NSG 101 Exam 1

What are the key responsibilities of a RN:

• Perform physical exam

• Provide health promotion and education

• Give medications and other treatments

• Coordinate care with other medical professionals

What does ACEN stand for?

Accreditation of Commission for education in Nursing

What does ACEN do?

Provides accreditation for nursing education to practice programs

Who regulates nurse licensure in Kentucky?

KBN

What is OSEN and that do they do?

Quality and safety education in nursing. They set standards for nursing programs

What are the core competencies listed by OSEN?

• Evidence based practice

• Quality improvement

• Safety

• Informatics

• Patient centered care

• Teamwork and collaboration

Who is the founder of modern day nursing?

Florence Nightingale

Why does quality matter to Hospitals?

It allows them to be reimbursed by Medicaid

What is the purpose of nursing theories?

They help with assessments, identifying problems and interventions

The nurse enters the room of a newly admitted client. The client is tearful and states they want to go home. VS: 140/90, o2sat 94%, RR 14, T 99. The client verbalizes a pain score of 7 out of 10. The client tells the nurse they are worried about leakage in the car and in public. What is the nurses first intervention?​
​
A. Assure the client things will get better.​
B. Ask more about pain.​
C. Give the client a damp cloth to wash face.​
D. Ask the patient why they are upset.​

B. Ask more about pain.

What is quantitative date?

Measured by numbers

What is qualitative date?

Not measured by numbers but through behaviors or feelings

What are the 3 categories of Maslow’s hierarchy of needs?

1. Physiological

2. Safety and security

3. Love and belonging

What is the nursing process?

ADPIE

Assessment, Diagnosis, Planning, Implementation, and Evaluation

What are assessments?

Gathering of data to help form care

What is subjective data?

received from patient or family (pain)

What is objective data

data that can be measured or observed (vitals)

List the following nursing diagnosis is in order of priority

1. Fluid excess secondary to renal failure
2. Risk for falls
3. Lack of knowledge

1,3,2

according to the NCLEX, "risk for ___" is always a lower priority

What is a diagnosis?

Analyze the data collected to see trends and come to conclusions

What are the different types of planning

• Initial planning

• Ongoing planning

• DIscharge planning

What is the ongoing planning?

A plan that is changed day to day based on pt evaluations

What is a discharge planning?

Plans for the pt. to take care of themselves after they leave the hospital. This starts immediately

Client X is readmitted to the hospital 2 days after discharge. Client X states he verbalized several times that he didn’t feel comfortable going home. Now he is back after a fall at home trying to go to the bathroom. Client X lives with his wife in a ranch style home in downtown Lexington. ​

VS: 145/95 HR 110 RR 18 O2 Sat 90 Pain 8 ​

Assessment: Alert and oriented, PERLA, speech is appropriate, gait is unsteady per baseline, lung sounds are diminished in LLL, bowel sounds normal, small abrasion to left knee, DP pulses present. ​

What should the nurse do first?​

1. A. Ask about quality of pain​

2. B. Ask the client his normal HR and BP​

3. C. Ask the patient if they are short of air ​

4. D. Give 500 mg of Tylenol stat​

C. Ask the patient if they are short of air

what should you never do (on exams) unless it is a medical emergency

Call the doctor

helpful tips for priority questions:

What can the nurse do to make this better now?

What would kill this patient the fastest?

What is important to consider when looking at vital signs

Trends

What is the normal range for temperature

97.5-99.5

What is the normal range for Heart rate?

60-100 bpm

What is the normal respiration rate?

12-20

What is the normal blood pressure

<120/80 mmHg

What is the normal range for Oxygen saturation?

95-100%

What is the normal pain level

0/10

When should vitals be assessed?

• On admission

• According to hospital policy (every so many hours)

• Change in condition

• Before and after surgery

• Before and after giving meds

• At discharge

What is temperature?

It is the balance between the heat the body produces and the heat lost from the body

What are the core temperatures?

Rectum, tympanic membrane, pulmonary artery, esophagus, and baldder

What are the surface temperatures?

Mouth, skin, and axillary

True or false: When you take axillary temps do you had 1 degree?

True

At what temperature do we treat a temp?

101.5 F

How long should you wait to take a temperature after eating for drinking?

20-30 mins

Hyperthermia is:

What are s/s:

Treatment:

body temp > 103 F

Can’t sweat, cramping, red skin, fast pulse

IV fluids, antibiotics, antipyretics, and removing clothing as needed

Hypothermia is:

What are s/s:

Treatment:

Body temp < 95 F

Shivering, dilated pupils, low bp, slow breathing

Warmed fluids and blankets

What is bradycardia?

<60 bpm

What is tachycardia?

> 100 bmp

Where is the apical pulse located?

5th intercostal space

What does systole refer to?

The contraction of the heart (top #)

What does diastole refer to?

The relaxation of the heat (bottom #)

What could an absent pulse on one side of the body indicate?

A blockage

What are some things we look for when assessing pulse?

• Rate: time per min

• Rhythm: regularity

• Strength: absent (0), diminished, (+1), brisk (+2), increased (+3), and bounding

• Equality: same on both sides

Client Y’s pulse is 50 and they complain of pain of a level 3 of 10. Client Y asks if they can have their narcotic pain medication. The proper response by the nurse is:​

1. A. Sure, I will be back shortly.​

2. B. No, your heart rate is too low.​

3. C. How about some Tylenol?​

4. D. No, your pain level has to be 4 to receive narcotics.​

C. How about some Tylenol?

What is bradypnea?

rr<12

What is tachypnea?

rr> 20

What is apnea?

rr 0- respiratory arrest

When assessing respirations what do we look for?

Depth: deep, shallow, normal

Rhythm: dyspnea (shortness of breath)

What is hypoventilation?

Low rate of breathing

What is hyperventilation?

Increased rate of breathing

What are Cheyne-Stokes?

Irregular rate and depth of respirations with a constant pattern that is associated with death

(slow, fast, normal, etc)

What is Kussmauls?

Increased respiratory rate with a regular pattern and this is associated with acidosis

A nurse is reviewing the vital signs for a client who was admitted with shortness of breath. The nurse notes the client’s respiratory rate is 24/min. The nurse should use which of the following terms when documenting this finding? ​

• A. Hypoventilation​

• B. Apnea​

• C. Tachypnea​

• D. Cheyne-stokes respirations​

• E. Labored ​

C. Tachypnea

Where can the pulse oximeter be placed?

Finger, toes, earlobe, nose

What is hypoxia?

<90%

What position could help with a raise in your BP

Trendelenburg

What is hypotension?

What causes it?

How do you treat it?

Is low blood pressure <90/60

Caused due to illness, dehydration, or low fluid volume

Treatments include, positioning, meds, and fluids

What is hypertension?

What causes it?

How do you treat it?

Is high blood pressure >130/80 or higher

Causes include fluid overload, heart failure, poor kidney function,

Treatments include medications

What is the name of the position where a pt is moved to their stomach

Prone

What is supine position?

Pt lays flat on back

What is the sims position?

Pt lays on their side

What is the common pt position where the head of the bed is 30-40 degrees raised?

Fowlers

What is the position where the pt’s feet is above their head

Trendelenburg

A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take first?

• A. Request a prescription for an antihypertensive medication.​

• B. Ask the client is they are having pain.​

• C. Request a prescription for an antianxiety medication.​

• D. Return in 30 min to recheck the client’s blood pressure.​

B. Ask the client is they are having pain

Which of the following is an unexpected assessment finding in a 40 year-old?​

• A. Brisk pulse strength of 2+​

• B. Equal time space between each pulsation​

• C. Pulse rate of 95 bpm​

• D. Stronger radial pulse on left compared to right​

D. Stronger radial pulse on left compared to right

A nurse is measuring the oxygen saturation of a client who has cyanosis of the extremities. Using a pulse ox, where does the nurse place the sensor probe?​
Select all that apply. ​

• Forefinger ​

• Thumb​

• Forehead​

• Bridge of nose​

• Earlobe​

• Great toe ​

Forehead, Earlobe, and Bridge of nose

A nurse is obtaining a client’s vital signs. The client has a new onset temp of 102° F. Which of the following vital signs would accompany this finding?

• A. An elevated pulse rate​

• B. A decreased blood pressure​

• C. An elevated blood pressure​

• D.A decreased pulse rate​ ​

A. an elevated pulse rate

What is a physical assessment?

Collection, organization, validation, analysis, and documentation of data

True or False: Assessments don’t have to be asked in pt preferred language?

False

True or False: Nurses should ask closed ended questions while performing physical assessments?

False

What is the assessment process look like?

First is an inspection of the area (look), next would be auscultation/listening to the area, and then would be palpations (touch) of the area if needed

What are some of the most important things to obtain from a patients medical history?

Code status and allergies

What is PERRLA?

Pupils are equal, round, reactive to light and accommodate

What does S1 sound like

Lub

What does S2 sound like?

Dub

True or False: you can palpate both carotid arteries at the same time

False

Rhonchi and crackle lung sounds are associated with what?

pneumonia, phlegm, fluid overload, heart failure

Absent bowel sounds can be expected after surgery, true or false?

True

What is the normal output of urine every hour?

30 ml/hr

During a cardiovascular examination, the nurse places the stethoscope on the left 5th midclavicular, intercostal space. Which of the following is the nurse trying to auscultate? Select all that apply.​

• A. Ventricular gallop​

• B. Mitral valve closure​

• C. Apical Heart Rate​

• D. Murmur​

B & C Mitral valve closure and apical hr

Client Y had abdominal surgery yesterday morning. He states he has not passed gas since surgery. What should the nurse do next?​

• A. Auscultate bowel sounds.​

• B. Call the doctor.​

• C. Give gas relief medication.​

• D. Ask patient to ambulate in the hallway

A. Auscultate bowel sounds

How long should you listen before documenting absent bowl sounds?

5 minutes

The nurse is obtaining a client’s blood pressure. Which information is most important for the nurse to document? ​

• A. The staff member who took the bp.​

• B. The client’s tolerance to having their bp taken.​

• C. Position of the client if not in a sitting position.​

• D. The client was talking during the reading.​

C. Position of the client if not in a sitting position.

Which of the following give the most accurate temperature?​

• A. Oral temperature​

• B. Tympanic temperature​

• C. Rectal temperature​

• D. Forehead temperature​

​

C. Rectal temperature

What is culture?

Its a concept that involves social norms, beliefs and behaviors

What does cultural competence mean?

being able to incorporate culture into care

What are microaggressions?

small insults

What are racial microinvalidations?

excludes a person’s of colors reality EX: “all lives matter”

What are sterotypes?

fixed ideas of a person or thing

What is Judaism?

• Based on the Toarah

• Foundation of Christianity and Islam

• One God and 10 Commandments

What is Yom Kippur and which religion celebrates it?

• Holiest day of the Jewish Calendar

• Special fast

What kind of diet do Jews follow?

Follow a Kosher Diet. That includes not mixing meat or dairy. Meat has to be killed a special way

True or False: Orthodox Jews believe in organ transplants

False

What are some things Catholics do not believe in?

Contraception and Sterilization

True or False: Jehovah’s Witnesses will not accept blood transfusions

True