ChancellorDuck951
Answer the following questions, being sure to describe each…
Answer the following questions, being sure to describe each question in detail.
1. Ms. Q, age 84 years, has been ill with vomiting and diarrhea. She has been running an
elevated temperature. Which type of thermometer would be best to use for Ms. Q and
which route would you use to check her temperature?
2. PRIORITY SETTING
Write the number from 1 to 5 in order of which patient you would obtain vital signs from
first
a. __________ Mrs. O has pneumonia and is receiving oxygen.
b. __________ Mr. S had an abdominal aortic aneurysm repair 2 days ago.
c. ___________Ms. J had a pacemaker implanted this morning due to cardiac arrhythmia.
d. ___________Mr. K is scheduled for surgery at 2:00 pm today.
e. ___________Ms. H had a colectomy 2 days ago and has been diaphoretic.
3. Your patient is a 75-year-old female with early stage Alzheimer disease who was
admitted this afternoon to the assisted living facility where you are employed. You are
completing the admission paperwork. You are measuring her blood pressure for the initial
assessment. The expectation is that vital signs are accurately obtained and documented.
Directions: Describe in detail how you would obtain blood pressure on this patient.
Make sure to list each step (use the 2-step method).
4. You are caring for an 86-year-old patient with diabetes, hypertension, and arthritis. This
patient has a large abdominal wound that requires irrigation daily; the wound is draining
yellowish exudate. You are preparing to perform a sterile wound irrigation for this
patient. Describe the steps needed to irrigate and clean the wound. Be sure to list in the
correct order.
5. Describe the steps needed to perform tracheostomy care.
6. A nurse is collecting data on a patient who has a heart rate of 56/min. Which of the
following findings should the nurse expect?
a. Hypoglycemia
b. Patient reports dizziness
c. History of cigarette smoking
d. Temperature of 39 degrees Celsius (102.2 degrees Fahrenheit)
7. A nurse is obtaining the oxygen saturation on a client. Which of the following actions
should the nurse take?
a. Choose a finger with a capillary refill less than 2 seconds
b. Wait 10 seconds after placing the probe before obtaining the oxygen saturation reading
c. Relocate the sensor every 8 hours
d. Place the sensor probe on the same extremity as the blood pressure cuff
8. When obtaining a head to toe assessment on a patient, describe the difference between
objective and subjective data and list 3 examples of each.
9. When performing the respiratory part of a head-to-toe assessment, what are the correct
steps? (Include how to auscultate, where to place the stethoscope and in which order to
complete).
10. When assessing the cardiac part of your head-to-toe assessment, what are the correct
steps? (Include how to auscultate, where to place the stethoscope and in which order to
complete).
11. When performing the abdominal assessment in your head-to-toe assessment, what are the
correct steps? (Include how to auscultate, where to place the stethoscope and in which
order to complete)
12. Describe how you obtain a neurological assessment. Include how you obtain the level of
consciousness and an overall neurological assessment. (Include what are you checking
for on the body)
13. Describe the steps to an eye irrigation. Also include the rationale for performing an eye
irrigation
14. Describe the steps to an ear irrigation. Also include the rationale for performing an ear
irrigation.
15. For Intramuscular and subcutaneous injections- include the locations that are appropriate
and technique for each type (include angle of needle, how to choose appropriate site).
