Font size
WorksheetsNursing Skills 101
Total questions: 45
Worksheet time: 4mins
Things that are observable through the senses (measurable).
tactile data
Objective data
measurements
subjective data
normal systolic and diastolic range
systolic: 60-80 diastolic: 90-120
systolic: 90-160 diastolic: 50-90
systolic: 90-120 diastolic: 60-80
systolic: 80-150 diastolic: 40-90
Choose all the factors which can decrease bp
decrease heart contraction
constipation
decreased blood volume
dehydration
hemorrhage
Choose all the factors that can increase bp
hemorrhage
pregnancy
exercise
hx of heart attack
arteriosclerosis
Force exerted by the blood against artery walls during ventricle contraction
pulse pressure
systolic pressure
cardiac output
diastolic pressure
what is pulse pressure and what is the normal range of it
deficit between the apical and radial pulse, 20-25
pressure felt on the temporal lobe, 1-10
radial pulse rate, 60-100
difference between the systolic and diastolic pressures, 30-50
Sounds heard during bp reading as you deflate the cuff are known as:
Korotkoff's sounds
pulses
heart beats
cheyne's stokes
First step in measuring bp
inflate cuff to 160 mmHg
Palpate distal pulse to the cuff,inflate to 70, slowly inflate till you can no longer palpate the pulse
place stethoscope over brachial pulse and begin auscultation while inflating the cuff 30mmHg above previously recorded number
slowly unscrew the valve and release air 2-3 mmHg per second while listening for Korotkoff's sounds
Define auscultatory gap
gap between your two front teeth
20-30 mmHg gap that can be heard in the korotkoff sounds
a gap that can be heard in between lub and dub
indention of the nasal cavity
what is orthostatic hypotension(postural)
drop in bp 15-25 mmHg systolic or 10mmHg diastolic with position changes
running out of breath with activity
dizziness with position changes
decrease bp due to weakened bones
Normal temperature range
97.9-100.1 F
90.1-100 F
36 to 38 C
96.8-100.4 F
Production of heat by our body.Product of metabolism
thermoregulation
homeostasis
thermogenesis
thermometer
What is the most accurate non-invasive route of temperature assessment?
rectal
oral
tympanic
temporal
Where do you place the thermometer when assessing an oral temp?
on the tongue
in the mouth
sublingual pocket
in the ear canal
How far do you insert the probe for a rectal temp?
1-1.5 inches
3 inches
1/2 inch
5 inches
contraindications for rectal temp assesment
diarrhea
hemorrhoids
chicken pox
risk of perforation
rectal surgery
signs of fever
diarrhea
flushed face
dry hot skin
glassy/droopy eyes
myalgia
nursing interventions for fever
assess vitals q2h
small frequent meals
limit activity
use minimal covers unless shivering occurs
apply cloth covered ice packs to groin/axillae are and forehead(avoid shivering)
normal pulse rate
50-90 bpm
40-60 bpm
100-160 bpm
60-100 bpm
When the radial pulse is different than the apical pulse.
auscultatory gap
pulse deficit
korotkoff's sound
cardiac output
Which peripheral pulse site is used in CPR and should not be palpated both at the same time?
brachial
temporal
femoral
carotid
Which pulse site is used in bp measurement and to assess pulse rate in small children?
radial
brachial
dorsalis pedis
popliteal
What 3 things will you assess during a pulse assessment?
rate,depth,effort
murmur,systolic,diastolic
rate,rhythm, strength
cap refill,turgor,color
If a pulse is not detectable or absent..whats the next step?
palpate for the next proximal pulse in the extremity,proceeding up the limb until a pulse is palpable
use a doppler
call the doctor
suggest amputation
If the lub dub in the apical heart sound is difficult to differentiate, how would you describe/document it?
clear or distinct
blurry
thready
muffled or distant
Normal respiration rate
10-20 per min
12-20 per min
5-10 per min
12-30 per min
resp rate below 12
tachypnea
eupnea
bradypnea
orthostatic hypotension
What is normal respiration rhythm defined as?
inconsistently spaced intervals between respirations
cheyne's stokes
inhalation and exhilation
regularly spaced intervals between respirations
Choose all the possible physical appearance traits of a patient with dyspnea
appears frightened/anxious or worried
wide-eyed startled expression
one-sided droopiness
flushed/red skin
decreased delivery of 02 to the tissues/cells
orthopnea
hypoxia
exertional dyspnea
hypoxemia
difficulty breathing unless positioned in upright position
exertional dyspnea
orthopnea
dyspnea
oxygenation
normal 02 level range
90%-100% sp02
96%-100 % sp02
80%-90% sp02
85%-95% sp02
What is the only subjective vital sign
temperature
pain assessment
bp
heart rate
When applying the principles of critical thinking in a situation, the student should begin by asking..
What is my opinion about this situation?
What are the facts that I know about this situation?
Do I need to do anything in this situation?
What did I do the last time in a similar situation?
A nursing student, a month into nursing school, finds herself becoming overwhelmed and feeling anxious and unable to sleep.What action should this student take?
Utilize the counseling services available at her college
reduce her course load by dropping classes
eliminate all extracurricular and family activities
create a study group with fellow classmates and divide the coursework between them
How will a student best prepare for their first clinical experience?
Teach the resident what the student has learned in class
Research health conditions of the student's assigned resident
ask the resident what care they would like to receive from the student nurse
Explain to the resident they are only a student nurse so they will not receive the same level of care as from a licensed nurse
What measures can be taken if a student finds themselves running out of energy frequently?
Implement exercise into their schedule
Eat high caloric meals more often during the day
Reduce his physical activity to conserve energy
drink more coffee :)
communication is best described as
talking
listening
data entry
the exchange of information
what is an example of nonverbal communication
a patient ringing his call light to ask for pain med
a patient falls during a transfer
a patient slouched over in his chair, grabbing his sides and grimacing
a patient yelling at a student
What factors contribute to the definition of a nurse's scope of practice?
state laws such as nurse practice act
Regulations and policies of the hospital
the professional standards of profession
the nurse's learning style and preferences
Fine rales can be described as :
hair being rubbed between the thumb and index fingers
Noisy snoring sounds
musical whistling
a sonorous wheeze upon inspiration
During palpation of a pulse, the nurse finds that the pulse obliterates. What does this mean
the pulse gets stronger
the pulse disappears upon palpation
the pulse becomes weak and faint
it indicates the contractions are perfusing
When should vital signs be assessed q4h?
when a patient is considered in critical condition
with 1 or more abnormal vital sign readings
when all vital signs are stable
with hemorrhage
In what situations will the nurse NOT delegate vital signs to a CNA?
post op
when a patient is being admitted to the facility
when a patient is obese
when a patient is on IV medications that can affect the vital signs
When the nurse feels "something is wrong"
When checking a tympanic temperature on a child, you pull the pinna
upward and back
downward and forward
downward and back
diagnol
