Nursing Skills Mid-term

Bradycardia is a medical condition characterized by a heart rate that is lower than the normal range, which is typically 60 to 100 beats per minute (BPM). Therefore, a heart rate lower than 60 BPM is considered bradycardia. Hence, the statement "Bradycardia is a heart rate lower than 60 BPM" is true.

A blood pressure reading of 182/112 is significantly higher than the normal range, indicating severe hypertension. Hypertensive crisis is a condition where blood pressure levels are dangerously high and can lead to organ damage or other complications. Immediate medical attention is required in such cases to lower the blood pressure and prevent further health risks. Therefore, the statement is true.

The correct answer is Assessment, Diagnosis, Planning, Implementation, Evaluation. These five steps make up the nursing process, which is a systematic method used by nurses to provide patient-centered care. Assessment involves gathering information about the patient's health status. Diagnosis involves analyzing the collected data to identify health problems. Planning involves setting goals and developing a care plan. Implementation involves carrying out the planned interventions. Evaluation involves assessing the effectiveness of the interventions and making any necessary adjustments to the care plan.

ROM (Range of Motion) refers to the extent of movement that a joint can go through. It represents the full range of movement, including both active and passive movements. Therefore, the statement that ROM is the maximum movement possible for a joint is true.

The PQRST pain assessment method is a widely used approach to evaluate and understand pain. It involves considering various factors such as the precipitating factors that worsen the pain, the quality of the pain (throbbing, achy, etc.), the region or location of the pain, the severity of the pain on a 0-10 scale, and the timing or duration of the pain. This method helps healthcare professionals gather comprehensive information about the pain experienced by a patient, which can aid in accurate diagnosis and effective management of pain. Therefore, the statement "True" is correct.

The statement "1kg = 2.2lbs" is true. This equation represents the conversion factor between kilograms (kg) and pounds (lbs). It states that 1 kilogram is equal to 2.2 pounds. This conversion is commonly used when converting weights between the metric system (kilograms) and the imperial system (pounds).

A normal pulse rate is considered to be between 60 and 100 beats per minute (BPM). This range indicates a healthy heart rate and is commonly seen in adults at rest. A pulse rate below 60 BPM is known as bradycardia, which may indicate a slower heart rate, while a pulse rate above 100 BPM is known as tachycardia, which may indicate a faster heart rate. Monitoring pulse rate is important in assessing cardiovascular health and can provide valuable information about heart function and overall well-being.

A normal respiratory rate for an adult is considered to be between 12-20 breaths per minute (RPM). This range is based on average measurements and is considered to be within the normal range for a healthy adult. A respiratory rate outside of this range may indicate an underlying medical condition or abnormality in breathing.

The urine output of less than 30cc/hr indicates a low urine production, which can be a sign of kidney dysfunction or dehydration. It is important to report this to the physician as they need to be aware of any changes in the patient's condition and take appropriate actions to address the underlying cause and ensure proper treatment.

A pulse oximetry reading of 79% indicates that the oxygen saturation level in the blood is dangerously low. Normal oxygen saturation levels are typically above 95%. When the oxygen saturation drops below 90%, it can lead to hypoxemia, which is a condition where the body tissues do not receive enough oxygen. Hypoxemia can be life-threatening and may result in organ damage or failure if not promptly treated. Therefore, a pulse oximetry reading of 79% would indeed be considered life-threatening.

The patient's symptoms of dizziness, nausea, and diaphoresis are indicative of hypotension, which is low blood pressure. Hypotension can cause a decrease in blood flow to the brain, leading to dizziness. Nausea can occur due to inadequate blood supply to the digestive system, and diaphoresis is the body's response to compensate for low blood pressure. Hypertension, on the other hand, is high blood pressure and does not typically present with these symptoms. Therefore, the correct answer is hypotension.

Yes, this task can be delegated to a UAP (Unlicensed Assistive Personnel) because repositioning a patient does not require specialized medical knowledge or skills. It is a routine task that can be performed by trained UAPs under the supervision of a nurse or healthcare professional. Repositioning helps prevent pressure ulcers and promotes patient comfort and circulation. However, it is important to ensure that the UAP is properly trained and follows the established protocols and guidelines for patient repositioning.

The correct order to use in an abdominal assessment is Inspection, Auscultation, Palpation, Percussion. Inspection involves visually examining the abdomen for any abnormal findings such as scars, masses, or distention. Auscultation involves listening to bowel sounds using a stethoscope to assess for any abnormal bowel sounds or bruits. Palpation involves gently feeling the abdomen with the hands to assess for tenderness, masses, or organ enlargement. Percussion involves tapping on the abdomen to assess the density of underlying organs and to detect any abnormal fluid or air-filled areas.

The statement is false because bedside rails should be in the raised position when the bed is at its highest point. This is done to ensure the safety and security of the patient, as raised bedside rails can prevent falls or accidents while the bed is elevated. Lowering the bedside rails when the bed is at its highest point would defeat the purpose of having them in the first place.

Restraints do require a Physician order. This means that a Physician must provide written authorization for the use of restraints on a patient. This is to ensure that restraints are only used when necessary and in the best interest of the patient's safety and well-being. Without a Physician order, the use of restraints would be considered unauthorized and potentially unethical. Therefore, the statement that restraints do not require a Physician order is false.

A gastrostomy is a medical procedure where a feeding tube is inserted through the abdominal wall into the stomach. This allows for direct delivery of nutrients and fluids into the stomach, bypassing the mouth and esophagus. The stomach is the correct answer because it is the specific organ that the feeding tube is inserted into during a gastrostomy.

A patient on a clear liquid diet would not be allowed dairy products because a clear liquid diet consists of fluids that are easily digested and leave minimal residue in the gastrointestinal tract. Dairy products, such as milk, yogurt, and cheese, are not considered clear liquids as they contain proteins and fats that require more digestion and can leave residue in the digestive system. Therefore, dairy products are not permitted on a clear liquid diet.

The characteristics of urine that should be documented include color, clarity, odor, and volume. These factors can provide important information about a person's hydration levels, kidney function, and overall health. By monitoring these characteristics, healthcare professionals can identify potential issues or abnormalities in the urinary system.

A pulse deficit refers to a condition where the radial pulse (felt at the wrist) and apical pulse (felt at the heart) do not match. This means that there is a discrepancy between the number of heartbeats felt at the wrist and the number of heartbeats heard at the heart. It indicates a potential problem with the circulation of blood and can be a sign of cardiac abnormalities or irregularities. Therefore, the statement "A pulse deficit is when the radial and apical pulses do not match" is true.

An Independent Nursing Intervention is a nursing decision that a nurse can make on their own without requiring any input or direction from others. This means that the nurse has the authority and knowledge to assess, plan, and implement the intervention without needing approval or guidance from anyone else. Therefore, the given statement is incorrect as it suggests that an Independent Nursing Intervention cannot be made by a nurse alone, which is false.

Shaving can cause small cuts or nicks on the skin, which can lead to bleeding. Anti-coagulant medications are drugs that prevent blood clotting, which means that even a small cut can result in excessive bleeding. Therefore, it is advisable not to shave a client who is on anti-coagulant medications to avoid any potential complications or risks.

Atelectasis refers to the partial or complete collapse of a lung or a section of a lung. It occurs when the air sacs (alveoli) in the lung become deflated, leading to a decrease in lung volume. This can be caused by various factors such as blockage of the airways, lung diseases, or post-surgery complications. Symptoms of atelectasis may include shortness of breath, chest pain, and coughing. Prompt medical attention is necessary to treat and resolve a collapsed lung.

The correct order of putting on PPE is gown, mask, gloves. This order ensures that the gown is worn first to cover the body and prevent contamination, followed by the mask to protect the respiratory system, and finally the gloves to protect the hands from potential exposure to pathogens. Wearing PPE in this sequence minimizes the risk of contamination and ensures proper protection for healthcare workers.

The patient's flushed appearance and headache are indicative of hypertension, which is high blood pressure. Hypertension often leads to symptoms such as flushing of the skin and headaches due to increased pressure in the blood vessels. Hypotension, on the other hand, is low blood pressure and would not typically present with a flushed appearance and headache.

The correct order of taking off PPE is gloves, gown, mask. This order is important to minimize the risk of contamination. Gloves should be removed first to prevent any potential pathogens on the gloves from spreading to other parts of the body. The gown should be removed next, followed by the mask, ensuring that the front of the gown and mask are not touched to avoid contamination. This sequence helps to maintain a safe and hygienic environment.

No, this task cannot be delegated to a UAP. UAPs (Unlicensed Assistive Personnel) are not trained or qualified to perform dressing changes on post-operative patients. This task requires specialized knowledge and skills that only a licensed practical nurse (LPN) or higher-level healthcare professional possesses. Delegating this task to a UAP could potentially compromise the patient's safety and well-being.

Apnea refers to the temporary cessation or pause in breathing. It is characterized by a complete absence of breathing, which differentiates it from other breathing difficulties such as heavy breathing or fast breathing. During an episode of apnea, the individual stops breathing for a period of time, which can range from a few seconds to minutes. This can lead to various symptoms and health issues, and it is often associated with sleep disorders such as sleep apnea.

In high fowlers position, the head of the bed should be elevated at an angle between 60-90 degrees. This position is commonly used in medical settings to promote lung expansion, improve breathing, and reduce the risk of aspiration. It also helps with reducing edema, facilitating digestion, and providing comfort to the patient.

The diastolic blood pressure is actually the pressure in the arteries when the heart is at rest or between contractions. It is the lower number in a blood pressure reading and represents the minimum pressure exerted on the arterial walls.

Passive range of motion is not when the client independently performs the exercises. Instead, it refers to the movement of a joint or body part that is performed by another person or with the assistance of a device. In passive range of motion exercises, the client does not actively participate in the movement but rather allows someone else to move their joints for them. This can be beneficial for individuals who are unable to move certain body parts on their own due to injury, illness, or other limitations.

Dysuria is the term used to describe painful or troubled urination. It is a common symptom that can be caused by various conditions such as urinary tract infections, bladder stones, or inflammation of the urethra. The discomfort or pain during urination is often accompanied by a burning sensation or a frequent urge to urinate. Therefore, dysuria accurately describes the condition of painful or troubled urination.

The normal range for blood pressure in an adult is typically 90-120 for the systolic pressure (top number) and 60-80 for the diastolic pressure (bottom number). This range indicates healthy blood flow and is considered normal for most adults.

In Fowler's position, the head of the bed (HOB) should be elevated at an angle of 30 degrees. This position helps to promote lung expansion and improve breathing by reducing the pressure on the diaphragm. It also helps to prevent aspiration and facilitates the drainage of secretions. Elevating the HOB to 30 degrees is a commonly recommended angle for patients in Fowler's position.

The Braden Scale is a widely used assessment tool that helps healthcare professionals identify risk factors for developing ulcers. It evaluates several factors such as sensory perception, moisture, activity, mobility, nutrition, and friction/shear. By assessing these factors, the scale helps determine a patient's risk level for developing pressure ulcers. This information allows healthcare providers to implement preventive measures and interventions to reduce the risk of ulcer formation.

A major complication of enteral feeding could be aspiration of gastric contents. Aspiration refers to the inhalation of foreign material, in this case, the gastric contents, into the lungs. This can occur when the feeding tube is not properly placed or secured, allowing the contents to enter the respiratory system instead of the stomach. Aspiration can lead to serious respiratory problems, such as pneumonia, as well as other complications. Therefore, it is important to take precautions and ensure proper placement and management of enteral feeding tubes to minimize the risk of aspiration.

The statement is false because postictal patients should not always be put in the supine position. The position of the patient should be determined based on their individual needs and any potential risks. In some cases, placing the patient in the recovery position may be more appropriate to maintain an open airway and prevent aspiration. Therefore, the supine position is not always the correct choice for postictal patients.

Nocturia is the term used to describe excessive urination during the night. It is a condition where an individual wakes up frequently during the night to urinate. This can disrupt sleep patterns and cause discomfort. Nocturia can be caused by various factors such as drinking excessive fluids before bedtime, urinary tract infections, bladder or prostate problems, or certain medications. Managing the underlying cause of nocturia is important to alleviate the symptoms and improve sleep quality.

Oliguria is the medical term used to describe a condition where the urine output is less than 400 cc (cubic centimeters) per day. This condition indicates a decreased production of urine, which can be caused by various factors such as dehydration, kidney dysfunction, or certain medications. Oliguria can be a sign of an underlying health issue and may require further investigation and treatment.

A catheter that is used for intermittent emptying of the bladder and is not kept inside the patient at all times is called a straight catheter. This type of catheter is inserted into the bladder to drain urine and then removed once the bladder is empty. It is different from an indwelling catheter, which is left inside the patient for a longer period of time. The term "straight" refers to the straight shape of the catheter, which allows for easy insertion and removal.

The correct answer is 1-1.5 inches. This is the recommended length to insert a rectal thermometer. Inserting the thermometer too shallow may not provide an accurate reading, while inserting it too deep can cause discomfort or injury. Therefore, a length of 1-1.5 inches is considered safe and effective for measuring body temperature rectally.

Stage 1 hypertension is characterized by a systolic blood pressure reading between 140-159 mmHg and a diastolic blood pressure reading between 90-99 mmHg. This means that the blood pressure of an adult with stage 1 hypertension would fall within this range.

A dusky color is a sign of diminished circulation in a male patient with a condom catheter. Diminished circulation can lead to inadequate blood flow, causing the skin to appear dusky or bluish in color. This can indicate poor oxygenation and potential tissue damage. It is important to monitor for this sign as it may indicate a need for immediate medical intervention to restore proper circulation and prevent further complications.

Pulse oximetry measures the oxygen saturation level in the blood. A normal range for pulse oximetry is considered to be 92%-100%. This means that the blood is adequately oxygenated, with a higher percentage indicating better oxygen saturation.

The normal range of a tympanic temperature is 97-99 F. This range is considered normal because it falls within the typical body temperature range for a healthy individual. Tympanic temperature is measured in the ear and is an accurate reflection of core body temperature.

The correct answer is False. A blood pressure cuff should be placed about 1 inch above the brachial artery, not 2 inches. Placing the cuff too high or too low can lead to inaccurate blood pressure readings.

An air mattress is used for a patient at risk for pressure ulcers because it helps distribute the pressure evenly across the body, reducing the risk of developing pressure ulcers. The air cells in the mattress can be adjusted to provide optimal support and pressure relief for the patient, preventing prolonged pressure on specific areas of the body. This helps improve blood circulation and reduces the likelihood of tissue damage and the formation of pressure ulcers.

A rotokinetic bed is used to maintain skeletal alignment. This means that the bed is designed to keep the bones in proper position and alignment. It may be used in medical settings or for rehabilitation purposes to help prevent or correct skeletal misalignment, such as in cases of fractures or joint injuries. By providing support and stability, the rotokinetic bed promotes healing and helps the skeletal system to maintain its natural alignment.

A jejunostomy is a surgical procedure where a feeding tube is inserted through the abdominal wall and directly into the small intestines. This allows for direct delivery of nutrients into the small intestines, bypassing the stomach. This procedure is often performed when a patient is unable to tolerate oral feeding or has a condition that affects the normal functioning of the stomach. By placing the feeding tube in the small intestines, nutrients can be absorbed and the patient's nutritional needs can be met.