.4 F Whats the average oral/tympanic temperature for adults? - ANSWER 98. What's the average rectal temperature for adults? - ANSWER 99.5What is normal SPO2? - ANSWER 95-100% What is the normal axillary temperature? - ANSWER 97.7 F 36.5 CBody temperature is affected by - ANSWER Body fat composition, physical ability, temperature extremes, hormones, circadian rhythm, hormones What pulse should you check in a child and infant? - ANSWER BrachialWhat pulse do you check on an infant? - ANSWER brachial what pulse do you check in emergency situations? - ANSWER Carotid What is the body's temperature control center? - ANSWER hypothalamus
pulse deficit - ANSWER difference between the apical and radial pulse rates how do you assess a pulse deficit? - ANSWER Have you and another providercount at the same time. The difference between the apical and radial pulse is the deficit. What factors influence temperature? - ANSWER Infection, Sepsis, Medication,Weather, Trauma, Injury, Medical Conditions, Immunosuppressive therapy, Infusion of blood product Respiration - ANSWER exchange of oxygen and carbon dioxide Ventilation - ANSWER movement of air in and out of the lungs Perfusion - ANSWER distribution of RBCs to and from pulmonary capillaries What is the significance of the brain stem in respirations? - ANSWER itincludes the respiratory center which regulates involuntary control of respirations based on levels of CO2, O2, and H+ in arterial blood.
Hypercarbia - ANSWER Increased carbon dioxide level in the bloodstream. hypoxemia - ANSWER deficient amount of oxygen in the blood Inspiration - ANSWER breathing in expiration - ANSWER breathing out eupnea - ANSWER normal breathing apnea - ANSWER absence of breathing Hyperventilation - ANSWER the condition of taking abnormally fast, deepbreaths
hypoventilation - ANSWER decreased rate or depth of air movement into thelungs
Cheyene-Stokes breathing - ANSWER a distinct pattern of breathingcharacterized by quickening and deepening respirations followed by a period of apnea
ANSWER Physical Assessment, Cultural Assessment, Safety Assessment,Psychosocial Assessment,
What is a nursing diagnosis? - ANSWER * A clinical judgement aboutindividual, family or community responses to actual and potential health probs or life processes *Client/pt centered *Prioritize nursing diagnoses What is an example of a NANDA I nursing diagnosis? - ANSWER Patient atrisk for depression due to immobility.
Who is at risk for seizures? - ANSWER Patients with neurological injury ormetabolic disturbances
What is a patient inherent accident? - ANSWER A self induced accident What is an equipment related accident? - ANSWER An accident due to theequipment in the room
What are medical restraints used for? - ANSWER Safety of the patient,patients who try to remove medical devices, and confused patients or combative patients. They can also be used to reduce injury. How often does a restraint need to be checked? - ANSWER every 15 minutesfor aggressive patients. Every 2 hours if non violent
The order for a restraint needs to be made in how much time? - ANSWER 24hours
Restraint orders must be reviewed every so often for each... Adults ??? Children ???Small Children ??? - ANSWER Adults - 4 hours Children - 2 hours Small Children - 1 hour Are restraints prn? - ANSWER no. Are helmets considered restraints? - ANSWER no
what is the difference between a medical diagnosis and a nursing diagnosis?- ANSWER A medical diagnosis identifies the problem
SMART stands for - ANSWER Specific, Measurable, Attainable, Realistic,Timely
What are the five points of delegation? - ANSWER Right time, Rightcircumstance, right person, right direction, right supervision
Can the nursing process be delegated? - ANSWER no What is included in the chain of infection? - ANSWER infectious agent,reservoir, portal of exit, mode of transmission, portal of entry, susceptible host What is the sign of a local infection? - ANSWER Redness, Tenderness, Heat,Swelling,
What is the sign of a systemic infection? - ANSWER Fever, increased WBCcount, malaise, anorexia, organ failure, nausea, vomiting, lymph node enlargement
What are the modes of transmission - ANSWER direct, indirect, droplet,airborne, vehicles, vector
HAI: Iatrogenic Infection - ANSWER From a procedure HAI: Exogenous - ANSWER from microorganisms outside the individual HAI: endogenous infection - ANSWER hypotension - ANSWER low blood pressure Hypertension - ANSWER abnormally high blood pressure Face Pain assessment - ANSWER Universal pain assessment How do you assist a patient with a fall? - ANSWER extend one leg,let thepatient slide against your leg, gently lower the patient to the floor protecting their head
