Download Test #3- RNSG 1105 Questions with Answers and more Exams Nursing in PDF only on Docsity!
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Test #3- RNSG 1105 Questions with Answers
1. Vital signs: Temperature pulse
respiration blood pressure polse oximetry
2. when do we take vital signs?: -admission to facility
-routine based on unit -anytime there is change in patient condition -before/during/after surgical or invasive procedures/blood transfusions -b/a any activity that may increase risk -before administering medications that effect cardiovascular or respiratory function.
3. guidelines for measuring vitals: -measuring is nurses responsibility
-make sure equipment is working properly -know pt range and health history -control environmental factors -systematic approach -collab to decide frequence -analyze results, identify significant findings -instruct patient in vital sign assessment
4. body temperature: balance between heat produced in the body and heat loss from the body
5. what regulates body temperature?: the hypothalamus acts as the body's ther- mostat.
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6. sources of heat loss: Skin (primary source) Evaporation of sweat
Warming and humidifying inspired air Eliminating urine and feces
7. radiation: loss of body heat from body to another cooler source
8. evaporation: transfer of heat when liquid is changed to a gas
9. conduction: loss via direct contact with a cool surface
10. factors effecting body temp: age exercise
hormone levels circadian rhythm stress environment temperature alterations
11. temperature ranges: 1) Oral - 96.8 to 100.4 F (36 to 38 C). Average is 98.6 F
(37 C)
variations: rectal: 1 degree higher axillary: 1 degree lower
12. pyrexia: fever/hyperthermia
13. heat stroke: very high fever, greater than 104
14. febrile: having a fever
4 / lightly palpate one side at a time to prevent decrease in O2 to the brain which causes fainting. assess this pulse in emergencies.
27. brachial pulse: the pulse felt in the upper arm. used most common in infants.
28. radial pulse: the pulse felt at the wrist. used most often with children and adults.
29. dorsalis pedis pulse: pulse located on top of the foot. used to assess circulation of the legs and feet.
30. tachycardia: fast heart rate over 100 BPM.
31. bradycardia: decreased heart rate belowe 60 BPM.
32. rate of pulse: 60-100 bpm
33. rhythm of pulse: equal time between pulses make normal rhythm, irregular rhythm is dysrhythmia.
34. strength of pulse: reflects volume of blood ejected against arterial wall with each bear.
35. pulse equality: pulses on both sides of the body should be equal
36. pulse palpitation: middle 2-3 fingers used, do not use thumb.
37. pulse auscultation: stethoscope used to find apical pulse.
38. doppler ultrasound: used to hear difficult pulses.
39. respirations: reflect the breathing rate of the patient- 12-20 RPM.
40. factors that increase respirations: age(newborn rate is 30-60), activity, ane- mia, medications, pain, smoking
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41. factors that decrease respirations: age (Older adults), activity, medications, pain
42. tachypnea: rapid breathing above 24rpm
43. bradypnea: decreased respiratory rate below 12 rpm.
44. depth of respirations: described as normal, deep, shallow
45. respirations rhythmm: evenly spaced in adult, irregular in infant. irregular res- pirations in an adult should be
reported.
46. effort of respirations: does the chest expand symmetrically with each inspira- tion?
difficulty breathing is dyspnea
47. blood pressure: measure of pressure on the walls of an artery as it flows.
48. cardiac output: The volume of blood pumped per minute by each ventricle of the heart.
49. resistance: resistance of blood flow determined by tone of vascular muscilature and diameter of blood vessels.
50. factors that increase BP: older adult, men, women (post menopausal), exer- cise, weight, emotion state,
race(high bp in african americans)
51. factors that decrease BP: women (lower bp than men of the same age), exercise body position, orthostatic
hypotension.
52. systolic pressure: Blood pressure in the arteries during contraction of the ventricles.
53. diastolic pressure: occurs when the ventricles are relaxed; the lowest pressure against the walls of an artery
54. pulse pressure: difference between systolic and diastolic pressure
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65. safety precations for oxygen therapy: no open flames in room, no smoking sign, instruct patient and visitors on
precautions, make sure electrical devices work to prevent sparks, avoid materials thatgenerate static electricity, avoid oils/petroleum jelly, ground equipment, know locations of fire extinguishers.
66. pulse oximetry: non invasive way to measure O2 saturation of hemoglobin in the blood. assesses SpO2 and heart
rate, risk for hypoxia, postop ventilation status.
67. factors effecting pulse oximetry: oxygen off, nail polish, cold extremity, not on patient correctly.
68. if SpO2 is less than 90%... intervention: Immediately put on oxygen.
69. feeding a patient- nurse must assist in maintaining: nutritional statis, inde- pendence, dignity
70. setting the stage for eating: remove unpleasant sights, remove obnoxious odors, clean the over bed table,
provide good lighting.
71. preparing patinet for eating: assess swallow reflex, apply special devices, asseble supplies, assist in toileting
priot, place in comfortable positon, provide oral hygiene, clothing protection ,provide dentures or glasses.
72. assisting patient with eating: assess tray for completeness, correct diet, order changes. wsh hands before serving
and handling food. sit in chair next to paitient. allow to eat in order and speer of choice, amount requested. do not hurry patient. cut food in bite size pieces. place one type of food on utensil at a time. provide fluids as requested. at end of meal- wash hands, provide mouth care, assist into comfortable position, document.
73. feeding visually impaired: identify food locations as if it were a clock. place food in similar locations in each
meal. open containers, cut food, apply condiments, and have ready for the patient to eat.
74. safety precautions for eating: check swallowing and gag reflex, check temp of foods, feed in upright position,
8 / do not feed patient who is asleep, unresponsive, choking, unable to swallow.
75. dysphagia: difficulty swallowing- complications: aspiration, weight loss, dehy- dration
76. aspiration precautions: assess at mealtime for risk, elevate heaf of bed or sit upright in a chair. add thickeners,
provide small bites, palpate to make sure swallowing occurs. may need to swallow twice. feed slowly and allow to chew and swallow before another bite. l
77. clear liquid diet: liquids that are clear and without pulp or dairy. can be poured at room temp. easily digested and
so not leave residue in the digestive tract.
78. full fiquid diet: addition of calories, can include dairy products. foods that are liquid at room temp.
milk, milkshakes, veggie juices, fruit juice, cooked cereals, sherbert, gelatin, honey, syrups, broth, buillon, cream
79. soft diet: minimal fiber, easily chewed
80. mechanical soft diet: food chopped, ground, or pureed. fish, diced meat, cot- tage cheese, rise, potatoes ,pancakes,
bananas, peanut butter, cooked vegetables.
81. regular diet: provides 2500 calories/, no restrictions.
82. fluid status: daily weigh\s are important indicator of fluid status. a kg of weight gaines or loss = a liter of fluid
gained or losss
83. who is at risk for fluid imbalances?: -those dependent on other to meet nutritional needs
-pre op patients -post op patients -NPO for diagnostics. N/V, chronic diseases, aspiration risk -severe trauma or burns
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88. guidelines for weighing a patient: -weighed at the same time evry day, using same equipment and same clothing.
-if daily weights are ordered, patient is weighed in the early AM -pstient height obtained only on admission to facility, shoes should not be removed.
89. bowel elimination: regular elimination is essential for normal body functioning
alterations in elimination are early signs with the gastrointestinal tract or other body systems. nurses can help manage a patients elimination problems and promote normal defecation.
90. enema: insertion of a solution into the rectum and sigmoid colon to stimulate defecation.
91. why do we administer enemas?: -kickstart a bowel movement
-prevent escape of fecal material during surgery or childbirth -bowel training -promote visualization of the bowel prior to diagnostics
92. how does an enema stimulate peristalsis?: -bowel distention
-irritation of bowel mucosa
93. bowel distension: filling bowel with a large volume enema from external source.
filling bowel with small volume enema which draws internal fluid into the bowel.
94. osmosis: Diffusion of water through a selectively permeable membrane from an area of low concentration to high
concentration.
95. cleansing enema: evacuates feces from the colon.
11 / infusion of large volumes of fluid or irritation of the bowel mucosa.
96. tap water (hypotonic) enema: hypotonic action: flow of water is OUT of the bowel into interstitial tissues that
have higher osmotic pressure. distends intestine, increases peristalsis, softens stool adverse effects: should not be repeated 3x, could cause water toxicity, circulatory overload, fluid and electrolyte imbalances.
97. Isotonic Normal Saline Enema: isotonic action: equal concentration, making this the safest type of enema.
distends intestine, increases peristalsis, softens stool. adverse effects: fluid and electrolyte imbalances, sodium retention
98. low volume hypertonic enema: hypertonic action: draws water OUT of inter- stitial tissues and IN to colon.
distends intestine, irritates intestinal mucosa adverse effects: sodium retention.
99. soapsuds enema: soapsuds cause intestinal irritation or stimulate peristalsis
100. oil retention enema: must be retained in the colon for a prolonged period of time.
feces absorbs the oil and it becomes softer and easier to pass. mainly used when a patient has an impaction.
101. a doctors order is needed to administer an enema.: TRUE
102. positioning a bedpan: remain flat and roll on to bedpan, deeper section of bedpan to front.
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113. heat devices: dry heat: k pad, instant heat pack, heating pad, thermal blanket
moist heat: sitz bath, compress, whirlpool therapy, paraffin bath
114. cold devices: dry cold: ice bags, ice gloves, ice collars, chemical cold packs, hypothermia blanket
moist cold: cold soaks, cold backs, cooling sponge bath.
