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NUR 436 Midterm Review Exam Questions with Latest Update
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NUR 436 Midterm Review Exam Questions with Latest Update
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NUR 436 Midterm Review ExamQuestions with Latest Update
360 check - Answer--working oxygen and suction
-ambu bag and correct size mask
-code sheet: correct client, correct weight in kg, 2 RNs signed off
-IVF and rates as ordered
-Alarm limits set for age
-side rail check
-call light within reach of client/caregiver
Safety upon entering patients room - Answer--2 patient identifiers
-gel in
-allergy band check
-fall band check
FACES pain rating scale - Answer--faces rated 0-10
-0,2,4,6,8,10
-no hurt- hurts worst
FLACC pain scale - Answer-F: Faces.
L: Legs.
A: Activity.
C: Cry
C: Consolability
0-10
General Survey: weight (pediatrics) - Answer--Ensure the child removes shoes and
stands on a calibrated scale
General Survey: height (pediatrics) - Answer-Child should stand straight against a wall
with chin parallel to the floor for measurement
General Survey: respiratory rate (pediatrics) - Answer--observe breathing
-regular: count for 30 seconds
-irregular: count for 1 minute
General Survey: pulse (pediatrics) - Answer--brachial/radial pulse
-regular: count for 30 seconds
-irregular: count for 1 minute
General Survey: temperature (pediatrics) - Answer-Use an oral, tympanic, or axillary
method depending on the situation.
,General Survey: blood pressure (pediatrics) - Answer-Use an appropriately sized cuff;
measure systolic and diastolic pressures.
Skin Examination (pediatrics) - Answer-Inspect from head to toe for:
-Color, moisture, rashes, birthmarks, bruising.
-Palpate for temperature (warm, cool) and texture (dry, clammy).
-Check capillary refill and the presence of edema.
-Examine nails for color and shape.
Head Examination (pediatrics) - Answer--Inspect for shape and symmetry.
-Palpate scalp for lesions or abnormalities.
Neck Examination (pediatrics) - Answer--Check range of motion.
-Palpate for lymph nodes, thyroid, and trachea alignment.
Eye Examination (pediatrics) - Answer--Inspect for size, placement, and drainage.
-Check pupil size, reaction to light, and accommodation (PERRLA).
-Assess extraocular movements by testing the six cardinal fields of gaze.
Ear Examination (pediatrics) - Answer--Inspect for shape and placement.
-Check for drainage and tenderness by palpating the pinna and tragus.
Nasal Examination (pediatrics) - Answer--Inspect and assess for symmetry and any
discharge.
-Check nostril patency.
Throat Examination (pediatrics) - Answer--Inspect for lesions, redness, or inflammation
in the oral cavity.
-Assess the uvula and tonsils for swelling.
Respiratory Assessment (pediatrics) - Answer--Inspect the chest for shape, symmetry,
and movement.
-Auscultate breath sounds in all lung fields, noting any abnormalities.
-Palpate for symmetry of chest movement.
Cardiovascular Assessment (pediatrics) - Answer--Auscultate heart sounds (S1, S2) at
five precordial landmarks.
-Palpate pulses in extremities (carotid, brachial, radial, femoral, etc.) and assess
capillary refill.
-Inspect for cyanosis or pallor.
Abdominal Assessment (pediatrics) - Answer--Inspect for symmetry, shape (rounded,
flat), and scars.
-Auscultate bowel sounds in all quadrants.
-Palpate for tenderness, masses, or distension
, Musculoskeletal Assessment (pediatrics) - Answer--Inspect and palpate joints for
swelling, heat, or tenderness.
-Assess muscle strength and symmetry, especially in the upper and lower extremities.
-Test the range of motion in all joints.
-Inspect the spine for alignment and assess gait
Neurological Assessment (pediatrics) - Answer--Assess level of consciousness and
orientation.
-Test cranial nerves (as appropriate for age).
-Observe coordination and balance by having the child walk heel to toe, hop on one
foot, and
perform the Romberg test.
O2 Administration: Preparation - Answer--Provide privacy.
-Introduce yourself to the client.
-Verify client identification.
-Check for client allergies.
-Provide education on the procedure.
-Gather equipment at the bedside.
-Open the oxygen tubing and connect it to the flow meter.
- Adjust the flow rate to the prescribed oxygen liters per minute.
O2 Administration: Nasal Cannula - Answer--Insert prongs into nostrils, pointing
downward.
-Place tubing over ears, with the adjuster under the chin.
-Ensure a snug but not tight fit.
O2 Administration: Non-Rebreather Mask - Answer--Position mask over nose and
mouth.
-Stretch elastic straps over the head.
-Ensure the reservoir bag does not collapse entirely during exhalation.
O2 Administration: Venturi Mask - Answer--Attach the correct jet orifice and adjust the
flow rate.
-Set the prescribed oxygen concentration.
-Position the mask over the nose and mouth.
-Adjust straps for a snug fit.
O2 Administration: final steps - Answer--Ensure the client is safe, with a call light within
reach.
-Document oxygen amount, delivery system, oxygen saturation, and client assessment
findings.
Asthma: Assessment Cues - Answer--Shortness of Breath (Dyspnea): Indicates airway
constriction.
-Wheezing: Sign of narrowed airways.
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