Nursing Foundations and Assessment Lecture Notes

Comprehensive practice questions covering nursing process, ethical principles, patient assessment techniques, physical assessment orders, and vital sign standards.

How long must a nurse listen for bowel sounds if none are initially heard?

Listen to each quadrant for $5$ minutes.

What are the three professional nursing behaviors listed in the notes?

Accountability, advocacy, and competence.

What specific heart valves close to produce the first heart sound ($S1$)?

Mitral and tricuspid valves.

Which part of the stethoscope is used to hear low-pitched sounds like murmurs?

The Bell of the stethoscope.

Which part of the stethoscope is used for high-pitched sounds such as heart, lung, and bowel sounds?

The Diaphragm of the stethoscope.

To what does carbon monoxide bind, effectively reducing oxygen levels?

Hemoglobin.

What are the six QSEN core competencies?

1. Patient-centered care, 2. Informatics/technology, 3. Evidence-based practice, 4. Quality improvement, 5. Safety, 6. Teamwork/collaboration.

What is the mnemonic for the nursing process?

ADPIE (Assessment, Diagnosis, Planning, Implementing, Evaluation).

In nursing ethics, what is the definition of 'Veracity'?

A commitment to tell the truth.

How is 'Fidelity' defined in the context of nursing ethics?

The fulfillment of promises.

What is 'Beneficence'?

Action that promotes good for others without any self-interest.

What is 'Non-maleficence'?

A commitment to do no harm.

What are the five auscultation sites of the heart and their locations?

1. Aortic ($2nd$ ICS right), 2. Pulmonic ($2nd$ ICS left), 3. Erbs point ($3rd$ ICS left), 4. Tricuspid ($4th$ ICS left), 5. Mitral ($5th$ ICS left).

What is the definition of a 'Bruit'?

Abnormal blowing or swishing sounds heard when there is decreased blood flow.

What are the four types of nursing assessment?

1. Initial (baseline), 2. Problem-focused, 3. Emergency (crisis), 4. Ongoing (reassessment).

According to Maslow’s Hierarchy of Needs, what is the first (base) stage?

Physiological needs.

What blood pressure reading defines hypotension?

Systolic less than $90$.

What temperature is considered a fever?

$100.4^{\circ}F$.

What factors can cause a false high blood pressure reading?

Cuff too small, deflating too slow, taking BP after smoking or activity, and unsupported arm.

What is the time limit for a physical restraint prescription for an adult?

$4$ hours ($24$ hours max).

What are the five steps for denture care?

1. Remove top denture first, 2. Remove bottom dentures, 3. Place towel in bottom of sink, 4. Use tepid water, 5. Place dentures in cup.

How long should a nurse wait to take an oral temperature after a patient eats or drinks?

$10-30$ minutes.

What five components are gathered during a General Survey?

1. Physical approach (age, sex, race), 2. Body structure (height, weight), 3. Mobility, 4. Behavior, 5. Vital signs.

What is 'Erbs point' known for in heart auscultation?

The transition period where the lub ($S1$) becomes louder than the dub ($S2$) sound.

What does the acronym PERRLA stand for in a head and chest assessment?

Pupils Equal Round Reactive to Light and Accommodation.

What is the correct physical assessment order for the abdomen?

1. Inspect, 2. Auscultate, 3. Percuss, 4. Palpate.

What is the difference between a 'Near miss' and a 'Sentinel event'?

A near miss is an event that could have involved the patient while a sentinel event causes death or permanent harm.

What does the FIRE safety acronym RACE stand for?

R-Rescue/Evacuate, A-Alarm, C-Contain, E-Extinguish/Evacuate.

What is the difference between somatic and visceral nociceptive pain?

Somatic pain occurs in joints, bones, or skin (sharp). Visceral pain occurs in the organs (abdominal).

What are the stages of hypertension according to the transcript?

Elevated: $120-129$ systolic; Stage 1: $130-139$ systolic or $80-89$ diastolic.