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Principles of Int.
Final questions, normal VS values
| Question | Answer |
|---|---|
| Normal temperature range for an adult | 36 - 38 degrees Celsius 96.9 - 100.4 degrees Fahrenheit |
| Average oral/tympanic temp | 37 degrees Celsius 98.6 degrees Fahrenheit |
| Average rectal temp | 37.5 degrees Celsius 99.5 degrees Fahrenheit |
| Average axillary temp | 36.5 degrees Celsius 97.7 degrees Fahrenheit |
| Rectal temperatures are usually _____ degrees ________ than oral temperatures. | 0.5 C (0.9 F), higher |
| Axillary temperatures are usually ______ degrees ______ than oral temperatures. | 0.5 C (0.9 F), lower |
| Acceptable pulse rate range for adults | 60-100 beats per minute |
| Acceptable respiratory rate range for adults | 12-20 breaths per minute |
| Acceptable blood pressure range for adults | Systolic: 90><120 Diastolic 40><80 |
| Acceptable pulse pressure range for adults | 30 to 50 mmHg |
| Newborn's body temperature range | 35.5-37.5 C (95.9-99.5 F) |
| Average body temperature of older adults | 36 C (96.8 F) |
| A fever is not harmful if it stays below ____ | 39 C (102.2 F) |
| Acceptable range of HR in infants | 120-160 bpm |
| Acceptable range of HR in toddlers | 90-140 bpm |
| Acceptable range of HR in Preschoolers | 80-110 bpm |
| Acceptable range of HR in school-age children | 75-100 bpm |
| Acceptable range of HR in adolescents | 60-90 bpm |
| Acceptable range of RR in a newborn | 30-60 breaths per minute |
| Acceptable range of RR in infants up to 6 months | 30-50 breaths per minute |
| Acceptable range of RR in toddlers up to 2 years | 25-32 breaths per minute |
| Acceptable range of RR in children | 20-30 breaths per minute |
| Acceptable range of RR in adolescents | 16-19 breaths per minute |
| Range of O2 sat | 95%-100% |
| Factors influencing Blood Pressure | Age, Stress, Ethnicity, Gender, Daily variation, Medications, Activity and weight, Smoking |
| Average BP in a newborn | 40 mmHg(mean) |
| Average BP in a 1-month old | 85/54 mmHg |
| Average BP in a 1-year old | 95/65 mmHg |
| Average BP in a 6-year old | 105/65 mmHg |
| Average BP in a 10-13 year old | 110/65 mmHg |
| Average BP in a 14-17 year old | 120/75 mmHg |
| Average BP in >18 | 120/80 mmHg |
| Prehypertension | 120-139/80-89 mmHg |
| Stage I hypertension | 140-159/90-99 mmHg |
| Stage II hypertension | >160/>100 mmHg |
| Mild hypothermia | 34-36 C (93.2-96.8 F) |
| Moderate hypothermia | 30-34 C (86.0-93.2 F) |
| Severe hypothermia | <30 C (<86.0 F) |
| Cheyene-Stokes respirations | Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. |
| Biot's respirations | Respirations are abnormally shallow for two to three breaths followed by irregular periods of apnea. |
| Diastolic pressure __________ throughout the body. | is constant |
| Which side should the nurse stand on when assisting a pt who uses a cane? | stand on the weaker side |
| Metabolic effects of immobility | negative nitrogen balance, decreased BMR, resorption of calcium, constipation, fluid and electrolyte imbalances |
| Respiratory effects of immobility | atelectasis and hypostatic pneumonia (inflammation of the lung from stases or pooling of secretions) |
| Cardiovascular effects of immobility | orthostatic hypotension and throbus formation |
| Muscle effects of immobility | loss of endurance, strength, muscle mass, muscle weakness, disuse atrophy. |
| Skeletal effects of immobility | Disuse osteoporosis, joint contractures, footdrop |
| Urinary effects of immobility | urinary stasis leads to higher risk of UTIs and renal calculi |
| Integumentary effects of immobility | pressure ulcers |
| Restraints require | a doctor's order |
| When restraints are in place... | periodically check the pt remove restraints periodically to check ROM |
| how many times do you perform ROM on a client in restraints? | 3 times (i.e. rotate wrists 3 times) |
| What are early signs of hypoxia? | faster breathing and restlessness, increased blood pressure |
| What are late signs of hypoxia? | turn blue, when the body can't compensate anymore the resp. and BP decrease |
| For a pt with a fractured hip, what kind of support device should be used? | trochanter roll (log roll) |
| How often should wrist restraints be removed to asses for circulation? | 2 hours |
| What are signs of respiratory distress? | increased respiratory rate distressed, anxious accessory muscle breathing |
| Chain of infection | host, infectious agent, reservior, portal of exit, mode of transmission, portal of entry |
| What affect does exercise have on the body? | It initially increases VS, but long-term effect is decreased VS |
| What do you do when you make an error on documentation? | single line through error. Date, initial, write "error" |
| What are the 8 principles of sterile technique? | sterile touches sterile in sight/above waist level inspect 4 integrity avoid air exposure no reach, cough, talk, sneeze over hold 4-6 in above field cap action will contaminate table top/ 1 inch border |
| What are the symptoms of Hypoglycemia? | shakiness, weakness, fatigue, irritability, hunger, cold clammy skin, headache, tremors |
| What are the symptoms of Hyperglycemia? | Thirsty, bathroom a lot, fruity breath, hunger, sweet-smelling urine, headache |
| Use sterile technique for? | urinary cath sterile dressing change |
| Use medical asepsis for? | blood glucose, removing a catheter, changing sheets |
| How often should you empty a cath bag? | every 8 hours |
| From where do you collect a sterile urine specimen? | the cath tubing, not the bag |
| What size catheters do you use? | 14-16 French |
| How do you collect a clean catch urine specimen? | clean the peri area, pee a little, stick cup under the stream, remove before the stream ends |
| When should you use standard precautions? | all the time with every pt |
| When should you wear a gown? | When there is a risk of being splashed with body fluids |
| What is the pulse rhythm? | The regularity of the HR |
| If pt has surgery on the bladder, what should you assess for following surgery? | The pt's ability to urinate |
| If pt has a cath anchored and the express the need to urinate, what should you assess for? | kinks in the tubing, pt laying on the tubing, blockage of the tubing. |
| How should you treat hypoglycemia? | fast-acting sugar, then protein |
| What is a normal urine output? | >30 ml/hr, >750 ml/day |
| How many times should the Type I diabetic check his/her blood sugar? | at least 4 times a day |
| Passive ROM | The nurse moves the joint through its motions for the pt. The pt does not participate. Provides circulation and joint mobility |
| Active ROM | The pt completes all ROM activities, the nurse only supervises. Better than Passive. |
| How far should you extend a joint? | Until you meet resistance. Do NOT push it to go farther than it will go. |
| Restraint is the _______ option. Do other interventions _______. | last, first |
| What is the purpose of restraints? | Restraints are used for the pt's safety. |
| How often should a restrained pt be checked? | At least every 2 hours |
| How should the nurse document? | By using specific observations, not assumptions |
| What is the primary method for preventing wound infections? | Hand washing |
| What are antibiotics used for? | To treat infections or prophylactically to prevent infection |
| What is a necessary piece of information on a pt? | Baseline VS |
| What should be done upon assessment of abnormal VS? | notify the physician |
| What is the next step after an irregular BP assessment? | Take the BP manually |
| What should the nurse do if the HR is irregular? | Listen to the apical pulse while feeling for the radial pulse |
| What is the best way to chart? | The best way to chart is by using the most detailed, correct information |
| Pulse deficit | Difference btwn apical and radial pulse |
| How should pain be assessed in babies? | Facial expressions, crying |
| How should pain be assessed in a 3-year old? | Use the Wong-Baker Faces pain scale |
| How should pain be assessed in an adult? | 0-10 scale |
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