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RNSG 1105 Exam 3 Questions with Complete Solution
1. Temperature Range for adult: 96.8-100.4 degrees F
2. Pulse Range for adult: 60-100 bpm
3. Respiration range for adult: 12-20 breaths/min
4. Blood Pressure Range for adult: 120/
5. O2 Saturation: >= 95%
6. When to Measure vital signs: on admission routine schedule based on
facility policy or HCP order change in pt condition before and after: admin of meds that affect respiratory, cardiovascular or tempera- ture-control function and physical activity as appropriate before,during, and after: surgery or invasive dx procedures and blood product transfusions
7. Hypothalamus decreases temperature by: vasodilation, sweating, and inhibi- tion of heat production
8. Hypothalamus increases temperature by: vasoconstriction, muscle contrac- tion, and shivering
9. Heat production: metabolism, physical exertion, hormones, and shivering
10. heat loss: evaporation, convection, conduction, and radiation
11. 90% of heat loss comes from: the skin
12. Factors affecting body temperature: age, exercise, hormone level, circadian rhythm, stress, environment,
2 / temperature alterations
13. Oral temp safety alert: if patient ate, drank, chewed gum, or smoked, wait 15-30 minutes
14. Rectal temp safety alert: lubricate the thermometer; avoid in patients with heart disease or heart surgery; may
stimulate vagus nerve, causing bradycardia; do not perform on patients with rectal disease or those who have had rectal surgery
15. Tympanic temp safety alert: do not perform on patients who have drainage from the ear
16. Axillary temp safety alert: axilla must be dry to obtain accurate reading
17. HR x Stroke Volume =: Cardiac Output (5000 mL/min)
18. Factors that increase pulse: hemorrhage activity
fever (increase 10 bpm per 1 degree above normal) pain emotions
19. Factors that decrease pulse: elderly endurance
athletes beta blockers calcium channel blockers hypothermia
20. Carotid pulse safety alert: lightly palpate one side at a time to prevent dimin- ished O2 to the brain
21. Assessment sites for pulse: temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibial, dorsalis
pedis
22. Doppler ultrasound: used when pulses are difficult to palpate or auscultate; produces high-frequency sound
waves
4 / anaphylaxis
33. Safety Guidelines for assessment of BP: do not take when limb alert is in place
do not take if pt has had mastectomy on same side do not take on limb with AV graft for dialysis remove cuff when not in use to avoid skin breakdown analyze trends and report abnormal findings
34. Why turn a post-op patient every 2 hours?: to assist with ventilation and redistribution of pulmonary blood
flow
35. What is the rationale for having a post-op patient do coughing exercises?-
: permits patient to remove secretions from both upper and lower airways
36. Proper technique for coughing: splint abdomen for patients with abdominal incision
Take 2 deep breaths (IN-2-3-4, OUT-2-3-4) On 3rd deep breath, COUGH on expiration
37. How does performing breathing exercises support post-op patient's respi- ratory function?: 1. loosens
respiratory secretions
2. improves pulmonary ventilation
3. counteracts the effects of anesthesia and/or hypoventilation
4. expands collapsed alveoli (atelectasis)
38. Which type of breathing do you teach to patients who are hypoventilating?-
: deep diaphragmatic breathing
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39. What type of breathing do you teach to patients with COPD or asthma (chronic breathing problems)?:
pursed-lip breathing
40. What is the purpose of using an incentive spirometer?: 1. increases inspi- ratory volume
2. inflate alveoli/lungs
3. allows patients to monitor their progress
4. provides visual reinforcement for the breathing efforts
41. What are key points to state when instructing pt how to use an incentive spirometer?: 1. inhalation - inhale
slowly like you are sucking on a straw
- hold breath for several seconds before exhaling through nose, if possible
42. Patient becomes short of breath when he lies down. What is the first nursing intervention?: Raise the
head of the bed to a semi-fowler's
43. Benefits gained from positioning: Activation of cough reflex Reduce pain
Increase ventilatory compensation Drainage of areas of the lungs Maintaining a patent airway
44. Why might a post-op, hypoventilating patient be a candidate for oxygen therapy?: with hypoventilation, he
could have inadequate transport of oxygen and develop hypoxemia
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3. postoperative ventilation status
52. Pt becomes confused and restless. Nurse thinks it might be a respiratory problem. What should the nurse
assess?: level of consciousness breath sounds o2 therapy correct pulse ox
53. My Plate: divided into sections of approx 30% grains, 30% vegetables, 20% fruits and 20% protein
54. Setting the stage for eating: remove any unpleasant sights remove any obnoxious
odors clean the over-bed table provide good lighting
55. What is the highest priority when preparing a patient to eat?: assess swal- low reflex
56. Strategies used to assist with eating: 1. assess tray for completeness, correct diet, order changes
2. wash hands before serving and handling food
3. sit in chair next to patient
4. allow patient to eat in order and speed of choice, and the amount requested
5. do not hurry patient
6. cut food into bite-sized pieces
57. Safety Precautions for feeding patients: Check the patient's swallowing and gag reflex first
8 / Check temperatures of foods - do not burn patient Feed the patient in an upright position Do not feed patient who is asleep, unresponsive, choking, unable to swallow
58. Aspiration Precautions: assess the patient for increased risk of aspiration elevate head of bed or sit up in
chair add thickener to thin liquids to create consistency of honey Provide smaller bites; place on strong side of mouth Feed slowly, allow patient to chew thoroughly and swallow before taking another bite Have patient sit up for 30-60 minutes after meal
59. Clear liquid diet: contains liquids that are clear without pulp or dairy products that can be poured at room
temperature; easily digested and leave no undigested residue in the intestinal tract Most often used after surgery, or with patients with diarrhea or vomiting
60. Full liquid diet: made up of only fluids and foods that are normally liquid and foods that turn to liquid when
they are at room temperature
61. Soft Diet: used as a transition to the regular diet or for those who have difficulty eating; designed to be chewed and
provide minimal fiber
62. Mechanical soft diet: food is chopped, ground, or pureed for those with difficulty chewing/poor teeth
63. Who is at risk for fluid and electrolyte imbalances?: Dependent on others to meet their nutritional needs
Pre and post operative patients NPO for diagnostic test, nausea, vomiting, chronic diseases, aspiration risk Severe trauma, burns Patients taking diuretics Special drainages or NG suction
64. 1 cup: 8 oz., 240 mL
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70. Guidelines for Weighing: 1. pt weighed at same time each day using the same equipment and with same clothing
2. pt weighed in early am
3. dr. may order a daily weight to assess fluid loss or gain and not for nutritional purposes
4. height usually obtained only on admission, shoes removed
71. Enema: an insertion of a solution into the rectum and sigmoid colon to stimulate defecation
72. What are the reasons for administering an enema?: 1. promote defecation by peristalsis
2. prevent involuntary escape of fecal material during surgical procedures and childbirth
3. promote visualization of the bowel when an x-ray or exam is to be performed
4. bowel training
73. Cleansing enema: Evacuate feces from the colon by infusing large volumes of fluid or irritation of bowel mucosa
74. Tap Water/Hypotonic enema: water flows out of bowel into interstitial tissues which have higher osmotic
pressure; distends intestine, increases peristalsis and softens stool before significant amounts of fluid are absorbed
75. Hypotonic enema safety alert: should not be repeated more than three times due to water toxicity, circulatory
overload, fluid and electrolyte imbalance, heart failure
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76. Isotonic/Normal Saline enema: equal concentration on both sides of the mem- brane making it the safest type;
distends intestine, increases peristalsis and softens stool
77. Isotonic enema adverse effects: fluid and electrolyte imbalance, sodium re- tention
78. Low volume/hypertonic enema: draws water out of interstitial tissues into the colon which has higher osmotic
pressure; distends intestine, irritates intestinal mucosa to stimulate defecation reflex
79. Hypertonic enema safety alerts: sodium retention; not for infants or patients with vomiting, diarrhea
(dehydrated)
80. Soapsuds enema: causes intestinal irritation or stimulates peristalsis
81. Oil retention enema: must remain in colon for prolonged period of time; feces absorb the oil and become softer
and easier to pass; used mainly when patient has an impaction
82. Digital removal of stool: if impacted stool cannot be expelled voluntarily and oil retention enema fails to break
up the mass, then the impaction must be broken up manually
83. Complications of digital removal: vagal stimulation - bradycardia, flushing irritation of rectal mucosa
84. What are the guidelines for measuring vital signs?: Select appropriate equipment
Know the baseline vital signs for the pt and meds they are taking that may affect vital signs Consider environmental factors Take vital signs using an organized systematic approach Analyze results, determine significant findings, document vital signs, communicate concerning findings
