NURS 251 : FINAL EXAM STUDY GUIDE
What are the steps in donning PPE? - ANS - hand hygiene
- gown
- facemask
- face shield
- gloves
What are the steps in doffing PPE? - ANS - remove gloves
- remove gown
- remove face shield
- mask
- hand hygiene
What are first level priority problems? - ANS emergent, life threatening, or limb threatening
What are second level priority problems? - ANS urgent, you need to prevent further
deterioration, can be a mental status change, these require prompt intervention
What is a third level priority problem? - ANS these are important to the patient's overall health
but can wait to be addressed after urgent conditions are addressed, long-term conditions
What are the steps in completing a health history? - ANS - orientation: introduce self and
purpose
- working phase: collecting and recording data
- closing: thank you, summarize, any questions?
What is a complete health history database? - ANS includes current and past health history, a
complete physical exam, and includes screens for pathology
What is a focused or problem centered health history database? - ANS it is more targeted,
limited, and looks at short-term problems (usually 1 problem)
What is an emergent health history database? - ANS includes just the facts, the key information
only, identifying and managing the emergent needs firsts
What is subjective data? - ANS what the patient says
What is objective data? - ANS obtained by observing and examining client
What are the components in collecting the history of present illness? - ANS O: onset
What is interdisciplinary communication? - ANS allows healthcare members from various
disciplines to communicate and work together
What is the purpose of the end of shift report? - ANS allows the nurse to explain to the
oncoming nurse the condition of their patients
What is SBAR? - ANS S: situation
B: background
A: assessment
R: recommendation
What is involved in the situation step of SBAR? - ANS - what are you talking about?
- concise statement of the patient problem
- identify self and where your calling from
What is involved in the background step of SBAR? - ANS - pertinent data to the current
problem
- any changes in mental status or uncontrolled pain
- what are your recent vitals
- pertinent lab results
What is involved in the assessment step of SBAR? - ANS - abnormal findings as well as
pertinent normal findings
- clearly what is the problem, is it severe or life threatening
What is involved in the recommendation or request step of SBAR? - ANS - what do you want or
need to continue to care?
- what solution can you offer or propose?
- if you want the client evaluated by the provider, say so and state a specific time
What are the components of a mental status exam? - ANS - appearance: posture, movement,
dress, grooming
- behavior: speech, and mood
- cognition: orientation, memory, attention span
- thought processes: does this make sense? logical? (includes anxiety and depression screen)
, What is Broca's aphasia? - ANS expressive (motor speech cortex), can understand but cannot
express self, understands written and spoken language
What is Wenicke's aphasia? - ANS receptive (association auditory cortex), speech is fluent, but
cannot understand, they make up words
What are the basic assessment techniques? - ANS inspection, percussion, palpation, and
auscultation
What is inspection? - ANS looking at the patient without touching
What is percussion? - ANS tapping the person's skin with short, sharp strokes to assess
underlying structures
What is palpation? - ANS examination of the body using touch
What is auscultation? - ANS listening to the sounds produced by the body using a stethoscope
What is the normal range for an oral temperature? - ANS 96.4 - 99.1
What are variances that could lead to a temperature outside the normal range? - ANS - heat
production or heat loss
- diurnal cycle
- menstrual cycle
- exercise
- age
- hyperthermia or hypothermia
What is the expected range for pulse? - ANS 60-100 bpm
What are variances that can affect pulse? - ANS - age
- fitness
- anxiety
- medications
What is bradycardia? - ANS a heart rate less than 50 bpm
- sources of variances are: well trained athletes, and certain medications
What is tachycardia? - ANS a heart rate greater than 95 bpm
- sources of variances are: fever, anxiety, exercise
What is the normal range for respirations in an adult? - ANS 10-20 respirations per minute
What are variances that can affect respiration rate? - ANS - awareness of the assessment
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