b. the nurse will assess by priority if the patient has any obstruction or abnormality with their
airway, they will then assess if they can breathe or not, lastly assess if anything is wrong with
their cardiovascular circulation.
c. If the patient is having trouble breathing but is still breathing that may show something lodged
in the airway. If nothing is seen then circulation could be the underlying problem.
4. What is HIPAA? Describe one situation when the nurse must adhere to HIPAA.
a. Health Insurance Portability & Accountability Act
i. Helps protect client’s medical records
b. When over hearing a coworker talk about their pt. to another coworker
5. Describe the process of taking a pulse. What is a normal pulse? What are qualities of a normal
pulse? What is the first action a nurse should take when the pulse is not as expected?
a. Assess by palpating the surface using gentle pressure over the artery location chosen
i. Normal qualities: 2+, equal in rhythm, rate, and strength, no signs of bruit or thrill
b. The nurse should normally take a pulse for 30sec. and x2, if irregular or abnormal, retake the
pulse for a full 1min/60sec., if irregular still take apical pulse for 1min/60sec. If pulse cannot be
felt at first, Doppler may need to be used
6. What is dehydration? List three subjective and three objective findings of dehydration. List the
expected vital signs of a patient who is dehydrated.
, 3
a. Lack of fluid volume in your blood
b. Sub: drowsiness, lightheadedness, increase thirst
c. Obj: dry tongue/mucosa, sunken eyes, decreased skin turgor
d. Decreased BP, increased RR/temp/HR (will be weak and thread)
7. How is fluid volume deficit related to dehydration? How would concentrations of some solutes
(solids) change with dehydration? Why?
a. Fluid volume deficiency involves the decrease of intravascular, interstitial, and/or intracellular
fluid-which leads to dehydration: water loss without change in sodium
8. What is an undesirable response of the body to a fever?
High fever
Why is this undesirable? What effect does it have?
Blood levels to go up
9. What is the most serious skin cancer? What is one risk factor for this cancer and one teaching
item to address with your patient? Describe this most serious skin cancer below.
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