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NCLEX- Module 1
(Fundamentals,
Study Tools +
Practice Questions)

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ADVANCE DIRECTIVES
Overview
1. Advanced Directives
a. Living Will
b. Medical Power of Attorney
Nursing Points
General
1. Patient Wishes & Advocacy
a. Patient Wishes
b. Patient Advocacy
2. Living Will
a. Legal Document
b. Written out for instances for which a patient cannot communicate their decisions.
c. Often DNR/Partial DNR/Full Code Wishes
i. Full Code
1. Chemicals/Drugs
2. Compressions
3. Shocks
4. Intubation
ii. DNR – Do Not Resuscitate
1. None of the Above
iii. Partial DNR
1. One or more, but NOT all of the above
d. State Dependent on executing them.
3. Medical Power of Attorney
a. Legal Document
b. Different than Durable Power of Attorney (DPOA)
c. Designates a particular person or persons to make medical decisions for the patient.
d. In the absence of a MPOA, state laws dictate who makes medical decisions.
i. Example – TX – Spouse, Adult Children, Living Parents, Nearest Living Adult
Relative, then providers
4. Who needs a Living Will and who needs a Medical Power of Attorney?
a. Living Wills and Plans of Care
i. Needed prior to injury, illness, hospitalization and/or treatment.
ii. Example: Healthy individuals or those with chronic illness who may expect to
receive treatment in the future
b. Medical Power of Attorney
i. Needed by those who may, at some point, be unable to voice their own decisions
regarding medical care.
ii. Example: Patients with dementia or cancer.
Nursing Concepts
1. Health Policy
2. Ethical & Legal Practice
3. End of Life
Patient Education
1. Patients should be educated on advanced directives.
2. Patients should be educated on Power of Attorneys and Living Wills
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3. Chaplain can assist with obtaining an advanced directive in the hospital.

STUDY TOOLS:
ADVANCED DIRECTIVES Ask all patients if they have an Advanced Directive. If so, be sure to get a
copy for their medical record!
Living Will
• Legal Document
• Written out for instances for which a patient cannot communicate their decisions
• Includes Code Status
• Full Code
• DNR – Do Not Resuscitate
• Partial DNR
• Needed prior to injury, illness, hospitalization and/or treatment
Medical Power of Attorney
• Legal Document
• Different than Durable Power of Attorney (DPOA)
• Designates a particular person or persons to make medical decisions for the patient
• In the absence of a MPOA, state laws dictate who makes medical decisions
• Needed by those who may, at some point, be unable to voice their own decisions regarding medical
care.

Hospital social workers or chaplains can help patients complete Advanced Directives while they are
hospitalized (Depends on Hospital Policy)
Quiz
Question 1 of 10
A patient is admitted to the hospital for surgery and the nurse discovers that the patient has a living
will. In addition to placing a copy of the document on the Patient’s chart, what would be a priority
action for the nurse?
1. Contact the pharmacy about withholding medications in case of patient compromise
2. Notify the surgeon on the case that the patient has a living will
3. Direct the family to their spiritual advisor to further discuss the living will
4. Inform the patient that the living will must be suspended during surgery
Question 2 of 10
A patient in the hospital has just expired. Which of the following personnel must the nurse notify in
the event of a Patient’s death? Select all that apply.
1. The nursing supervisor
2. The organ donation network
3. The social worker
4. The attending provider
5. The Patient’s roommate
Question 3 of 10

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A nurse is performing post-mortem care on a patient who has just died. Which of the following
actions should be included as part of post-mortem care? Select all that apply.
1. Keep the body in the last position it was found for the Medical Examiner
2. Remove the Patient’s jewelry and give to the family
3. Place a sign on the door restricting others from entering
4. Put a clean gown on the patient
5. Close the Patient’s eyes
Question 4 of 10
A nurse is admitting a patient to the long-term care facility. During the admission process, the
nurse asks the patient if they have an advance directive, and the patient says no. How should the
nurse respond?
1. Tell the patient to make an appointment with an attorney to draw up paperwork
2. Explain that the facility cannot care for the patient unless there is an advance directive present
3. Inform the rest of the nursing staff that the patient does not have an advance directive
4. Give information about advance directives so the patient can make an informed decision
Question 5 of 10
An older adult patient who has been diagnosed with lymphoma does not have a living will in place
but has filled out a values history. Which of the following is associated with this type of directive?
Select all that apply.
1. Choosing a significant other to make healthcare decisions if the patient is unable
2. Making a statement about the Patient’s religious background
3. Clarifying the parts of life that have meaning to the patient
4. Indicating that the patient does not want intubation
5. Designating certain treatments that the patient does not want
Question 6 of 10
Which of the following best describes a healthcare proxy as part of an advance directive?
1. A person who helps a patient fill out a living will
2. The documentation kept on file about the person's end of life care decisions
3. A statement that indicates exactly what the patient wants if he or she is unable to communicate
4. A person who makes healthcare decisions for the patient when the patient is unable
Question 7 of 10
Which best describes a psychiatric advance directive?
1. A psychiatric patient agrees that he or she does not want resuscitation if hospitalized
2. A psychiatric patient makes a decision about who will recover his or her financial information if
mandatory treatment is required
3. A person with a mental illness chooses the provider who will write prescriptions for medications
4. A person with a mental illness gives instructions about what treatment he or she wants if a crisis
is experienced

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Question 8 of 10
The nurse is caring for a patient who just arrived on the unit from PACU after a craniotomy for
tumor debulking. After completing the initial assessment, the nurse administers morphine for pain.
The patient is groggy, but oriented and compliant. The Patient’s daughter is outside of the room
and asks, “Can you just knock him out? He is agitated and getting on my nerves. He’s probably in
pain and just needs to sleep off the rest of the day. I’m his health care power of attorney as you can
see in the chart.” What is the most appropriate response?
1. Of course. I will call the provider now for the appropriate orders
2. Let me verify that you are the only person listed, otherwise I will need to contact all listed parties
prior to administering any additional medication
3. Even though you are the health care POA, he makes his own decisions at this point. That much
sedation is inappropriate
4. May I see your government-issued ID to verify your identity as the healthcare power of attorney?
Question 9 of 10
In the event that a patient becomes incompetent to make his or her own decisions, the person who is
medical power of attorney can authorize which of the following? Select all that apply.
1. Make decisions on behalf of the patient after the Patient’s death
2. Make choices for what medical treatment to give to the patient
3. Decide which provider and/or facility to utilize for treatment
4. Allow management for the Patient’s healthcare decisions
5. Authorize a change to the Patient’s last will and testament
Question 10 of 10
Studies have shown that although care planning and advance directives are available to patients,
only a small percentage have actually completed them. Which of the following has been shown to be
associated with a greater likelihood of completing an advance directive? Select all that apply.
1. South Asian ethnicity
2. Younger age
3. Lower socioeconomic status
4. Higher level of education
5. History of a chronic disease

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Legal Considerations
Overview
1. Legal Considerations
a. Federal Law
b. State Law
c. Torts
d. Criminal & Civil Law
Nursing Points
General
1. Federal Law
a. Health Insurance Portability and Accountability Act – HIPAA
b. American Disabilities Act – ADA
c. Emergency Medical Treatment and Active Labor Act – EMTALA
d. Restraints
e. Accreditation
i. The Joint Commission (TJC)
ii. Center for Medicaid and Medicare Care Services (CMS)
2. State Law
a. Boards of Nursing
i. State Practice Act
1. Laws differ per state regarding scope of practice
ii. Licensure
b. National Council of State Boards of Nursing (NCSBN)
i. Compact License
1. Must follow laws in state of active practice
ii. NCLEX
3. Torts
a. What is a Tort?
i. Wrongdoing against a person
b. Unintentional
i. Negligence
ii. Malpractice
c. Quasi-Intentional
i. Defamation
ii. Privacy Breach
d. Intentional
i. Assault / Battery
ii. False Imprisonment
4. Criminal & Civil Law
a. Criminal
i. Fines / penalties
ii. Serve time
b. Civil
i. Fines / penalties
ii. Payments

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Nursing Concepts
1. Health Policy
2. Ethical & Legal Practice
3. Professionalism
Patient Education
1. Educate the patient on their rights

Quiz
Question 1 of 10
Which of the following situations best describes a breach of duty to act?
1. The nurse did not ask for consent before starting a procedure
2. The patient was harmed because of the nurse's negligence
3. The patient feels that his or her protected health information was violated
4. The nurse did not act appropriately or failed to act at all to care for the patient

Question 2 of 10
A registered nurse is asked to administer a drug that is considered an anesthesia induction agent.
The nurse is not sure if this is within her scope of practice. Which of the following describes the
nursing scope of practice? Select all that apply.
1. The scope of practice outlines what the nurse can and cannot do based on experience and
education
2. The scope of practices defines the actions permitted by law for the nursing profession
3. The scope of practice is a law set forth by the American Nurses’ Association
4. The scope of practice dictates the legal actions taken against the nurse if the nurse practices
outside of nursing boundaries
5. The scope of practice is identical to policies and procedures in healthcare institutions

Question 3 of 10
A patient is upset about the treatment received while in the hospital, and wants to leave AMA. The
nurse should inform the patient that it is within the Patient’s right to leave the hospital but should
also include what information when care is refused? Select all that apply.
1. Remind the patient that he can always return for treatment if he changes his mind
2. Ask the patient about what could be done to make it better
3. The patient cannot return to this facility for treatment if he refuses care now
4. Inform the patient that leaving AMA means that insurance will not pay for the visit
5. Tell the patient that he has a right to refuse care even if it is not the best decision

Question 4 of 10
Which best describes the difference between a nurse’s scope of practice and a nurse’s standard of
care?
1. The scope of practice determines criteria used for job proficiency, while the standard of care
determines the extent of the nurse's activities under law
2. The scope of practice is a guideline that is determined by each facility's policies, while the
standard of care is governed by the nurse practice act of each state

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3. The scope of practice is the boundary of what the nurse can perform by law, while the standard of
care determines the quality of the care given by the nurse
4. The scope of practice guides the nurse about how to provide the most appropriate patient care,
while the standards of care are reflected differently between various levels of nursing
professionals

Question 5 of 10
A nurse who works in the emergency department has been caring for a patient who is angry and
complains about the care given. Before leaving the room, the patient tells the nurse, “I’m going to
sue this hospital. This has been terrible!” What actions could the nurse take that would best
prevent litigation? Select all that apply
1. Document the Patient’s statements
2. Approach the patient using appropriate body language that conveys caring
3. Tell the patient what the nurse is going to do and follow through
4. Listen to the patient and respond with empathy
5. Confront the patient about the inappropriateness of suing an emergency department

Question 6 of 10
A nurse works in a busy and crowded clinic where there is little privacy for patients or the nursing
staff. The nurse needs to discuss a Patient’s condition with another nurse but does not want to
breach the Patient’s privacy. Which best describes how the nurse would best uphold patient
privacy in this environment?
1. Walk away to as quiet of area as possible and move away from others
2. Wait until the end of the shift and more people have left the area
3. Write down the information and pass it back and forth in printed form
4. Step into an area such as an elevator, where there may be fewer people

Question 7 of 10
A nurse made a mistake with administering a medication, which caused her patient to become ill
and to stay in the hospital an extra day. The nurse is considering telling the patient that it was the
nurse’s mistake that caused the complications. Which implications should the nurse consider when
disclosing this information to the patient?
1. The patient will be more likely to sue the nurse
2. The patient may be angry at the hospital instead
3. The patient will no longer be upset
4. The nurse manager should be informed prior to talking to a patient

Question 8 of 10
A nurse is taking care of a patient at the beginning of a shift. Upon walking into the room, the nurse
finds the patient and the wife very upset. The wife says, “That last nurse was terrible! She
reprimanded my husband for not taking his medication on time!” The patient wants to leave
against medical advice (AMA). Which response from the nurse best demonstrates conflict
resolution between the patient and the organization?
1. If you want to leave AMA, that is your choice
2. Let's talk about what I can do that would change your mind
3. Do you think you could consider what role you played in this disagreement?
4. I'm so sorry about what happened. Please do not hold it against our organization

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Question 9 of 10
A 12-year-old patient needs to have treatment that involves a surgical procedure that will save the
child’s life. The parents refuse to give consent for the procedure based on their personal
convictions. Which of the following is allowable for the healthcare team in response?
1. Allow the 12-year-old to give consent for the procedure
2. Transfer the care of the child to the next closest adult relative to sign the consent
3. Contact the court system with the information about the case
4. Perform the procedure, anyway, citing that it is in the Patient’s best interest

Question 10 of 10
After finishing a shift, a nurse uses the public restroom and encounters a colleague with a syringe
and needle. The nurse remembers that this colleague has had odd behavior for the past three
months and has become much more irresponsible and sloppier with work. The nurse is considering
reporting the situation. Which best describes the action the nurse should take first?
1. Assess whether it is important to report the colleague and if it will ruin the friendship
2. Confront the co-worker about the erratic behavior and ask if something is wrong
3. Write down the incident and file it to use later if strange behavior is noted again
4. Report the incident to the nursing manager with concerns about the employee's suspected drug
use

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HIPAA
Overview
1. HIPAA
a. What is HIPAA?
b. Patient Privacy
c. PHI Pitfalls
d. HIPAA Violations
Nursing Points
General
1. What is HIPAA?
a. Health Insurance Portability and Accountability Act
b. Focuses on Patient Health Information
c. Stipulates how healthcare workers can share information
2. Patient Privacy
a. “Need to Know”
b. Sharing info with providers
c. Sharing info with family
i. With the patient’s permission
3. PHI Pitfalls
a. Turn off your computer screen
b. Don’t talk in public places
c. Shred PHI
d. Social Media
4. HIPAA Violations
a. Who’s affected?
i. The healthcare worker
1. Dietician
2. Provider
3. Nurse
4. CNA
5. Anyone with access to PHI
ii. The hospital
iii. The patient
b. What happens if I violate HIPAA?
i. Suspension
ii. Termination
iii. License Revocation
iv. Fines
v. Criminal Charges
vi. Civil Lawsuit
Nursing Concepts
1. Health Policy
2. Ethical & Legal Practice
3. Professionalism
Patient Education
1. Educate the patient on their right to privacy

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STUDY TOOLS
HIPAA PRO-TIPS
What is HIPAA?
• Health Insurance Portability and Accountability Act
• Focuses on Patient Health Information (PHI) & Patient Privacy
• Only share PHI with providers and family, with patient permission
• Steep potential fines, penalties and criminal charges for non-compliance
When CAN I Share PHI?
• PHI can be shared with anyone directly involved in the patient’s care
• PHI can be shared with a legal guardian or appointee (power of attorney) if the patient is a minor
or incapacitated
• PHI can be shared with family or friends, IF and ONLY if the patient gives you permission to
share
• PHI cannot be provided over the phone
Pro-tips
• Turn off your computer screen/Hide computer screen
• Log off computer
• Shred PHI
• Don’t talk about patients in public places (elevator, cafeteria, etc.)
• Don’t share anything about a patient on Social Media
• Don’t take photos of PHI OR the patient!

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QUIZ
Question 1 of 10
Despite HIPAA regulations regarding confidentiality, there are some situations in which
confidentiality can be breached and information reported to other entities. This includes which of
the following? Select all that apply.
1. The patient is a physician
2. The situation involves child abuse
3. The patient is from a correctional institution
4. The breach of information was unintentional
5. An injury occurred from a firearm

Question 2 of 10
A nurse is caring for a patient who recently had blood testing for HIV. The results of the test came
back as HIV positive. According to standards set by HIPAA, which of the actions of the nurse is
most appropriate?
1. Place a sign on the Patient’s door that others need to use isolation precautions
2. Notify the other nurses in the unit for a team meeting
3. Contact the health department with the Patient’s name and information
4. Notify the provider of the result so that the provider can discuss it with the patient

Question 3 of 10
A nurse was upset about a Patient’s behavior and feels very angry. The nurse wants to discuss it
with someone but doesn’t know what to do. Which of the following potential responses from the
nurse constitutes a HIPAA violation? Select all that apply.
1. Commenting on social media without using any patient identification
2. Talking to the patient about the Patient’s behavior and how it makes the nurse feel
3. Talking with a professional counselor about the situation
4. Discussing the situation with the provider in charge of the case
5. Talking to her spouse about the situation

Question 4 of 10
The charge nurse on a healthcare unit walks into the conference room and finds another nurse
looking up private health information on the computer for a patient that the nurse is not assigned
to. The charge nurse knows that protecting health information, according to HIPAA, is designed
for which of the following?
1. Prevent those in law enforcement from finding out any information about the patient
2. Avoid reporting of private information to public health officials
3. Impose criminal penalties if a Patient’s privacy rights are violated
4. Prevent those who are involved with direct patient care from accessing personal information
about the patient

Question 5 of 10
Which best explains the difference between confidentiality and privacy?
1. Privacy is covered by HIPAA laws, while confidentiality is not supported
2. Confidentiality refers to the communication of personal information while privacy refers to the
right to be left alone
3. Confidentiality is covered by HIPAA laws, while privacy is not supported
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4. Privacy refers to the communication of personal information while confidentiality refers to the
right to be left alone

Question 6 of 10
Which of the following is not part of HIPAA provision for protection of confidentiality?
1. A patient has a right to see their own health record
2. A patient has a right to have a copy of his or her entire medical record
3. A patient has a right to have his or her record protected while it is viewed electronically
4. A patient has a right to file claims with his record to the insurance company

Question 7 of 10
A nurse wants to ensure that a breach the Patient’s privacy and confidentiality does not occur.
Which situation of disclosure of protected health information is allowed under HIPAA? Select all
that apply.
1. When discussing a Patient’s case with students from a nursing school class
2. When permission is obtained from the patient to disclose information
3. When leaving a message about a patient on a voicemail
4. For payment of health care activities
5. To notify public health officials

Question 8 of 10
A patient is being admitted to the hospital for medical care and upon admission, he signs a general
release of medical information. Which of the following entities can receive patient information from
signing this release?
1. Legal guardian
2. Employer
3. Minister
4. Sibling

Question 9 of 10
The nurse is caring for a male patient with several supportive family members. The Patient’s sister
from out of state calls the unit to ask how he fared overnight. Which of the following responses by
the nurse is appropriate?
1. "If you tell me your phone number, I will call it back to confirm its you and give you the
information"
2. "I am not allowed to give out medical information to anyone over the phone"
3. "I cannot give any information unless I confirm it with your brother first"
4. "Sure. Is there anything specific that you would like to know?"

Question 10 of 10
Which of the following individuals has an automatic right to view a Patient’s medical record
without the consent of the patient?
1. A member of the military
2. A police officer
3. A coroner
4. A paramedic

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Brief CPR (Cardiopulmonary

Resuscitation) Overview
Overview
1. This is based on actions IN a healthcare facility – as if you are the nurse and find an unconscious
patient.
a. In the community, the algorithm is slightly different, refer to the American Heart
Association for details.
Nursing Points
General
1. Patient found unconscious:
a. Always assess first
b. Determine responsiveness (sternal pressure, yelling)
c. Check for carotid pulse (MAX 10 seconds)
d. Know/ask if a neck injury is suspected
2. If no pulse
a. Call for help (Code Button, yell, call light)
b. Send someone for AED
c. Begin chest compressions at a rate of 100-120 beats/min
d. Do NOT delay chest compressions
e. During chest compression, do not stop unless instructed
i. Minimizing chest compression interruptions is ESSENTIAL
ii. Push hard and fast
iii. Must allow for recoil
3. Help arrives
a. Another health care provider will open airway
b. Use BVM to administer breaths after 30 compressions
i. 30 : 2 ratio until secured airway
c. Other health care providers should be attaching the defibrillator pads, ensuring IV access.
d. Do not use the pediatric/child defibrillator pads on an adult
4. 2-minute cycle finishes
a. Check carotid pulse
b. Analyze rhythm (AED mode if no ACLS providers present)
5. If shock advised
a. Resume compressions while defibrillator charges
b. Clear patient to administer appropriate shock
c. Immediately resume compressions
6. If pulseless and no shock indicated, immediately resume CPR
7. Begin ACLS algorithms when advanced practitioners available
Nursing Concepts
1. Clinical Judgment
2. Perfusion
3. Oxygenation

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STUDY TOOLS:
CPR OVERVIEW
1) Patient found unconscious
a) Try to rouse patient (yell and shake)
b) Check pulse (MAX 10 seconds)
2) NO Pulse
a) Call for help
b) IMMEDIATELY being chest compressions at 100-120 beats/min
c) Call for AED/Crash cart
3) CPR cycles
a) 2 minute cycles
b) 30 compressions, then 2 breaths
c) At the end of cycle, check a rhythm and pulse
4) If shock is advised:
a) Continue compressions until defibrillator is ready to deliver shock
b) CLEAR PATIENT BEFORE DELIVERING SHOCK
c) Immediately resume compressions
5) Continue until advanced help arrives
a) ACLS providers will take over to provide higher level CPR care
b) Advanced Airway will be placed by providers

Always refer to the most recent AHA guidelines

QUIZ
Question 1 of 10
A nurse is responding to a patient who has collapsed in the hallway where several people are
performing CPR. After two minutes, the nurse arrives with the AED, turns it on, and attaches the
appropriately sized leads to the patient’s chest. Which step should the nurse take next?
1. Clear the victim
2. Perform chest compressions for one full minute
3. Check the Patient’s heart rate
4. Press the shock button

Question 2 of 10
A patient in the ICU has gone into cardiac arrest. The code team has arrived and begun
compressions. The nurse brings in the crash cart and sets up the defibrillator. Which of the
following would be a shockable rhythm for defibrillation? Select all that apply.
1. Pulseless ventricular tachycardia
2. Pulseless electrical activity
3. Atrial fibrillation
4. Asystole
5. Ventricular fibrillation

Question 3 of 10
What are the main findings in a cardiopulmonary arrest? Select all that apply.
1. Unconsciousness
2. Fixed and dilated pupils
3. Absence of breathing
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4. Absence of pulse
5. Widened pulse pressure

Question 4 of 10
A nurse is performing CPR on a patient who is in cardiac arrest. The external defibrillator is
brought to the bedside and the nurse removes the leads from the AED case. What is the next step of
the nurse?
1. Turn on the defibrillator to follow prompts
2. Apply the defibrillator leads
3. Check the Patient’s carotid pulse
4. Cleanse the skin around the defibrillator leads

Question 5 of 10
A nurse calls the charge nurse and asks for a vial of Epinephrine 1:10,000 to be brought to a
Patient’s room STAT. The charge nurse knows that what situation is likely occurring in the
Patient’s room?
1. Cardiac arrest
2. Hemorrhaging
3. Anaphylactic reaction
4. Respiratory distress

Question 6 of 10
Two nurses have responded to help an adult family member of a patient who collapsed in the
hallway. The person is not responding to stimulation and the first nurse checks for a carotid pulse,
but does not feel anything. The patient has snoring respirations. What describes the appropriate
actions the nurses should perform with CPR? Select all that apply.
1. Open the airway using the head-tilt-chin-lift
2. Deliver 2 breaths after giving 30 compressions
3. Perform chest compressions at a rate of 100 per minute
4. Apply chest compressions at a depth of 2 inches
5. Check for a pulse using the brachial artery

Question 7 of 10
The nurse is on a rapid response team that has responded to a code blue. The victim is a visitor who
has fallen down a flight of stairs and is unresponsive. A cervical spine injury is suspected. To
perform CPR safely, what is the best initial intervention?
1. Jaw thrust maneuver
2. Cricothyroidotomy
3. Nasotracheal intubation
4. Chin tilt maneuver

Question 8 of 10
A patient is in the hospital after having cardiac surgery. The Patient’s family tells the nurse that the
patient does not want CPR if the Patient’s heart were to stop. During recovery from surgery, the
patient goes into cardiac arrest. Which action of the nurse is most appropriate?
1. Monitor the patient and do not attempt resuscitation
2. Begin CPR using chest compressions
3. Contact the provider about getting an order for a DNR
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4. Ask the family again what they would like for the patient

Question 9 of 10
A patient has gone into ventricular fibrillation. Two nurses run into the room and one nurse tries
unsuccessfully to find a pulse. The other nurse immediately begins CPR while the first nurse calls a
code and grabs the ambu bag. What is the most important aspect of this attempted resuscitation?
1. Minimizing interruptions for effective compressions
2. Initiating a hypothermia protocol as soon as ROSC is obtained
3. Obtaining a STAT 12-lead ECG
4. Immediate advanced airway placement

Question 10 of 10
The nurse is caring for a patient who verbally expresses his wish to not be resuscitated. Later in the
nurses shift the patient codes. The nurse looks at the chart and notes that the patient is listed as full
code. What should the nurse do?
1. Call the provider to clarify
2. Refrain from starting CPR, because the patient does not want to be resuscitated
3. Call the family and clarify with them
4. Start CPR and continue until proper paperwork had been presented

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Fire and Electrical Safety

Overview
1. Fire safety

a. Patient safety

b. Activate alarm

c. Contain fire

d. Use an extinguisher

e. Prevention of fires

Nursing Points
General

1. Electrical prevention

a. Inspect equipment

b. Don’t use near water

c. If patient is shocked, unplug equipment

d. Tag and remove unsafe equipment

e. Use red plugs when necessary

2. Fire prevention

a. Check equipment

b. Follow smoking policies

c. Don’t block doors

d. Know where the oxygen shut off is

3. In the event of a fire

a. RACE

i. R – Rescue

ii. A – Activate

iii. C – Contain

iv. E – Extinguish

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b. PASS

i. P – Pull pin

ii. A – Aim nozzle

iii. S – Squeeze trigger

iv. S – Sweep
Nursing Concepts

1. Safety

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STUDY TOOLS:
Fire Safety 1
PASS

• P-Pull Pin

• A-Aim

• S-Squeeze

• S-Sweep

This is how a fire extinguisher is used to contain and extinguish a small fire.
Fire Safety 2
RACE

• R-Rescue (the patient)

• A-Alarm (activate)

• C-Contain (the fire)

• E-Extinguish (the fire)

This is the prioritization of caring for a patient during a fire.

QUIZ
Question 1 of 8
The nurse is caring for a medically stable patient who states that he is extremely busy at work. The
patient has multiple electronic devices in the room. What is the nurse’s priority?
1. Allow the patient to continue working
2. Inspecting any charger to ensure they are safe to use in the facility
3. Calling the Patient’s place of employment to let them know he won't be in tomorrow
4. Inspect all of the Patient’s belongings

Question 2 of 8
A school nurse participates in monthly fire drills in which all students are to file out of the building.
What best describes the nurse’s role during a fire drill?
1. Coordinating with the principal to ensure that everyone has followed directions
2. Notifying the fire department that it is only a drill
3. Checking rooms to ensure that all students have left the building
4. Bringing the first aid kit outside in case anyone has been injured
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Question 3 of 8
A nurse is caring for patients during the day shift when the fire alarm goes off, and the nurse is told
to evacuate the unit. The nurse remembers the RACE acronym for fires, and does which of the
following actions for E in RACE?
1. Establishes a safe area on the first floor for people to gather
2. Checks rooms for people, informing them to evacuate the building
3. Uses blankets or buckets of water to eradicate the fire when it reaches the unit
4. Encases the cracks in the doors with linens and cloth to prevent airflow

Question 4 of 8
Using bones and muscles to maintain proper alignment and body posture while performing a task is
known as which of the following?
1. Assistive positioning
2. Stabilization
3. Body mechanics
4. Ergonomics

Question 5 of 8
A fire breaks out in a long-term care facility and a nurse is in a Patient’s room. The nurse and the
patient cannot get out. Which of the following actions should the nurse perform to keep the two of
them as safe as possible?
1. Cover the cracks around the door and vents with cloth
2. Leave the room door open to be found easily by firefighters
3. Dispose of trash or other flammable items in the room
4. Assist the resident to lie under the bed

Question 6 of 8
A nurse walks into a Patient’s room and realizes that a fire is burning in the bathroom. Which
actions should the nurse do in response? Select all that apply.
1. Turn off oxygen supplies as directed
2. Close and stuff wet towels under the bathroom door
3. Call the hospital operator to report the fire
4. Evacuate the patient from the room
5. Evacuate the unit, starting with all non-ambulatory patients

Question 7 of 8
A nurse walks into the dirty utility area of the unit and finds a small fire burning in the corner. The
nurse is able to quickly put it out with a nearby fire extinguisher before it activates the fire alarm.
Which of the following should be the next step of the nurse?
1. Contact the fire department and report the fire
2. Clean up the room and dispose of any damaged items
3. Call housekeeping to sanitize the area
4. Return the fire extinguisher to the maintenance department

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Question 8 of 8
The nurse is working on a busy hospital unit. A small fire has started in a trashcan in the nurse’s
break room, away from patients, and a colleague has pulled the fire alarm. What is the next
priority action?
1. Contain the fire to the trashcan
2. Fill out an incident report
3. Turn off the oxygen in all patient rooms on the floor
4. Begin a hospital-wide evacuation

Fall and Injury Prevention

Overview
1. Fall & Injury Prevention

1. Fall risks

2. Fall prevention

3. Assistive devices

4. Body mechanics

5. Make life easier

Nursing Points
General

1. Fall risk

1. Age

2. Education

3. Cognition

4. Tripping Hazards

1. SCD

2. Other equipment

2. Fall prevention

1. Call light

2. Declutter room

3. Nonskid socks

4. Bed alarm
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5. Lighting

6. Frequent toileting

3. Using assistive devices

1. Walker

2. Cane

3. Wheelchair

4. Crutches

4. Body mechanics

1. Lift with legs

2. Never bend and twist

3. Step up

5. Make life easier

1. Move bed up

2. Use PT/OT

3. Grab other HCP for moving patients

Nursing Concepts

1. Safety

Patient Education
1. Make sure patients understand the use of call light and place it within reach

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QUIZ
Question 1 of 10
The nurse is caring for a patient who is confused. This patient has multiple cardiac IV drips,
sequential compression devices, and a Foley catheter. The patient is becoming increasingly agitated
and is pulling at the IV lines and Foley catheter tubing. Which of the following is an appropriate
intervention?
1. 5 mg IV haloperidol
2. A bedside sitter
3. A Posey vests
4. Bilateral soft wrist restraints

Question 2 of 10
A nurse is working in the surgical unit and is assigned the following patients.
Patient A, a 78-year-old male patient who recently had a hip fracture and who suffers from
Parkinson’s disease.
Patient B, a 60-year-old patient who is visually impaired and who is post-op day three after hernia
surgery.
Patient C, a 56-year-old patient who has a prescription for ketorolac and who had shoulder
surgery.
In which order would the nurse categorize these patients’ fall risk from greatest risk to least risk?
1. A, C, B
2. A, B, C
3. C, A, B
4. B, C, A

Question 3 of 10
A patient is being discharged home after being evaluated for a fall. Which of the following should
the nurse include in discharge instructions for the patient? Select all that apply.
1. Make sure to have adequate lighting in the home
2. Clear clutter and widen walking pathways in the home
3. Place rugs in all walking areas to improve traction
4. Make sure the bottoms of shoes have good traction
5. Not using a walker when the doorway isn't wide enough

Question 4 of 10
A patient who is exhibiting behavioral and psychological symptoms should be medically cleared to
rule out which of the following?
1. Ludwig's angina
2. Myocardial infarction
3. Head trauma
4. Pertussis

Question 5 of 10
The emergency room has four patients that have had a fall. Which of the following types of falls is
the priority for the nurse to see first?
1. Off a chair with obvious leg deformity
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2. On side walk and hit head

3. Second story roof
4. Down 5 stairs

Question 6 of 10
A nurse is caring for a 9-year-old patient who is considered a fall risk because of a history of
seizures. Which of the following interventions should be implemented to prevent falls in a pediatric
patient? Select all that apply.
1. Keep the Patient’s bed in the lowest position
2. Provide non-slip socks for the patient to wear while ambulating
3. Keep personal items out of reach of the child
4. Ensure the patient wears an identification bracelet containing the child's name and hospital
number
5. Move furniture and room items so that there is a clear walkway

Question 7 of 10
The nurse is caring for an older adult patient who has a urinary tract infection. The patient has
mild dementia, is confused but easily reoriented, and continues to attempt to get out of bed. Which
of the following is an appropriate safety measure for this patient? Select all that apply.
1. A sitter
2. 5 mg IV haloperidol
3. Non-skid footwear
4. A bed alarm on the most sensitive setting
5. Bilateral soft wrist restraints

Question 8 of 10
A home care nurse is working with a patient who is a fall risk. The nurse notes that the patient uses
a step stool in the kitchen and has many items placed high in the cupboards. Which information
should the nurse provide, that would best help this patient to stay safe?
1. Explain to the patient that he is unaware of what increases a person's fall risk
2. Give examples of situations in which people have fallen from step stools
3. Talk with the Patient’s spouse instead of the patient
4. Teach the patient to organize his home to keep frequently used items within reach

Question 9 of 10
A nurse is assessing a patient for a suspected injury. The nurse knows that which of the following
are signs of a possible head injury? Select all that apply.
1. Grey-Turner sign
2. Halo sign
3. Battle's sign
4. Kehr's sign
5. Raccoon eyes

Question 10 of 10
The risk management nurse at a long-term care facility is reviewing the facility’s data related to
recent patient falls. The nurse should consider which of the following as a risk factor for patient
falls? Select all that apply.
1. Age-related vision changes
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2. Hypertension
3. Change in mental status
4. Muscle deconditioning
5. Gait disorders

Isolation Precaution Types (PPE)

Overview
1. Isolation precautions types

1. Standard precautions

2. Contact precautions

3. Droplet precautions

4. Airborne precautions

Nursing Points
General

1. Standard precautions

a. Hand hygiene

b. Gloves

c. Examples:

i. Body fluid contact

2. Contact precautions

a. Transmission

i. Direct physical contact

1. Person to person

2. Fecal-oral

b. Standard precautions

c. Gown

d. Examples:

i. MRSA(Methicillin resistant Staphylococcus aureus)

ii. MDRO (Multidrug resistant organism)

iii. C. diff (Clostridium difficile)

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3. Droplet precautions

a. Transmission

i. Sneezing

ii. Coughing

iii. Talking

b. Standard precautions

c. Mask

d. Examples:

i. Flu

ii. Mumps

iii. Meningitis

iv. Anything transmitted greater than 5 microns in size

4. Airborne precautions

a. Transmission

i. Sneezing

ii. Coughing

b. N95 Mask & hood

i. Need to be sized and fitted

ii. Nurses with facial hair

c. Negative pressure room

i. Use ante room

ii. Make sure everyone else uses ante room

d. Examples:

i. Measles

ii. Tuberculosis

iii. Anything smaller than 5 microns

5. Things to consider

a. Build rapport

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b. Ask questions

c. Engage the patient and family

Nursing Concepts

1. Safety

2. Infection control

Patient Education
1. Educate patients on need for isolation control while encouraging positive rapport building

and reducing feelings of isolation.

STUDY TOOLS:
Isolation Precautions
These represent the MINIMUM required Personal Protective Equipment (PPE) for each set of
precautions. You can always add more PPE!
Standard precautions
• Hand hygiene
• Gloves
• WHO:
▪ All patients
▪ Risk of contact with fluids
Contact precautions
• Transmission
▪ Direct physical contact
• Standard precautions + Gown
• WHO:
▪ MRSA
▪ VRE
▪ C-Dif
Droplet precautions
• Transmission
▪ Droplets from sneezing or coughing
• Standard precautions + Surgical Mask
• WHO:
▪ Meningitis
▪ Pertussis
▪ Influenza
Airborne precautions
• Transmission
▪ Breathing - airborne particles
• Standard precautions + N95 Respirator OR hood
• WHO:
▪ Measles
▪ Tuberculosis
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▪ Varicella
Isolation Precautions

Airborne Isolation

Reference: https://www.priceindustries.com/library/engineeringupdates/volume/21/roompressuremonitors

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Contact Isolation
By IdS - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=934040

Contact Isolation Gowns

QUIZ
Question 1 of 6
A 50-year-old patient with measles has been admitted to the hospital and is in isolation. The
Patient’s daughter asks the nurse, “How can I keep from catching this myself if I have been
vaccinated?” Which answer from the nurse is most appropriate?
1. You should be fine if you consistently wash your hands
2. You are protected since you have received the MMR vaccine
3. I will have the doctor check a measles titer for you to see if you are immune
4. Make sure that you adhere to the isolation precautions when you are in close proximity

Question 2 of 6
A nurse is caring for a patient with varicella zoster. The nurse is instructing the patient and the
family about how to prevent transmission of the disease while in the hospital. Which directions
should the nurse provide as part of this teaching? Select all that apply.
1. The door to the Patient’s room will remain closed
2. There will be a sign on the door that states the type of precautions that are in use
3. Air will flow into the Patient’s room but not out of it
4. The inside of the room will have a specified area of patient contact
5. Visitors will be required to wear a gown and gloves when in the room

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Question 3 of 6
A 31-year-old patient has developed meningococcal meningitis after recently traveling out of the
Canada. Which type of precautions would the nurse most likely implement in this situation?
1. Airborne precautions
2. Contact precautions
3. Custom precautions
4. Droplet precautions

Question 4 of 6
A 60-year-old patient has been admitted to the hospital with Creutzfeldt-Jakob disease. Which type
of isolation precautions must the nurse use while caring for this patient?
1. Droplet precautions
2. Contact precautions
3. Airborne precautions
4. Standard precautions

Question 5 of 6
Which of the following actions requires the use of standard precautions? Select all that apply.
1. Contact with blood
2. Cleaning up vomit
3. Contact with patient sweat
4. Contact with mucous membranes
5. Touching intact skin

Question 6 of 6
The nurse is caring for a patient with watery diarrhea following a course of clindamycin. The nurse
suspects clostridium difficile. Which of the following isolation precautions are necessary for this
patient? Select all that apply.
1. Place the patient in a private room
2. Obtain a door sign indicating the level of precaution and necessary personal protective equipment
(PPE)
3. Place the patient a negative airflow room
4. Obtain personal protective equipment outside the door for staff and family members
5. Educate the patient and family members to use soap and water for hand washing instead of hand
sanitizer

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Maslow’s Hierarchy of Needs

Overview
1. Maslow’s Hierarchy of Needs

a. What is Maslow’s Hierarchy of Needs

i. Physiologic Needs

ii. Safety Needs

iii. Love/Belonging Needs

iv. Esteem Needs

v. Self-Actualization Needs

b. How does it pertain to nursing care?

i. Prioritization

Nursing Points
General

1. Maslow’s Hierarchy of Needs

a. Developed by Abraham Maslow

b. Psychological Theory based on human needs

c. Based on Priority Needs

2. Priority Based Needs

a. Physiological Needs

i. Take priority over other needs

ii. Highest priority level of Maslow’s Hierarchy

1. Examples of physiological needs:

a. Oxygen

b. Fluids

c. Nutrition

d. Shelter

e. Elimination

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b. Needs for Safety and Security

i. Second level prioritization

ii. Physical Safety

1. Patients want to feel physically safe

iii. Psychological Safety

1. People will attempt to seek safety before meeting any

other needs

iv. Examples:

1. Law and order

2. Shelter

3. Employment

4. Health

c. Needs of Love and Belonging

i. Third Level Need

1. Needs for social relationships

ii. Satisfies the acceptance of others

iii. Examples

1. Relationships with family members

2. Friendships

3. Social Relationships

4. Intimate Relationships

d. Self-Esteem Needs

i. Fourth Level Need

ii. Become more important once other needs levels are met

iii. Focus on outer acceptance first, then focus on esteem

1. Need to feel useful

2. Need for feelings of accomplishment

3. Need for self-confidence and self-worth

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iv. Examples

1. Recognition

2. Status

3. Respect

e. Self-Actualization

i. Must meet all other needs levels before fulfilling this level

1. Need to actualize full potential of self

2. Focuses on Coping

3. Encourages problem solving capabilities

4. “Being your best self”

ii. Examples

1. Pursuing a talent

2. Personal growth

3. Creativity

3. Maslow and Nursing

a. Nurses should prioritize care for their patient(s) based on this model

b. Meet physiological needs first

i. Patient becomes winded during conversation – stop conversation

(love/belonging needs) and focus on O2 status (physiologic needs)

c. Encourage Safety Needs

i. Observe safety in your patients room

ii. Encourage patient to engage in safe behavior

d. Love and Belonging Needs

i. Build Rapport

ii. Encourage Family Support

1. As long as the presence of family is healthy and positive

e. Self-esteem needs

i. Meet this through therapy

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ii. Encourage Success

f. Self-Actualization Needs

i. Focus on long term goals

ii. Rehabilitation and return to home

4. Put Maslow into practice

a. Prioritize your care of multiple patients

i. Use Maslow to determine which patient should come first

ii. Physiologic needs over Self-actualization needs

b. Meet your patient needs

i. Patients often come to the hospital with unmet needs

ii. Identify needs through assessment

iii. Meet those needs in categorical order

1. Physiologic needs, then safety, then love…

Nursing Concepts

1. Prioritization

2. Clinical Judgment

Patient Education
1. Look for opportunities to educate patients on higher priority needs over others

a. Example: For a patient who wants to have a long conversation but becomes

winded and having a decrease in oxygen saturation. You would need to

emphasize the need for the patient to take a breath and to pause the conversation

until the patient’s oxygen saturation improved.

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STUDY TOOLS:
Maslow’s Hierarchy of Needs

Maslow’s Hierarchy of Needs

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QUIZ
Question 1 of 10
A nurse is preparing to start a shift at the hospital and is considering which patients are highest
priority to see first. Which of the following patients would be considered second level priority for
the nurse to see? Select all that apply.
1. A patient who has low blood sugar
2. A patient who has developed severe peripheral edema
3. A patient who has a mental status change
4. A patient who is going into cardiogenic shock
5. A patient who requires a ventilator to help him breath

Question 2 of 10
A nurse is caring for a patient who will need bariatric surgery. According to Maslow’s hierarchy of
Needs, which of the following patient needs would be categorized in the love and belonging
classification? Select all that apply.
1. An order for medication to control pain and nausea
2. A feeling of success that the surgery went well
3. A visit from his spouse after surgery
4. A secure room in the hospital in which to recover
5. A phone call from co-workers to check on him

Question 3 of 10
A float nurse comes to help in the emergency room and is triaging patients with an experienced
nurse. The experienced nurse helps the float nurse understand that the patient with which of the
following is the priority.
1. Left flank pain with hematuria
2. A motor vehicle accident: the right sclera completely red, ecchymosis noted around right eye
3. Cough and congestion after finishing an antibiotic treatment regimen, no respiratory distress
4. Anxiety attack and depression after failing a college exam

Question 4 of 10
The triage nurse has 4 patients in the waiting room with one bed open in the emergency
department. All Patient’s ABCs (airway, breathing, circulation) are intact, and their vital signs are
within normal limits. Which patient is the priority to bring back?
1. 43 year old female with right arm pain
2. 17 year old female with a laceration, bleeding controlled
3. 25 year old male with a Crohn's flare up
4. 98 year old male with abdominal pain

Question 5 of 10
A patient with post-traumatic stress disorder has been brought into the emergency department
after attempting suicide by carbon monoxide poisoning. The nurse assesses the patient and finds
that the patient is short of breath, with a respiratory rate of 30/min, HR 98 bpm, and a blood
pressure 110/80 mmHg. The patient is irritable and withdrawn and his wife is at his side. Which
intervention is the highest priority in this situation?
1. Ask the patient why he tried to end his life
2. Help the Patient’s spouse by making her comfortable and providing support
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3. Administer oxygen and connect the patient to a hemodynamic monitor

4. Contact the provider for a prescription for antidepressants

Question 6 of 10
A nurse is caring for a patient who has been diagnosed with lung cancer. The patient tells the nurse
that she has not spoken with her mother in 8 years and really wants to reconnect with her. The
nurse recognizes that this need falls under which category of Maslow’s Hierarchy of Needs?

1. Safety
2. Physiological
3. Love and belonging
4. Self-esteem

Question 7 of 10
A nurse is starting a shift in the morning. After receiving report on the patients, the nurse reviews
what needs to be done and starts to prioritize tasks. The nurse has the following patients:
A: A 68-year-old patient who must take his medication with breakfast whose tray has just arrived
B: A 42-year-old patient who has become unresponsive in the last 5 minutes
C: A 51-year-old patient who is complaining of pain when he moves his shoulder
D: A 38-year-old patient who wants to take a shower right away
In which order should the nurse prioritize activities?
1. A, B, D, C
2. B, C, A, D
3. B, A, C, D
4. C, B, A, D

Question 8 of 10
Which is an example of a first-order priority need when providing patient care?
1. Starting an IV
2. Providing pain medications
3. Managing a patient's nausea
4. Maintaining a patient's airway
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Question 9 of 10
What is an example of a self-esteem need found within Maslow’s hierarchy?
1. Friendships
2. Family relationships
3. Secure employment
4. Achievements

Question 10 of 10
What is the highest order of Maslow’s Hierarchy of needs?
1. Self-actualization
2. Self-esteem
3. Safety and security
4. Physiological

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Delegation
Overview
1. Delegation

a. What is delegation?

b. Why delegate?

c. What can be delegated?

d. 5 Rights of delegation

Nursing Points
General

1. What is delegation?

a. Delegation

i. Request of an act or task be done by someone else

ii. Delegation only transfers the ACT of the task to someone else

iii. RN maintains the responsibility of the act or task

b. Who an RN can delegate a task to:

i. Other nurses (both RNs and LPNs)

ii. UAP (unlicensed assistive personnel)

2. Why delegate tasks?

a. Delegating tasks is efficient

i. There is only a finite amount of time during a shift

ii. RNs should utilize their time as much as possible

b. Delegate tasks that:

i. Need little to no supervision

ii. Do not detract from RN care

iii. Do not REQUIRE RN care

3. What can be delegated to UAPs?

a. Ok to delegate:

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i. ADLs

ii. Feeding

iii. Toileting

iv. Bathing

v. Ambulating

b. Not Ok to delegate:

i. Assessments

ii. Meds

iii. Education

iv. IV Access

v. Anything that fosters the primary RN to patient relationship (i.e.

plans of care)

4. Facilities/Institutions and State Laws all vary

a. It’s important to know what you can delegate

i. RN v. LPN Scope of Practice

b. Rule of thumb: If you don’t know if you can delegate it to a UAP, then do it

yourself

c. Ok to delegate tasks of equal competency to equal staff

i. RN to RN delegation ok

ii. UAP to UAP delegation ok

5. 5 Rights of Delegation

a. Right Person

i. Ensure they are authorized by the facility/institution AND state to

perform the task

ii. Make sure it falls within their license

iii. Question to ask: Is this person allowed to do it?

b. Right Task

i. Ensure the task is appropriate for the person

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ii. Ensure competency

iii. Question to ask: Is this person competent to do this task?

c. Right Circumstances

i. Make sure the patient can tolerate the task being performed by that

person

ii. Question to ask: Will the patient tolerate this task if it isn’t

performed by an RN? or Does this patient need an assessment

afterward?

d. Right Communication

e.

i.

i. Communicate clearly and succinctly with the person

assigned a task

ii. Questions to ask: Did I, as the nurse, clearly explain

what I needed done? Did I specify a time frame and

what should be reported back?

f. Right Supervision

g.

i.

i. Make sure that the task if properly supervised

ii. Question to ask: Have I followed up with care? OR At

what level should I supervise this task? OR How much

involvement should I have?

1.

Nursing Concepts

1. Clinical Judgment

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2. Teamwork & Collaboration

STUDY TOOLS:
Nursing Delegation
• Examples of things that are ok to delegate to UAP
▪ ADLs (bathing, feeding, toileting)
▪ Ambulation
▪ Alerting nurse to vital sign changes
▪ Perineal care
▪ Simple dressing changes
▪ BLS
• Examples of things that are not ok to delegate to UAP
▪ Patient Education
▪ Assessments
▪ Giving Meds
▪ Creating and documenting care plans
▪ Starting IV’s
▪ ACLS
Communicate
▪ The task itself
▪ A timeframe
▪ Where you or someone else will be to answer questions, or if there is a written resource available
(binder, policy)
▪ What needs to happen specially
▪ What to report back
▪ What needs to be documented
▪ If they have any questions
Prior to Delegating Ensure:
▪ They are competent to complete the task
▪ It is appropriate for them to complete
▪ If they feel comfortable with the task
▪ If the task ts within their scope of practice (these can di-er widely from state to state and facility
to facility, please check out your State Board of Nursing website and institutional policies
5 Rights of Delegation
1) Right task
2) Right Circumstance
3) Right Person
4) Right Direction/Communication
5) Right Supervision/Evaluation

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QUIZ
Question 1 of 10
A provider has ordered the following tests for a patient with chest pain. Which of these can the
nurse delegate to the nursing assistant? Select all that apply.
1. Titrating oxygen up to 2 liters
2. Vital Signs
3. X-Ray
4. Blood work
5. Nitroglycerin administration

Question 2 of 10
The nurse is working with a large patient load and has many tasks to complete. Which tasks can be
delegated to the nursing assistant?
1. Get vitals on an unstable patient
2. Dressing change on a post-surgical patient
3. Walk a patient 20 yards
4. Swallow screening on a post stroke patient

Question 3 of 10
The nurses on a busy unit are all needing help so a nurse assistant is asked to assist them. Which of
the following tasks should the nurse assign to the nursing assistant?
1. Administer insulin using the sliding scale
2. Get nutrition information for a newly diagnosed diabetes patient
3. Teach a patient how to adjust cooking techniques for a diagnosis of diabetes
4. Get a temperature and glucose on a patient

Question 4 of 10
A nursing student is practicing delegation with other students. The nursing students would be
correct in saying which of the following tasks is not appropriate to delegate to a nursing assistant?
1. Take a POC glucose before a patient eats
2. Emptying a urinary catheter and charting the output
3. Turning a patient that is bed ridden
4. Placing a nasogastric tube

Question 5 of 10
The nurse has the following tasks to perform. Which of these can be delegated to the unlicensed
assistive personnel? Select all that apply.
1. Administer an over-the-counter medication
2. Perform an assessment
3. Take vital signs
4. Give a bed bath
5. Feed a patient

Question 6 of 10
After receiving report, the nurse is planning patient tasks. Which of the following tasks can be
delegated to the nursing assistant?
1. Get a POC glucose on a patient
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2. Make arrangements for a ride home for a patient

3. Listen to a Patient’s lung sounds after a breathing treatment
4. Get vitals on an unstable septic patient

Question 7 of 10
A nurse is providing post-mortem care for a patient who died 30 minutes ago. Which of the
following components of this care can the nurse delegate to unlicensed assistive personnel?
1. Putting clean linens on the Patient’s bed
2. Telling the family members about the Patient’s death
3. Gathering paperwork for the mortuary
4. Removing tubes from the Patient’s body

Question 8 of 10
A nurse is working in a busy clinic and must provide teaching to a patient about caring for a new
colostomy. The nurse has a nurse aide to help with some tasks. Which of the following tasks could
the nurse delegate to the unlicensed assistive personnel while working with this patient?
1. Gathering informational materials to give to the patient
2. Instructing the patient about which foods are least likely to cause odor
3. Teaching the patient about how to change the colostomy bag
4. Checking and measuring the output from the foley

Question 9 of 10
A registered nurse is setting up parenteral nutrition for a patient in the medical-surgical unit of the
hospital. Which of the following actions is most appropriate for the RN delegate to an LPN who is
assisting with starting TPN?
1. Checking the Patient’s weight and BMI
2. Priming the catheter tubing
3. Looking up the Patient’s electrolyte levels
4. Flushing the central venous catheter

Question 10 of 10
The nurse has a list of tasks to accomplish. Which task is most appropriate to delegate to the
nursing assistant?
1. Place a patient on the cardiac monitor
2. Bring a warm blanket to a patient with a temp of 38.5C
3. Talk to upset family members to fix the situation
4. Watch the nurse's patients while the nurse eats

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Prioritization
Overview
1. Nursing Prioritization

a. What does prioritization mean?

b. Categories of prioritization

c. Interdisciplinary Communication

d. Prioritization Considerations

Nursing Points
General

1. What does prioritization mean?

a. Ranking a situation in urgency or whatever requires immediate action first

i. Emergent

1. Airway

2. Breathing

3. Circulation

4. Safety

ii. Urgent

1. Time sensitive tasks

2. Risk for emergency

iii. Not Urgent

2. Interdisciplinary Communication

a. Consider the priority

b. Communicate cordially

c. Follow HIPAA

i. Disclose information only when necessary

4. Delegation

Considerations

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0. Maslow’s Hierarchy of Needs

i. Consider individual patient’s needs vs other patients

ii. ABC-Safety

1. Physiologic Needs first

1. Efficiency

i. Cluster care

2. Stat Orders/Stat Labs

i. Follow policy

ii. Recognize impact that the orders and labs have on the patient

3. Prioritization is subject to frequent change

i. Be adaptable to change
Nursing Concepts

1. Prioritization

2. Clinical Judgment

Patient Education
1. Explain priorities to patients when addressing families

a. Example: Explain that even though the sweet grandmother needs to go to the

restroom, your patient in your other room needs your immediate attention

(delegate to an UAP and follow HIPAA)

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STUDY TOOLS:
Trauma – Assessment (Emergency)
ABCDEFGHI

• A-Airway

• B-Breathing

• C-Circulation

• D-Disability

• E-Expose / Examine

• F-Full set of Vitals

• G-Give Comfort Measures

• H-Head to Toe Assessment

• I-Inspect Posterior

Rapid assessment and treatment of the trauma patient is essential to their overall survival.
Working through this framework will aid in remembering where to focus your efforts. Always
remember your ABC and patient safety. Once those have been secured, you can move on to less
vital components.

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QUIZ
Question 1 of 10
The night shift nurse gives report to the charge nurse. After reviewing the diagnosis and symptoms
the charge nurse should see which of the following patients first?
1. Strep throat and now has a fever and a rash
2. Cellulitis that is now itchy
3. Kidney failure and now has an arm laceration
4. Kidney stones and burning upon urination

Question 2 of 10
Four pediatric patients have just come into the emergency room. The nurse should see the patient
with which of the following first?
1. Jaundice
2. Wheezing and cough
3. Fever
4. Dehydration

Question 3 of 10
The nurse is prioritizing tasks at the beginning of the shift. The patient with which of the following
should be the priority?
1. Rash
2. Extreme epigastric pain
3. Shortness of breath
4. Ankle injury

Question 4 of 10
A nurse in the emergency room has just received report from the day shift nurse on four patients.
Which of the following patients should the nurse see first?
1. Ischemic stroke treated with TPA and needs a neuro check again in 30 minutes
2. Chest pain who has orders for an ECG, blood work, and vital signs
3. Child with a fever, received acetaminophen 10 minutes ago and will need a temperature re-check
4. Abdominal pain who needs a line, labs, and assessment

Question 5 of 10
A student nurse is trying to understand how to prioritize the following four patients. The nurse is
helping the student understand the order of priority. Which of the following patient symptoms
should be the top priority?

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1. Nail stuck in the foot

2. Burning upon urination for a week
3. Chest pain after doing a lot of lifting at the gym
4. Facial droop and new onset confusion

Question 6 of 10
The nurses in the emergency room have four patients to prioritize for the float nurse to see. The
patient with which of the following should be seen first by the float nurse?
1. Missing teeth after a bar fight with a fat lip
2. Swallowed a gold dental crown
3. Battles sign after a bar fight
4. Dental abscess with pain so bad it makes the patient vomit

Question 7 of 10
The nurse receives a patient that was a victim of a fall and is complaining of chest pain and
dyspnea. The nurse knows that the priority after assessing a Patient’s airway would be to do which
of the following?
1. Order a chest X-ray
2. Perform a 12-lead EKG
3. Start 100% oxygen via a non-rebreather mask
4. Prepare for an IV fluid bolus

Question 8 of 10
A nurse is trying to prioritize time according to the tasks that must be completed for the day.
Which of the following elements must the nurse consider with prioritization? Select all that apply.
1. The needs of each patient in order to prioritize
2. The presence of the Patient’s family
3. The chance that other events may occur that are not planned
4. The time involved to complete some tasks
5. The available resources for help from other staff

Question 9 of 10
There are four patients in the emergency room with different concerns. The nurse knows that
which of the following abdominal symptoms is the most concerning and should be seen first?
1. Abdominal distension, no bowel movement for 5 days
2. RUQ abdominal pain
3. Abdominal swelling and ecchymosis
4. LLQ abdominal pain

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Question 10 of 10
The nurse has just clocked in to work on the medical-surgical floor and receives report on assigned
patients. Which of the following patients is the highest priority currently?
1. A 47-year-old patient who had a left lower lobe thoracotomy 2 days ago, reporting pain 8/10 and
is due for a pain medication
2. A 61-year-old patient who had a left below the knee amputation 5 days ago with a dose of 5000
units of subcutaneous heparin due now
3. A 92-year-old patient who had an ischemic stroke 2 days ago and won't wake up for breakfast
4. A 52-year-old patient who had a heart catheterization earlier today with a radial attempt. He has
an order for pulse checks every hour, with the last one completed 50 minutes ago

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Triage
Overview
1. Triage

1. What is triage?

2. Situations for triage

Nursing Points
General

1. What is triage?

a. Categorization system that establishes severity

b. Method of Prioritization

2. ESI Emergency Triage Algorithm

a. ESI is the algorithm used by emergency rooms to triage

i. Does the situation require a life-saving, immediate intervention?

ii. Is the situation high risk? Is the patient lethargic or confused? Is the

patient in severe distress or pain?

iii. Is the patient’s vital signs in a dangerous range?

iv. How many additional resources are needed?

1. If 1 or more additional resources are needed, it changes

the algorithm.

b. See the link attached to this lesson for more information

3. Situations

a. Emergency Department

i. Emergent

1. Needs immediate treatment

2. Right now

3. Ex: Trauma, Stroke, MI, Head injuries

ii. Urgent

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1. Needs to be seen in 1-2 hours

2. Ex: Fever, HTN, Fractures

iii. Non-Urgent

1. Can wait

2. Stable Patients

3. Ex: Sprains, minor injuries, cold/virus

b. Disasters

i. Survivable Injuries

1. Immediate threat of death

2. Stable Patients

ii. Non-Survivable Injuries

1. Dead on arrival or actively dying with non-survivable

injuries
Nursing Concepts

1. Prioritization

2. Clinical Judgment

Patient Education
1. Educate patients who are in the ER waiting room with stable illnesses or minor injuries that

there are other patients that have life-threatening emergencies

a. Be compassionate

b. Be patient

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STUDY TOOLS:

Reference: https://www.criticalcare.theclinics.com/article/S0749-0704(19)30048-X/fulltext

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Simple Triage and Rapid Treatment

Reference: https://canadiem.org/tiny-tips-start-protocol-for-mass-casualty-triage/

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QUIZ
Question 1 of 10
Four patients arrive to the emergency room at the same time. The nurse is triaging them and knows
that the patient with which of the following should be brought back to be evaluated by a provider
first?
1. Suicidal ideations, brought by a parent
2. Nausea, vomiting, and diarrhea for one day
3. Fever 102.9 F, received acetaminophen prior to arrival
4. A rattlesnake bite on the upper arm

Question 2 of 10
The nurse in the trauma bay is concerned that a patient is suffering from a stomach injury related
to a gun shot wound. Which of the following signs and symptoms is the nurse observing?
1. Right upper quadrant spasms and guarding
2. Pain in the epigastrium or upper left quadrant
3. A palpable abdominal mass
4. Pain in the left shoulder

Question 3 of 10
A nurse is working in a pediatric emergency room and has 4 patients that need assessment. The
nurse would be accurate in seeing which patient first?
1. Dehydration
2. Fever
3. Fussiness
4. Epiglottitis

Question 4 of 10
A patient is brought into the trauma bay after being stabbed in the abdomen with a 12-inch knife.
The blade is still present in the patient. The patient is complaining of severe abdominal pain and is
restless. After completing the initial survey, which of the following is the next thing the nurse
should do?
1. Stabilize the knife
2. Remove the knife
3. Insert a chest tube
4. Intubate the patient

Question 5 of 10
Right at shift change, four patients arrive to the emergency room and the nurse is putting them on
the board in order of priority. The patient with which of the following should be the first priority?
1. Cerebral palsy with a new pressure ulcer on their right buttocks
2. Coffee ground emesis, hematochezia, cap refill 4 seconds, BP 90/50
3. Shortness of breath, tachypnea, and tachycardia with an SpO2 of 97%
4. Recent cardiac catheterization with a 2cm hematoma over the right femoral artery

Question 6 of 10
After receiving report on four patients the emergency room nurse should see the patient with which
of the following diagnosis first?
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1. Chronic back pain 8/10

2. Liver failure and now has petechiae
3. Cellulitis that is now itchy
4. Ovarian cyst

Question 7 of 10
A nurse is floated to the emergency room to help. The charge nurse gives the float nurse a list of
patients that have not been seen. The patient with which of the following should be seen first?
1. A degloved right pinky finger
2. Chest pain and a history of heart attack
3. A sucking chest wound
4. Confusion and a temp of 101 F

Question 8 of 10
A nurse is working in the hospital emergency department when three patients enter the building at
the same time. Patient A, a person who was injured from a 4-foot fall and has a broken elbow.
Patient B, a patient who has suffered a head injury from a blow to the face and is bleeding from the
mouth and nose. Patient C, a patient with cancer who has a fever of 101F. The nurse must triage
these patients. In which order would the nurse place these patients, most urgent to least?
1. B, C, A
2. C, A, B
3. A, B, C
4. C, B, A

Question 9 of 10
A patient is brought to the trauma bay after being stabbed in the upper abdomen with a sword at a
costume event and is displaying signs and symptoms of a ruptured diaphragm. Which of the
following situations is a priority for the nurse to monitor?
1. Impaired gas exchange
2. Fluid volume deficit
3. Pain related to injury
4. Anxiety secondary to respiratory distress

Question 10 of 10
A nurse is working in triage during a mass casualty event that sent 50 patients to the emergency
room for care. According to the principles of triage, which of the following patient conditions is
correctly matched with its appropriate priority level? Select all that apply.
1. Priority 3: A patient with severe anxiety about the event
2. Priority 3: A patient with an arm fracture
3. Priority 1: A patient with a penetrating head wound who is unresponsive
4. Priority 1: A patient with a sucking chest wound
5. Priority 2: A patient with 2nd and 3rd degree burns on 30 percent of his body

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Overview of the Nursing Process

Overview
1. Nursing Process Overview

a. Way to provide care

b. ADPIE

c. Prioritization

d. Critical Thinking

e. Nursing Process – “Thinking Like a Nurse”

Nursing Points
General

1. Way to Provide Care

a. Modified Scientific Theory

b. Method to consistently provide care

2. ADPIE

a. Assessment

b. Diagnosis

c. Plan

d. Implementation

e. Evaluation

3. Prioritization

a. Gather data quickly to determine needs for a patient or patients

4. Critical Thinking

a. Recognizing problems

b. Gathering information

c. Evaluate possible solutions

d. Implement with best possible outcomes in mind

5. Nursing Process

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a. “Thinking Like A Nurse”

b. Culmination of ADPIE, Prioritization and Critical Thinking

c. Cyclical
Nursing Concepts

1. Professionalism

2. Clinical Judgment

STUDY TOOLS:
Nursing Process

Steps in the Nursing Process 1

ADPIE (A Delicious PIE)

• A-Assessment

• D-Diagnosis

• P-Planning

• I-Implementation

• E-Evaluation

These are the steps of the nursing process. Gather information, determine the problem and the
best approach. Implement your interventions, and then evaluate! Never skip a step!!
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Steps in the Nursing Process 2

AAPIE (An Apple PIE)

• A-Assessment

• A-Analysis

• P-Planning

• I-Implementation

• E-Evaluation

These are the steps of the nursing process. Gather information, determine the problem and the
best approach. Implement your interventions, and then evaluate! Never skip a step!!

Steps In the Nursing Process 3

SOAPIE

• S-Subjective

• O-Objective

• A-Assessment

• P-Planning

• I-Implementation

• E-Evaluation

A way to remember the steps to in the nursing process.

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QUIZ
Question 1 of 6
Which of the following is the best example of a nurse utilizing critical thinking and judgment when
making delegation decisions?
1. Checking with the patient to ensure the work was completed
2. Accepting additional activities requested by other departments
3. Clearly communicating what needs to be done
4. Watching to ensure that the delegate performed the job correctly

Question 2 of 6
A tornado has hit a small community and the staff at the hospital have lost power in the facility.
The nurses and other staff are working by flashlight. One of the nursing assistants becomes very
upset and tells a nurse, “I can’t handle this! I don’t know what to do!” Which of the following
responses by the nurse best reflects nursing leadership skills?
1. You should take a break. The patients can wait.
2. The shift is almost over. You can do it!
3. After I finish this task, is there something I can do for you?
4. Join the club, we are all struggling here!

Question 3 of 6
A nurse is caring for a patient who had a seizure in his room. Which of the following critical
thinking steps would the nurse utilize to respond to this situation? Select all that apply.
1. Assume that the situation needs to be reported
2. Understand what information is important and what is irrelevant
3. Identify if there is a problem
4. Evaluate the Patient’s response
5. Set priorities for the patient

Question 4 of 6
A nurse is preparing to give the first dose of an oral medication to a patient. Which answer best
describes how the nurse would utilize critical thinking when administering this drug?
1. The nurse checks with the pharmacy to verify that the drug is available
2. The nurse prepares the dose based on the information on the bottle
3. The nurse charts the administration of the prescribed drug
4. The nurse verifies patient allergies and whether the patient has ever taken the medication.

Question 5 of 6
A nurse is preparing to administer medication to a patient who is recovering from surgery. Which
of the following demonstrates that the nurse is using critical thinking skills when administering this
drug? Select all that apply.
1. The nurse knows how long it will take the medication to work
2. The nurse monitors physiological data, such as vital signs, when giving a drug
3. The nurse is not aware of side effects of the drug, but knows how to recognize that the drug is
working
4. The nurse evaluates the effectiveness of the drug after administering the dose

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5. The nurse familiarizes herself with other drugs that can interact with the medication

Question 6 of 6
A nurse is not sure if the provider should be contacted about a Patient’s condition. What elements
of the problem-solving method should the nurse consider that would help with this decision? Select
all that apply.
1. Formulating a plan about the best action to take for the problem
2. Creating a document that describes the situation
3. Analyzing potential choices the nurse could make
4. Making a decision to think about the problem
5. Assessing the situation to recognize a potential problem

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Therapeutic Communication
Overview
1. Therapeutic communication

a. Relationship

b. Communication

c. Patient needs

d. Response

Nursing Points
General

1. Connection

a. Build rapport

b. Be aware of own values

c. Remove biases

d. Common ground

2. Communication

a. Active listening

b. Rephrase

c. Clarify

d. Summarize

e. Empathize

3. Understanding patient needs

a. Venting and expression

b. Reaffirmation

c. Advice vs unsolicited advice

4. Response

a. To feelings

b. To words

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c. To expressions
Nursing Concepts

1. Communication

2. Professionalism

3. Interpersonal relationships
STUDY TOOLS:

Therapeutic Communication
These therapeutic communication techniques can be used with all patients to support them and provide
information in a way that is easily received.

Active Listening:
Really hearing what the patient is saying…
Demonstrate active listening by rephrasing, summarizing,
or paraphrasing what the patient is saying, or by asking for clarification.

“What I hear you saying is…”

“It sounds like you’re frustrated about…”
“...is that what you meant to say?”

Exploring:
Asking open-ended questions can help the patients to explore how they
feel and explore more about their experience.

“Tell me more about…”

“How did you feel when…”

Offering General Leads:

These encourage the patient to continue talking more about their concerns
without feeling the need to allow you to chime in.

“Yes…”
“Go on…”
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“I see…”

Giving Recognition:
Giving recognition is about acknowledging the patient’s efforts o
accomplishments, without overtly complimenting.

“I saw you walking in the hallway!”

“I noticed you took all your meds today!”

Using Silence:
Sometimes, it’s most beneficial to say nothing at all. It can give the patient a
chance to process and have space to discuss difficult topics.

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QUIZ:
Question 1 of 9
A 39-year-old patient is talking with a nurse about the Patient’s sexual relationship with a
committed partner. Which describes how the nurse should discuss an awkward topic with a
patient?
1. Bring another nurse or professional in for support when starting the conversation
2. State that it is normal to feel awkward discussing this topic
3. Ask the patient to watch a video and then see if questions arise
4. Provide brochures of information to have the patient read

Question 2 of 9
A nurse is performing an intake interview on a patient who has come to the hospital for abdominal
pain. Which action demonstrates that the nurse is actively listening during the patient interview?
1. The nurse waits to interrupt until after the patient has reached a pause in speaking
2. The nurse closes the doors and the blinds and dims the lights in the room
3. The nurse mentally prepares a response while the patient is talking
4. The nurse occasionally nods while the patient is talking

Question 3 of 9
A patient and her spouse are seen at the primary care clinic for assessment for infertility. The
patient becomes tearful as she tells the nurse that she has been trying to become pregnant for over a
year without success. The patient says, “I do not think I could handle it if I knew I could never start
a family.” Which intervention by the nurse best demonstrates therapeutic communication to assist
the patient with coping with her situation?
1. I know it is difficult, but if it is meant to be, it will happen
2. Is there something you are doing that you think might be keeping you from getting pregnant?
3. Keep repeating to yourself that you can get pregnant and use your positive energy to cope
4. Have you had other struggles that you were able to successfully cope with in the past?

Question 4 of 9
While talking to a patient about how she lost her job, the nurse utilizes clarifying techniques as
therapeutic communication. Which of the following are examples of clarifying during the
conversation? Select all that apply.
1. What would you say is most important about this?
2. Are you saying you do not regret this?
3. Would you like to sit or stand while you talk?
4. Do you have a plan for the future?
5. Do you have to use the restroom?

Question 5 of 9
A nurse is caring for a patient who is experiencing severe stress associated with her family. The
nurse knows that which form of non-verbal communication would most likely indicate interest in
what the patient is trying to say?
1. Giving the patient space
2. Steepling the fingers
3. Leaning back in the chair
4. Providing eye contact
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Question 6 of 9
Which of the following is a true statement regarding communication between the nurse and the
patient?
1. Environmental factors that affect communication include the emotions and knowledge level of
the nurse
2. Communication is 90 percent verbal and 10 percent non-verbal
3. Communication is affected by personal and social factors but is usually unrelated to ethnic
background
4. Social factors that impact communication include health beliefs and practices of the patient

Question 7 of 9
Which is an example of a qualitative open-ended question that the nurse may use in therapeutic
communication with the patient?
1. How are you feeling about your job?
2. So you are saying that you want to try to visit your sister again
3. Are you sure that you do not want to talk about this?
4. Can you tell me what voices you are hearing?

Question 8 of 9
A patient with lung cancer tells the nurse about how difficult it has been to go through cancer
treatment. Which response from the nurse best demonstrates therapeutic communication?
1. Why do you believe it is so difficult to undergo treatment for your condition?
2. Tell me more about what has been difficult with treatment
3. You seem upset about your diagnosis
4. Don't worry, everything will be okay

Question 9 of 9
A nurse is preparing to discharge a patient with bronchitis to home from the hospital. The nurse
has the patient demonstrate that he understands how to use his inhaler appropriately. After
successfully demonstrating use of the inhaler, the nurse says, “You seem pretty confident about
using that inhaler.” This is an example of which type of therapeutic communication?
1. Offering hope
2. Active listening
3. Making observations
4. Giving recognition

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Defense Mechanisms
Overview
1. Defense Mechanisms

1. Recognizing defense mechanisms

2. Types of defense mechanisms

3. What you can do as the nurse

Nursing Points
General

1. Recognizing defense mechanisms

a. Response to anxiety

b. Way to cope

c. Defense mechanisms are a manifestation of anxiety

2. Types

a. Unhealthy

i. Denial

1. Refusal to accept reality

ii. Regression

1. Reverting back to an earlier stage of childhood

iii. Projection

1. Misattributing feelings of anxiety

b. Moderate

i. Displacement

1. Redirecting anxiety to others

ii. Intellectualization

1. Overthinking when confronted with anxiety

iii. Undoing

1. An attempt to take back behavior or thought

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c. Healthy

i. Sublimation

1. Channeling inappropriate responses into more

appropriate actions

ii. Anticipation

1. Planning for future discomfort

iii. Suppression

1. Using tools to set aside feelings of anxiety to a more

appropriate time
Assessment

1. Recognize and identify

a. Recognize defense mechanism

i. Acknowledge that a rejection of reality may be a sign of anxiety

ii. Ask questions regarding anxiety

iii. Health history

b. Utilize nursing process

i. Physical manifestation of anxiety

1. Elevated HR or BP

ii. Investigate for causes of anxiety through communication

Therapeutic Management

1. The nurse’s role

a. Recognize the anxiety

b. Communicate

i. Focus on the cause

ii. Ask questions

iii. Don’t blame or accuse

c. Use therapeutic communication

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Nursing Concepts

1. Communication

2. Professionalism

3. Interpersonal relationships

Patient Education
1. Provide patient with education regarding anxiety

2. Identify needs for resources for anxiety such as specialized health care providers

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QUIZ
Question 1 of 10
The nurse is caring for a 90-year-old patient with a potential fracture of the radius. The patient was
brought in by the caregiver, is wearing a brief that is soiled with urine and feces, and there is a
pattern of multiple finger-sized bruises on the Patient’s body. Which of the following are
appropriate actions by the nurse? Select all that apply.
1. Report incident to the state
2. Discharge the patient home after a negative X-ray
3. Facilitate a patient bath
4. Provide a safe environment
5. Document that the patient has been falling at home

Question 2 of 10
A patient who delivered a baby 6 weeks ago is a victim of intimate partner violence. Which of the
following psychological conditions is also associated with victims of domestic abuse?
1. Depressive disorder
2. Schizoaffective disorder
3. Obsessive-compulsive disorder
4. Antisocial personality disorder

Question 3 of 10
Explain the difference between environmental and individual risk factors in a perpetrator of sexual
abuse.
1. Environmental factors are associated with violence while individual factors are associated with
mental illness
2. Environmental factors cannot be controlled while individual factors can be modified
3. Environmental factors are those surrounding factors that contribute to abuse while individual
factors are within the perpetrator
4. Environmental factors contribute to the abuse while individual factors tend to prevent the abuse

Question 4 of 10
A 6-year-old child has been brought in for care and treatment after suffering from physical abuse
by her father. The child is experiencing a post-traumatic fight-or-flight response. Which signs or
symptoms would the nurse most likely expect to initially see in this patient?
1. Stuttering and refusal to respond to caregivers
2. Crying and screaming
3. Dissociation
4. Somnolence

Question 5 of 10
While assessing a child who has unusual injuries, a nurse suspects that abuse or violence is going on
in the child’s home. Which of the following would be part of gathering forensic evidence for this
case?
1. Asking the child if someone is hurting her
2. Obtaining consent for photographs
3. Providing pain medication for injuries incurred
4. Identifying the abuse and reporting it to child protective services
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Question 6 of 10
A 3-year-old patient is being seen in the healthcare clinic for a fractured arm. The nurse suspects
that the child is being neglected. Which of the following signs indicates potential child neglect?
Select all that apply.
1. The child is dehydrated or malnourished
2. The child has more than one injury
3. The child has an injury in a hidden area
4. The child does not have a coat on a day in which the temperature is below freezing
5. The child has a wound that was never treated

Question 7 of 10
A nurse is caring for a patient who has been physically abused and threatened by her partner.
Which of the following describes what the patient would most likely experience during the tension-
building phase of the relationship?
1. Loving and apologetic behavior
2. A feeling that the abuser will soon abuse the victim
3. Angry and explosive responses
4. Hitting, kicking, and battering of the victim

Question 8 of 10
A nurse is caring for a 36-year-old patient who has been hit on the head. During the initial
assessment, the nurse suspects that the patient is a victim of domestic violence. Which question
should be included as part of the screening for domestic violence in this situation?
1. Do you live with someone who has a history of mental illness?
2. How are you and your partner relating?
3. Do you lock your doors at night?
4. What could you have done to avoid this situation?

Question 9 of 10
A school nurse suspects a 12-year-old student is a victim of child abuse. The nurse contacts child
protective services and then the police. Following the incident, the child’s parent approaches the
nurse and says, “Why did you call child protective services? Now I’ll be suspended from my job!”
Which response from the nurse is most appropriate?
1. You are responsible for your job, and I am responsible to report suspected violence in my job
2. I am not allowed to talk about this situation with you since I am the reporter and you are the
perpetrator
3. You should have considered that before hitting your child
4. I'm sorry if this will hurt your job. I hope you will continue to bring your child to this school

Question 10 of 10
A nurse is caring for a patient who may be in a domestic violence situation. What actions can the
nurse perform that would uphold this Patient’s privacy? Select all that apply.
1. Avoiding contact with authorities to disclose the information
2. Filing an incident report about the patient instead of contacting hospital administration
3. Placing the patient in a private room and keeping the door closed
4. Not calling the Patient’s spouse to notify of the Patient’s suspected situation
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5. Only giving updates to the attending provider and those directly involved with the Patient’s care

Abuse
Overview
1. Abuse

a. Reasons for abuse

b. Types of abuse

c. Nursing Role

Nursing Points
General

1. Abuse

a. Violence or cruelty inflicted on someone

b. Means

i. Physical

ii. Mental

iii. Verbal

iv. Emotional

v. Extortion & financial abuse

vi. Neglect

c. Result of power or control

d. Affects all ages and genders

e. Some cultures don’t consider abuse actual abuse

i. I.e. corporal punishment

2. Types

a. Elder

b. Child

c. Sexual

d. Domestic Violence
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e. Patient-Nurse

f. Mental & verbal

Assessment

1. Role

a. Assessment is imperative

i. Pay attention to chief complaints

1. Observe for injuries consistent with abuse

ii. Be objective and remove bias

iii. Observe body language

iv. Observe interactions

b. Mandatory reporting

i. Nurses are required to report abuse

1. Follow chain of command

2. Follow policy

c. Build trust

i. Suspend opinion

1. Don’t assume your patient is abused – investigate to

confirm

ii. Use therapeutic communication

iii. Don’t directly ask about abuse

1. Patient’s will shut down

d. Provide resources

i. Chaplain

ii. Mental health

iii. Women’s/Children’s/Geriatric services

Nursing Concepts

1. Safety

2. Communication

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3. Patient-Centered Care

4. Ethical & Legal Practice

Patient Education
1. Educate patients on misinformation regarding abuse

2. Provide resources and educate patient on available resources for them

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Overview of Developmental Theories

Overview
1. Overview of Developmental Theories

1. Overview

2. Piaget

3. Kohlberg

4. Erikson

Nursing Points
General

1. Overview

1. Why you need to know about development

1. Expected patterns of patients

2. Developmental theories include:

1. Morality

2. Psychosocial development

3. Cognitive ideals

3. Complex

4. Remove self from situation to understand patient view

2. Piaget

1. Cognitive development

2. Cover 4 periods

3. Kohlberg

1. Moral development

2. Expanded on Piaget

3. 3 levels with 6 stages

4. Erikson

1. 8 stages of development

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2. Must master a stage before moving on to the next stage

Nursing Concepts
1. Human Development

2. Cognition

3. Health Promotion
STUDY TOOLS:
Theories of Development

QUIZ
Question 1 of 5
Health and development issues commonly experienced by a school-aged child include which of the
following? Select all that apply.
1. Difficulty with verbalization of needs
2. Difficulty with ambulation
3. Difficulty with safety
4. Enuresis
5. Feelings of inadequacy

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Question 2 of 5
The infant is sitting alone using her arms for support. At what age is this child at this stage of motor
development?
1. 3 months
2. 12 months
3. 4 months
4. 7 months

Question 3 of 5
What is an important developmental activity in a school-age child?
1. Learning to cook
2. Learning to drive
3. The ability to be independent in toileting
4. Finding significance in peer groups

Question 4 of 5
The nurse is assessing an adolescent in the clinic. For which of the following areas are the
adolescent years most critical?
1. Learning disability issues
2. Body image issues
3. Toileting issues
4. Athletic performance issues

Question 5 of 5
A nurse is preparing to educate a school-aged child and her parents. The psychosocial development
of this child’s age group includes which of the following components?
1. Teaching the child to use parents as role models for behavior
2. Teaching the child ambulation skills
3. Developing a bowel and bladder program
4. Teaching the child good nutrition

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Positioning
Overview
1. Positioning

a. Reasons for positioning

b. Common types

c. Other types

Nursing Points
General

1. Reasons for positioning

a. Identify Needs

b. Response to a need

c. Think “form and function”

2. Common Types

a. Fowlers

i. Elevation of the head of bed

1. Degree dependent on the problem or complaint

2. Higher degree indicates better thoracic expansion

3. Decreases likelihood of aspiration

ii. Low Fowler’s

1. 15°-30°

iii. Semi-Fowler’s

1. 30°-45°

iv. Fowler’s

1. 45°-60°

2. Most common position

v. High Fowler’s

1. 60°-90°

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2. Promotes best chest expansion

b. Flat types

i. Supine

1. Face up

2. Most common

ii. Prone

1. Face down

2. Used commonly in surgery

3. Also used with specialty beds like the Roto-Prone for

respiratory disease

iii. Flat

1. Used for spinal precautions

iv. Trendelenburg

v. Trendelenburg

1. Used for certain procedures

vi. Reverse Trendelenburg

1. Used to promote gastric emptying

3. Others

a. Sims position

i. Used for pregnant patients or ideal for suppository administration

b. Dorsal recumbent

i. Lying flat, but with arms overhead

ii. Used most commonly for abdominal exams

c. Lithotomy

i. Used in pelvic exams

ii. More commonly used by providers, but still used by nurses for

dilation exams

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Assessment

1. Needs of patient may change ordered position.

a. Use nursing judgment

b. Promote prioritization

c. Discern patient’s primary ABC needs in patient positioning

i. Don’t sacrifice airway because of an order

2. Take heed of any cervical or spinal precautions

3. Assess patient’s pain and comfort needs

a. Consider this when using interventions like traction

Therapeutic Management

1. All positioning can be implemented unless there is a strict order

2. Use additional resources such as UAPs or other RNs to properly position a patient

3. Promote airways, breathing, circulation priority

a. Consider aspiration risks

Nursing Concepts

1. Safety

2. Patient-Centered Care

3. Comfort

4. Clinical Judgment

Patient Education
1. Educate patient on need for turning to offset pressure if capable

2. Explain to patient that certain positions are needed

3. Walk through with your patient the different maneuvers for patient positioning

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STUDY TOOLS:

POSITION
High-Fowler’s
WHAT
HOB 60-90° with the patient sitting up in bed. Knees can be bent or straight.
WHEN
Used during episodes of respiratory distress, when inserting a nasogastric tube, and during oral intake
with feeding/aspiration precautions
NURSING CONSIDERATIONS
This may be uncomfortable to maintain for an extended period. A patient may slump over if they lack the
strength to stay sitting upright. Repositioned every 2 hours to prevent skin breakdown. High-Fowler's
places quite a bit of pressure on the coccyx. May need to -oat heels to prevent pressure injury.

POSITION
Fowler’s
WHAT
HOB 45-60° with the patient sitting up in bed. Patient lying on their back in bed, with HOB reclined
WHEN
Facilitates chest expansion - it is helpful with patients who are having difficulty breathing. Used during
tube feeding administration because it facilitates peristalsis while minimizing aspiration risk. Used in
postpartum period to facilitate excretion of lochia. Simply a comfortable position.
NURSING CONSIDERATIONS
Minimal concerns. May need to -oat heels to prevent pressure injury. Knees can be bent or straight, may
be called Standard Fowler's.

POSITION
Semi-Fowler’s
WHAT
HOB flat, patient on back

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WHEN
Post cardiac catheterization procedures to maintain hemostasis at insertion site, frequent position for
many surgeries in the post-op phase
NURSING CONSIDERATIONS
Many pressure points (including the top of toes from the sheet,) therefore you must be diligent in turning
patient. May be uncomfortable to maintain. Increases apnea in OSA. Avoid after 1st trimester of
pregnancy due to the added pressure on vena cava and subsequent hypotension.

POSITION
Prone
WHAT
HOB flat, patient on stomach with head to one side
WHEN
Not used frequently; use as a therapeutic measure in advanced ARDS, during and after some surgeries
NURSING CONSIDERATIONS
Not comfortable for long, dicult for full respiratory expansion, not easy to put a patient into this position
(especially if they have multiple lines and tubes)

POSITION
Trendelenburg
WHAT
Flat on back, feet raised higher than head by 15-30°
WHEN
During CVC (subclavian or IJ) placement, if an air embolism is suspected as it traps air in the right
ventricle. Can convert supraventricular tachycardia with a valsalva maneuver. Used to increase perfusion.
Not ideal with increased ICP. Uncomfortable.
NURSING CONSIDERATIONS
Frequently used by nurses during instances of hypotension, however evidence does not support this
practice. Current recommendations are to use a passive leg raise to give a small bolus to the patient from
their own circulation in legs.
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POSITION
Reverse Trendelenburg
WHAT
Flat on back, head raised higher than feet by 15-30°
WHEN
For some surgeries or procedures, pre-surgery intervention for some vascular surgeries, may be used to
facilitate respirations in patients who need to lay -at post-procedure, reduces GERD symptoms
NURSING CONSIDERATIONS
Somewhat uncomfortable, if patients are confused it might be difficult to maintain them safely in this
position for long periods

POSITION
Dorsal Recumbent
WHAT
Flat on back, knees bent, rotated outwards, feet -at on the bed (head/shoulders typically on a pillow)
WHEN
During or after various surgeries, for comfort
NURSING CONSIDERATIONS
Minimal concerns. This is a common position of comfort for many patients.

POSITION
Lateral
WHAT
On side, top knee and arm flexed and supported by pillows

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WHEN
Relieves pressure on sacrum, great for patients who are immobile as it is typically quite comfortable and
provides good spine alignment, supporting and off-loading common pressure points
NURSING CONSIDERATIONS
Minimal concerns. May specify a side, "place the patient in left lateral position"

POSITION
Sim’s
WHAT
Halfway between lateral and prone
WHEN
Occasionally used with unconscious patients as it facilitates drainage of oral secretions, pregnancy, during
enemas, for patients who are paralyzed as it takes pressure of of the hip and sacrum
NURSING CONSIDERATIONS
Must remember to turn patient on schedule

POSITION
Orthopneic
WHAT
Sitting at the side of the bed, leaning over a table
WHEN
Facilitates respiratory expansion, makes it easier to breathe in patients with respiratory difficulty, and
used during a thoracentesis
NURSING CONSIDERATIONS
Ensure patient can safely sit back in bed; don't leave unattended if a fall risk and sitting at the side of the
bed.

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QUIZ
Question 1 of 8
The nurse is caring for a patient who is being hospitalized for illness. The nurse is repositioning the
patient into the Trendelenburg position. This position is best used for a patient with which
condition?
1. Dyspnea from pneumonia
2. Bed rest and immobility
3. Postural drainage in cystic fibrosis
4. Heart failure with jugular venous distention

Question 2 of 8
A patient just returned from the OR after a gastrectomy. What position would be most appropriate
for the patient after this particular surgery?
1. Prone
2. High Fowler's
3. Dorsal recumbent
4. Semi-Fowler's

Question 3 of 8
A nurse is caring for a patient that is healing from an Achilles tendon surgery. While practicing
active range of motion with the patient, the nurse notes that the patient is still unable to point the
toes up toward the ceiling. The nurse should chart this as the patient being unable to do which of
the following?
1. Pronation
2. Supination
3. Plantar flexion
4. Dorsiflexion

Question 4 of 8
A nurse has positioned a patient in the high Fowler’s position for an intervention. For which
intervention is this position useful? Select all that apply.
1. Administering a breathing treatment
2. Reducing gastroesophageal reflux
3. Feeding the patient
4. Minimizing abdominal pain
5. Promoting venous return

Question 5 of 8
A nurse is positioning a patient on the table in the operating suite while preparing him for surgery.
Which of the following principles would the nurse follow when properly positioning this patient?
Select all that apply.
1. Maintaining proper body alignment for the patient
2. Ensuring anesthesia has proper access to the patient
3. Preserving the Patient’s dignity until anesthetized
4. Keeping the Patient’s legs crossed to promote circulation
5. Not allowing any part of the Patient’s body to extend past the edges of the bed
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Question 6 of 8
The nurse is caring for a patient who has just had a bronchoscopy. In which of the following
positions should the nurse position this patient?
1. Head of bed 30 degrees
2. Supine
3. Prone
4. High-Fowler's

Question 7 of 8
A patient who underwent neurosurgery must remain prone in bed for the next 24 hours. Which of
the following principles should the nurse adhere to when positioning this patient in bed? Select all
that apply.
1. Keep the ankles at a 90-degree angle
2. Abduct the arms and position externally rotated at the shoulder joint
3. Turn the Patient’s head to the side
4. Place a rolled towel under the shoulder to relieve pressure on the Patient’s chest
5. Maintain the feet and lower legs in a position that is lower than the upper portion of the body

Question 8 of 8
A nurse is caring for a 35-year-old patient who has been diagnosed with hypovolemic shock as a
result of severe hemorrhage. In which position should the nurse place this patient to promote
optimal circulation?
1. Left side-lying with the head flat
2. Trendelenburg
3. Supine with the legs elevated
4. In the Sims' position

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Complications of Immobility
Overview
1. Complications of Immobility

a. Psychologic

b. Cardiovascular

c. Pulmonary

d. Gastrointestinal and renal

e. Musculoskeletal and skin

Nursing Points
General

1. Psychologic

a. Frustration

b. Anxiety and depression

c. Delirium

i. Increases length of stay

ii. Decreases compliance

2. Cardiovascular

a. Coagulopathies

i. Blood pooling

ii. Increased risk of deep vein thrombosis

1. Increased risk of pulmonary embolism

b. Edema

c. Changes in blood pressure

i. Orthostatic hypotension

3. Pulmonary

a. Decreased gas exchange

i. Due to decreased thoracic expansion

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ii. Increased risk of pneumonia

b. Weakened cough

i. Inability to clear secretions

4. Renal and gastrointestinal

a. Urinary

i. Urinary stasis

1. Increased risk of UTI

ii. Risk of urinary incontinence

1. Due to positioning

b. Gastrointestinal

i. Risk of aspiration

ii. Malnutrition

iii. Difficulty with bowel movements

1. Mobility increases peristalsis

5. Musculoskeletal & skin

a. Musculoskeletal

i. Atrophy

ii. Foot drop

iii. Decreased strength

b. Skin

i. Pressure and poor oxygenation

1. Skin breakdown

ii. Friction and shearing

1. Increases abrasions, skin injuries

1. Infections

2. Pain
Assessment

1. Psychologic

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a. Complete neurologic assessments as ordered

b. Observe for changes in mentation or alertness

c. Observe for signs of delirium or withdrawn affect

2. Cardiovascular

a. Observe for changes in blood pressure, and orthostatic hypotension

b. Assess for new leg pain or difficulty breathing

3. Pulmonary

a. Assess lung sounds for adventitious sounds

b. Watch for any changes in cough, secretions or sputum

c. Like cardiovascular, watch for changes in breathing

i. Breathing difficulty and a feeling of “impending doom” could be

pulmonary embolism

4. Renal and gastrointestinal

a. Complete ins and outs to verify fluid and nutrition status

b. Ensure regularity of bowel movements

5. Musculoskeletal and skin

a. Assess range of motion and strengths daily

b. Check over bony prominences for skin breakdown

Therapeutic Management

1. Promoting mobility

a. Increases strength, cardiovascular functioning, respiratory strength

2. Turn patient or assist in turning patient to reduce skin breakdown

3. Use orthotics to prevent foot drop

4. Work with physical therapy and occupational therapy to assess and promote mobility

5. Work with registered dieticians to promote optimal nutrition

Nursing Concepts

1. Patient-Centered Care

2. Safety

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3. Mobility

4. Health Promotion

Patient Education
1. Encourage patient to participate in their own care by promoting education

2. Educate patient on different types of mobility exercises

3. Reinforce teachings from other disciplines such as PT & OT, speech therapy and respiratory

therapy

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STUDY TOOLS:
Pressure Ulcer Staging

QUIZ
Question 1 of 10
An immobile patient has developed a pressure ulcer on his ankle from lying in the same position for
too long. Which nursing intervention would be most appropriate in this situation?
1. Implement a positioning schedule to turn the patient every 4 hours
2. Elevate the extremity to keep the ankle off of the bed
3. Increase the Patient’s level of activity to promote circulation
4. Check the Patient’s skin for signs of incontinence

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Question 2 of 10
A nurse is caring for a patient who had knee surgery and is morbidly obese. The patient has
difficulties with mobility and needs two-person assistance when getting out of bed. Which of the
following best describes appropriately education about preventing skin breakdown?
1. Educating the patient that increased adipose tissue results in an increased risk for skin breakdown
at bony prominence sites
2. Teaching the patient that increased pressure on certain body areas can cause poor circulation and
skin breakdown
3. Teaching the patient that because of his immobility, skin breakdown cannot be prevented but can
be treated
4. Telling the patient to closely monitor the area behind the knee for skin breakdown after knee
surgery

Question 3 of 10
An immobile patient has developed an area of skin breakdown on the hip. The nurse recognizes
that there are several factors that potentially contributed to this skin breakdown. Select all of the
following extrinsic factors that would have contributed to skin breakdown in a patient.
1. Shear
2. Friction
3. Tissue perfusion
4. Moisture
5. Nutrition

Question 4 of 10
A nurse is caring for a patient with reduced mobility following hip surgery the day before. Which
best describes how the nurse would help prevent skin breakdown from immobility?
1. Turn and reposition the patient every 4 hours
2. Use padding and pillows under the heels and other bony prominences
3. Massage bony prominences with emollient cream after giving the patient a bath
4. Help maintain skin integrity by teaching the patient how to move up in bed

Question 5 of 10
A nurse is preparing to apply sequential compression devices to her patient who has just returned
from surgery. The nurse performs an assessment prior to applying the devices. Which of the
following is a component of using sequential compression devices (SCDs)? Select all that apply.
1. SCDs are one size fits all
2. The nurse can initiate the order for SCDs
3. Most SCDs are knee length unless thigh-length devices are ordered
4. SCDs should not be used in patients who have deep vein thromboses

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5. The nurse should periodically assess the Patient’s circulation, pain, and edema when SCDs are in
place
Question 6 of 10
A nurse is caring for a patient who has a pressure ulcer on the sacrum from immobility. The nurse
ensures that the patient is turned frequently while in bed. Which of the following would most likely
demonstrate that the patient is responding to this intervention?
1. The patient does not develop infection in the wound bed
2. The patient does not complain of pain from the wound
3. The pressure ulcer heals at a much faster rate
4. The patient does not develop any other pressure ulcers
Question 7 of 10
A 45-year-old patient has been diagnosed with amyotrophic lateral sclerosis (ALS) and is unable to
get out of bed. Which of the following nursing interventions are appropriate to prevent
complications of immobility in this patient? Select all that apply.
1. Decrease patient intake of magnesium
2. Encourage the patient to stay home and rest
3. Support proper body alignment
4. Help the patient to continue with activity as long as possible
5. Encourage adequate fluid intake
Question 8 of 10
A nurse is assisting a bedridden patient with moving up in bed and repositioning. Which of the
following interventions would most likely prevent friction against this Patient’s skin while
transferring? Select all that apply.
1. Ensure the patient receives adequate hydration and nutrition
2. Apply a barrier dressing over high-risk areas
3. Avoid dragging a patient across the bed when moving
4. Use a slide sheet while moving the patient
5. Raise the head of the Patient’s bed before repositioning
Question 9 of 10
A bedridden patient requires cradle boots bilaterally to prevent foot drop while in bed. Which of
the following describes how to apply cradle boots? Select all that apply.
1. Ensure that the patient wears a pressure dressing around the ankle before applying the boot
2. Maintain the foot in the flexed position
3. Place the foot into the bottom portion of the boot
4. Apply the boots only when the patient is lying prone
5. Secure the boot snugly around the foot

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Question 10 of 10
A nurse is using the Banner Mobility Assessment Tool (BMAT) to determine a Patient’s level of
mobility while in the long-term care center. Which of the following is an element of assessment
during this portion of the exam? Select all that apply.
1. Ask the patient to stretch the leg forward to straighten the knee
2. Ask the patient to point and flex the foot
3. Ask the patient to stand at the bedside and turn in a circle
4. Ask the patient to reach down and try to touch his toes
5. Ask the patient to reach across midline to shake a hand

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Urinary Elimination
Overview
1. Urinary Elimination

a. Nursing care priorities

b. External aids

c. Internal aids

d. Surgical interventions

Nursing Points
General

1. Nursing care priorities

a. Dignity

i. Provide comfort

ii. Provide privacy

b. Safety

i. Reduction of infection

ii. Skin care

c. Measure output

i. Measure every device

d. Urine output output

i. Check for consistent urine output

ii. Some drugs can change the color of urine

iii. Address concerns with providers as necessary and promptly

2. External aids

a. Bedside toilet

i. Use for ambulatory patients

ii. Check for safety

1. Reduce fall risk

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b. Urinals

i. For difficult mobility

ii. Available for male and female

c. Bedpan

i. Available for female patients to urinate

ii. Use fracture pans for ortho patients

d. Condom cath

i. When to use

ii. Orders are sometimes necessary

iii. Check for skin integrity and seal

3. Internal aids

a. Foley (indwelling urinary catheter)

i. Coudé

1. Male insertion with prostate problems

ii. 3-way Foley

1. Use for continuous bladder irrigation

iii. Use sterile technique for insertion and catheter care

iv. CAUTI (Catheter Associated Urinary Tract Infection

1. Perform Cath care regularly

2. Remove as soon as possible

b. In-and-Out Catheter

i. Single pass to insert and drain bladder

ii. Provider order necessary

iii. Use same care for in-and-out as Foley

4. Surgical interventions

a. Suprapubic catheter

i. Used when voiding can’t occur below the level of the bladder

1. Ex: urethral injury

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ii. Sometimes can leak

1. Check skin integrity

b. Nephrostomy tube

i. Used when voiding can’t occur below the level of the kidney

1. Typically inserted in the back

c. Ileal conduit

i. Used when removal of the bladder is necessary

ii. Creates stoma

1. Provide stoma care

2. Monitor similar to Foley

Assessment

1. Assess for patient knowledge regarding elimination aids

2. Assess output based on the type of device used

3. Check skin integrity frequently

4. Determine if device is still necessary

Nursing Concepts

1. Elimination

2. Safety

3. Functional Ability

4. Comfort

Patient Education
1. Educate patient on the type of device necessary for care

2. Educate patient on need to notify the nurse for elimination needs

a. Provide call light, and educate patient on use

b. Observe patient using call light appropriately

3. Educate patient on long term use of devices such, as ostomies.

a. Provide teaching for ostomy and stoma management

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b. Utilize teaching methods such as the teach back in reducing the probability of

complication

STUDY TOOLS:
Promotion and Evaluation of Normal Elimination
POOPER SCOOP

• Promotion:

• P-Position

• O-Output

• O-Offer Fluids

• P-Privacy

• E-Exercise

• R-Report Results

• Evaluation:

• S-Size (Amount)

• C-Consistency

• O-Occult Blood

• O-Odor

• P-Peristalsis

Use the mnemonic POOPER to remember things that will promote normal bowel function, and
SCOOP to remember what to evaluate about a patient's bowel movement.

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Elimination Aids

Urinals
For difficult mobility, available
for male and female
Bedpan
Available for female patients to urinate,
use fracture pans for orthopedic patients

Foley Catheter
Indwelling urinary catheter used for urinary retention or urinary diversion Perform catheter care regularly;
remove as soon as possible.

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Other Urinary Elimination Aids:

Coudé - Male insertion with prostate problems
3-way Foley - Use for continuous bladder irrigation
In-and-Out Catheter - Single pass to insert and drain bladder
Use sterile technique for insertion and catheter care to avoid CAUTIs
(Catheter Associated Urinary Tract Infections)

Elimination device – suprapubic catheter

Elimination device – condom catheter

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Elimination device – Urinary catheters

Diagram of indwelling Foley catheter types, used for a variety of reasons based on the needs of the patient."> M•Komorniczak -talk- (polish
Wikipedist)Illustration by : Michał KomorniczakThis file has been released into the Creative Commons 3.0. Attribution-ShareAlike (CC
BY-SA 3.0)If you use on your website or in your publication my images (either original or modified), you are requested to give me
details: Michał Komorniczak (Poland) or Michal Komorniczak (Poland).For more information, write to my e-mail address:
[email protected] [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], from Wikimedia Commons

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Elimination device – Foley

Diagram of an indwelling Foley catheter, used for urine elimination."> Olek Remesz (wiki-pl: Orem, commons: Orem) [CC BY-SA 3.0
(https://creativecommons.org/licenses/by-sa/3.0)], from Wikimedia Commons

QUIZ
Question 1 of 8
A nurse is assessing a patient that arrived to the emergency department after being hit in the
abdomen with a bat. The nurse knows that which of the following organs are most likely to sustain
a rupture?
1. Pancreas
2. Kidney
3. Bladder
4. Liver

Question 2 of 8
Which of the following changes in elimination would most likely occur in a patient who is unable to
get out of bed and is immobile? Select all that apply.
1. Positive nitrogen balance
2. Urinary tract infections
3. Increased risk of kidney stones
4. Urinary stasis
5. Diarrhea

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Question 3 of 8
A patient has been diagnosed with stress incontinence and has frequent episodes of leaking urine.
Which of the following nursing interventions are most appropriate in this situation? Select all that
apply.
1. Collect a urine sample to test for infection
2. Help the patient to use an anti-incontinence device
3. Examine the patient for signs of pelvic muscle weakness
4. Teach the patient how to perform intermittent catheterization
5. Teach the patient to perform Kegel exercises

Question 4 of 8
A patient has urinary incontinence diagnosed because of instability of the detrusor muscle. Which
of the following describes a form of management of this type of incontinence? Select all that apply.
1. Self-catheterization
2. Avoiding caffeine
3. Anticholinergic drugs
4. Bladder training
5. Cranberry juice

Question 5 of 8
A patient in a long-term care facility is having elimination problems and suffers from incontinence.
Which nursing intervention would most likely help to prevent skin breakdown in this patient?
1. Providing privacy when the patient must use the bathroom
2. Inserting a urinary catheter
3. Applying emollient to the skin after the Patient’s bath
4. Assisting the patient to use the bedpan every eight hours

Question 6 of 8
A nurse is performing a continuous bladder irrigation on a patient. The bag from the pharmacy
contained 650 mL of fluid. The order is for 30 mLs every hour. The nurse notes that 2 hours ago,
the bag had 200 mLs in it. What is the total amount of fluid that has been irrigated?
1. 200 mLs
2. 60 mLs
3. 510 mLs
4. 390 mLs

Question 7 of 8

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A nurse is performing continuous bladder irrigation on a patient. The bag from the pharmacy
contained 400 mLs of fluid. The order is for 20 mLs every hour. The nurse notes that 4 hours ago,
the bag had 200 mLs in it. What is the total amount of fluid that has been irrigated?
1. 280 mLs
2. 80 mLs
3. 120 mLs
4. 200 mLs

Question 8 of 8
A 67-year-old patient has been given a nursing diagnosis of Altered Patterns of Urinary
Elimination related to stress incontinence. Which of the following most accurately explains this
condition?
1. The patient has no control over the passage of urine
2. The patient loses urine with increased abdominal pressure
3. The patient loses urine when the bladder reaches a particular state of fullness
4. The patient loses urine after experiencing a strong need to void

Bowel Elimination
Overview
1. Elimination

a. Nursing care priorities

b. External aids

c. Internal aids

d. Surgical interventions

Nursing Points
General

1. Nursing care priorities

a. Dignity

i. Provide comfort

ii. Provide privacy

b. Safety

i. Reduction of infection

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ii. Skin care

c. Measure output

i. Measure every device

d. Fecal output

i. Check for consistent bowel output

ii. Address concerns with providers as necessary and promptly

iii. Use stool softeners and laxatives appropriately

2. External aids

a. Bedside toilet

i. Use for ambulatory patients

ii. Check for safety

1. Reduce fall risk

b. Bedpan

i. Ideal for patients who have reduced mobility

ii. Use fracture pans for ortho patients

3. Internal aids

a. Fecal containment device

i. Device for fecal incontinence

1. Must be liquid stool

2. Use for concern for skin integrity

3. Ensure appropriateness

a. Cannot be used for certain bowel surgery

patients

4. Use if concern for C. diff

5. Device names

a. Flexi-seal

b. Malecott

4. Surgical interventions

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a. Ostomies

i. Used at varying areas of bowel

1. Dependent on area of illness or injury

ii. Provide stoma care

iii. Stool will look different depending on the level of stoma

1. Ileostomy

a. Yellow liquid

2. Colostomy

a. Loose to firm stool

b. Appears similar to normal color, especially

the closer to the rectum to the ostomy is

placed.
Assessment

1. Assess for patient knowledge regarding elimination aids

2. Assess output based on the type of device used

3. Check skin integrity frequently

4. Determine if device is still necessary

Nursing Concepts

1. Elimination

2. Safety

3. Functional Ability

4. Comfort

Patient Education
1. Educate patient on the type of device necessary for care

2. Educate patient on need to notify the nurse for elimination needs

a. Provide call light, and educate patient on use

b. Observe patient using call light appropriately

3. Educate patient on long term use of devices such, as ostomies.

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a. Provide teaching for ostomy and stoma management

b. Utilize teaching methods such as the teach back in reducing the probability of

complication

Colostomy Care

Stoma Locations
Patient Care
• Assess stoma appearance. Normal color is pink to red. Report stoma that is pale, dark, purple or
brown.
• Stoma appliance (bag) should be cut 1/16 - 1/8 in larger than the stoma.
• Cleanse stomal area and keep dry.
• Apply skin barrier before applying appliance.
• Empty appliance frequently to avoid complications. Generally, when 1/3 full.
• Special attention needs to be paid to patient diet:
• Foods that increase gas:
✓ beer, broccoli, Brussel sprouts, cabbage, carbonated drinks, beans, dairy, spinach
• Foods that thicken stool:
✓ applesauce, banana, bread, cheese, yogurt, rice, pasta
• A small needle sized hole can be made in the pouch to allow flatus to escape. Seal with a band
aid.

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Promotion and Evaluation of Normal Elimination

POOPER SCOOP

• Promotion:

• P-Position

• O-Output

• O-Offer Fluids

• P-Privacy

• E-Exercise

• R-Report Results

• Evaluation:

• S-Size (Amount)

• C-Consistency

• O-Occult Blood

• O-Odor

• P-Peristalsis

Use the mnemonic POOPER to remember things that will promote normal bowel function, and
SCOOP to remember what to evaluate about a patient's bowel movement.
Elimination device – colostomy

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QUIZ
Question 1 of 5
A 68-year-old patient complains to the nurse that she has been struggling with constipation. The
nurse is discussing the different causes of constipation with this patient. Which of the following best
describes slow-transit constipation? Select all that apply.
1. The patient develops constipation because of a surgical resection
2. Constipation develops because of poor glucose control
3. Hirschsprung disease is an example of this type of constipation
4. The patient perceives that she has a difficulty with constipation that is not real
5. Constipation is caused by dysfunctional reflex mechanisms in the colon

Question 2 of 5
Your patient had an ileostomy placed 2 weeks ago. Which bowel pattern would be expected for this
patient?
1. Output every 2-3 hours
2. Output once per day
3. Continent, controlled output
4. Continuous output

Question 3 of 5
The nurse is caring for a patient who suffers from chronic constipation. The nurse asks questions to
evaluate whether the patient uses laxatives to manage this condition. Which of the following best
describes the rationale for this action?
1. The laxatives may cause a buildup of magnesium in the body, leading to diarrhea
2. The patient may have inadvertently damaged his rectal sphincter by using laxatives
3. The patient may have used laxatives incorrectly and contributed to constipation
4. The laxatives may replace increased fiber intake in treatment of constipation

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Question 4 of 5
The nurse is caring for a patient with an ileostomy. During assessment of the patient, the nurse
notes that the pouch opening is 1/2 inch larger than the stoma site. Which of the following poses a
risk for this patient?
1. Stoma pain and burning
2. Peristomal skin breakdown
3. Leakage and odor from the site
4. Pouch system detachment
Question 5 of 5
A patient with a feeding tube has developed constipation as a result of inactivity. Which nursing
intervention would most likely help to resolve this complication?
1. Administer fiber and fluids as ordered
2. Check feeding tube residual prior to all feedings
3. Monitor blood glucose levels as ordered
4. Take precautions to ensure the tube is secure

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Pain and Nonpharmacological Comfort

Measures
Overview
1. Pain

a. Patient perspective

b. Understanding pain

c. Pain goals

d. Managing pain

Nursing Points
General

1. Patient perspective

a. Pain is what the patient says it is

i. Always subjective, even though it’s given a number

b. Acute versus chronic

c. Will be different between patients

2. Understanding pain

a. OLDCARTS vs PQRST

i. OLDCARTS

1. Onset

2. Location

3. Duration

4. Character

5. Alleviating or aggravating factors

6. Radiation

7. Timing

8. Severity

ii. PQRST

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1. Provoking factors

2. Quality

3. Region or radiation

4. Severity

5. Time

b. Nonverbal or physiologic responses

i. Assess for grimacing, guarding or reacting

ii. Observe BP and heart rate

3. Pain goals

a. Nonpharmacologic response

b. Cannot eliminate pain

i. Reduce to manageable level

ii. Set realistic goals

4. Managing pain

a. Pain scales

i. Use appropriate scale

b. Escalating pain measures

i. Use nonpharmacologic pain meds first,

ii. Nonopiate analgesics

iii. Oral opiates

iv. Injectable opiates

c. De-escalating pain measures

i. Patients can’t go home on IV pain meds

ii. Work to utilize non pharmacological pain measures

Nursing Concepts

1. Comfort

2. Patient-Centered Care

3. Health Promotion

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4. Mobility

Patient Education
1. Educate patient on realistic pain goals

2. Educate patient on medication side effects

3. Explain to patient benefits of nonpharmacologic pain efforts

STUDY TOOLS:
Pain Assessment Questions
OPQRST

• O-Onset

• P-Provoke or palliative

• Q-Quality or character

• R-Region or radiation

• S-Signs, severity, symptoms

• T-Time of onset, duration and intensity

It is important not only to assess and document pain, but also assess and document the following
characteristics so that the appropriate interventions occur.

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Common Screening Tools

SKIN BREAKDOWN RISK ASSESSMENT
Score every patient on admission or transfer and at least once a shift (BRADEN SCALE)
1 2 3 4
Sensory Completely Very limited Slightly limited No impairment
perception limited

Secondary Constantly moist Moist Occasionally Rarely moist

Diagnosis moist.

Activity Bedfast Chairfast Walks Walks frequently

occasionally

Mobility Completely Very limited Slightly limited No imitations

Immobile

Nutrition Very poor Probably Adequate Excellent

Inadequate

Friction and Problem Potential problem No apparent -

Shear problem

Risk Level:
✓ Severe: 9 or less
✓ High: 10-12
✓ Moderate: 13-14
✓ Mild: 15-18
✓ Low or No Risk: 19-23
✓
FALL RISK ASSESSMENT SCALE
Score every patient on admission or transfer and at least once a shift
Item Response Score
History of falling; immediate No 0
or within 3 months Yes 25
Moisture No 0
Yes 15
Ambulatory aid Bed rest/nurse assist 0
Crutches/cane/walker Furniture 15
30
IV/Heparin Lock No 0
Yes 20
Gait/Transferring Normal/bedrest/immobile Weak 0
Impaired 10
20
Mental status Oriented to own ability Forgets 0
limitations 15
Total Score

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Risk Level:
No Risk 0 - 24
Low Risk 25 - 50
High Risk ≥ 51

PAIN ASSESSMENT IN CRITICAL CARE

Rates critically ill patients’ pain based on clinical observation when they cannot report a numeric
scale, scored from 0-8, with 8 being the highest pain score.

Item Observation Score

Facial Relaxed, 0
Expression Neutral Tense 1
Grimacing 2
Body None or Normal 0
Movements Protection 1
Restlessness 2
Ventilator Compliance Tolerating vent 0
OR OR Normal, or no sound 1
Vocalization Coughing OR sighing, moaning 2
Fighting vent OR crying,
sobbing
Muscle Relaxed 0
Tension Tense, Rigid 1
Very Tense, Rigid 2
Total Score

PAIN SCALE FOR CHILDREN 7 MONTHS TO 2 YEARS

Based on activity related to Face, Legs, Activity, Cry, and Consolability
Behavior 0 1 2
Face No particular Occasional grimace or Frequent to constant
expression or smile frown, withdrawn, quivering chin,
disinterested clenched jaw
Legs Normal position or Uneasy, restless, tense Kicking or legs drawn
relaxed up
Activity Lying quietly, normal Squirming, shifting, Arched, rigid, or
position, moves easily back and forth, tense jerking
Cry No cry (awake or Moans or whimpers; Crying steadily,
asleep) occasional complaint screams or sobs,
frequent complaints
Consolability Content, relaxed Reassured by touching, Difficult to console or
hugging or being talked comfort
to, distractable
Total score

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SCREENING FOR AGITATION AND LEVEL OF SEDATION

Typically used in ICU, but also in PACU and procedural areas.
Score Term Description

+4 Combative Combative or violent; immediate

danger to staff
+3 Very agitated Pulls on tube(s) or catheter(s) or is
aggressive toward staff

+2 Agitated Frequent nonpurposeful

movement or fighting ventilator
+1 Restless Anxious or apprehensive but not
aggressive
0 Alert and calm Spontaneously pays attention to
caregiver
-1 Drowsy Not fully alert, but maintains eye
contact for > 10 seconds
-2 Light sedation Briefy (< 10 seconds) awakens with
eye contact to voice

-3 Moderate sedation Any movement (but no eye

contact) to voice
-4 Deep sedation No response to voice, but
movement to physical stimulation

-5 Unarousable No response to voice or physical

stimulation

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Pain Management
Types of Pain

✓ Superficial Somatic
Skin, tongue, mucus membranes
✓ Deep Somatic
Muscles, tendons, bones
✓ Visceral
internal organs
• Lack of blood supply
• Overstretching
✓ Referred
Pain originates in one location ➞ felt in another
• Ex: Heart attack felt in left arm
• Theory: shared interneuron

Non-pharmacologic Pain Management

Non-pharmacologic measures should be chosen based on the specific injury or source of pain. Not all
techniques will be effective for every type of pain

✓ Bedrest
For muscle or joint pain, bedrest can help to decrease irritation or inflammation in the affected
area.
✓ Massage
Massage can help to relieve tension and improve blood flow to the affected area, which can
decrease pain.
✓ Relaxation Techniques
• Hypnosis
• Guided Imagery
• Breathing
These measures help with the “mind over matter” aspect of pain, and help with psychological
coping.
• Example: breathing through a contraction during labor
✓ Bracing or Splinting
Bracing, splinting, casting, and/or traction can help limit movement in an affected area, which can
decrease irritation of the area.
• Example: splinting abdomen with a pillow when coughing after abdominal surgery
✓ Electrical Stimulation
Stimulation, such as a TENS unit can help reduce muscle spasm and decrease soft tissue edema.
✓ Heat or Ice
Heat ➞ increases blood flow
Cold ➞ decreases inflammation

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Pharmacologic Pain Management

Non-Opioid Analgesics
• NSAIDs (ibuprofen, aspirin, ketorolac)
• Cox-2 Inhibitors (celecoxib)
• Acetaminophen
• Muscle relaxants can also relieve pain caused by
muscle spasm or tension
Oral Opioid Analgesics
• Hydrocodone
• Oxycodone
• Tramadol
• Methadone
Injectable Opioid Analgesics
• Morphine
• Hydromorphone
• Fentanyl
Also transdermal/intranasal : (Always escalate from least “invasive” to most invasive based on patient’s
response)
• Use consistent pain scoring and evaluate on appropriate timeline.
• If pain still unacceptable:
- Consider increased dose or frequency
- Alternate 2 or more drug classes
- Advance to the next level
Tips (When to reassess patient after administering Medication)
1. Nonpharmacologic measures
2. Non-Opioid Analgesics
a. Evaluate after 30-60 minutes
3. Oral Opioid Analgesics
a. Evaluate after 30-60 minutes
4. Injectable Opioid Analgesics

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a. Evaluate after 30 minutes

Consult with Pharmacy regarding dosing or appropriateness Confer with Provider if ordered pain
management does not appear effective Follow provider orders regarding administration dosing and
frequency

QUIZ
Question 1 of 10
The nurse is caring for a patient on post-operative day 1 after a right lower lobe thoracotomy. The
patient states she in terrible pain. Which is the most appropriate response?
1. What is your pain level on a scale of 0-10? 0 is no pain, 10 is the worst pain possible
2. How bad is it?
3. I will use the Wong-Baker faces scale to figure out which pain medication to give you
4. I will set up a guided imagery session for you right away

Question 2 of 10
A nurse is using a TENS device to help a patient with low back pain. Which of the following
considerations should the nurse keep in mind when using this type of device? Select all that apply.
1. A patient who has a monitor should not use TENS over leads
2. The TENS unit involves electrical stimulation
3. TENS can be used all over the body
4. TENS may induce contractions in a pregnant person
5. TENS can cause damage to the skin

Question 3 of 10
The nurse is caring for a patient who is suffering from an acute migraine headache.
Dihydroergotamine (DHE) has been prescribed. How does this drug act to control the migraine
headache? Select all that apply.
1. It inhibits inflammatory neuropeptide release
2. It acts as a vasoconstrictor in the brain’s blood vessels
3. It is an agonist to serotonin receptors
4. It acts on the brain's pain center to reduce pain perception
5. It causes vasodilation of the central nervous system

Question 4 of 10
A nurse is caring for a patient with chronic pain and recommends relaxation therapy as part of
pain management. How would relaxation therapy work in this situation?
1. Relaxation causes the affected person heal from the painful condition more quickly
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2. Relaxation can decrease anxiety, which reduces muscle tension and helps ease pain
3. Relaxation is used to channel pain receptors away from signaling the brain
4. Relaxation increases endorphins, which results in a decrease in pain

Question 5 of 10
A nurse is utilizing effleurage as part of non-pharmacological pain management for a patient in
labor. Which describes the techniques of effleurage? Select all that apply.
1. The nurse uses the forearms to apply effleurage
2. The nurse lightly massages the abdomen or back
3. The nurse applies gentle pressure that slightly tickles the skin
4. The process promotes relaxation and pain relief
5. The process is distracting from the pain of labor for the patient

Question 6 of 10
A nurse is caring for a patient who uses a morphine PCA for pain control. The patient calls the
nurse and says that the PCA does not seem to be working because he is still having significant pain.
Which response from the nurse is most appropriate?
1. "Are you sure you are pushing the button often enough?"
2. "Here, let me push the button for you."
3. "I will check the settings and see if everything is working correctly with the machine."
4. "I will call the physician."

Question 7 of 10
A patient has come to the healthcare clinic complaining of pain in his left arm after an injury.
Which describes the characteristics of nociceptive pain? Select all that apply.
1. Nociceptive pain is categorized as being either somatic or visceral pain
2. Nociceptive pain can be referred pain
3. Nociceptive pain may be localized to the area of injury
4. Nociceptive pain develops after an injury to the central nervous system
5. Nociceptive pain includes transduction, transmission, perception, and modulation

Question 8 of 10
A 50-year-old patient is recovering from abdominal surgery. He complains of pain that has been
continuously rated at a 6 on a 0-10 scale despite the intervention of giving morphine Q4H PRN.
Which implication must the nurse consider when controlling this patient’s pain?
1. Whether the patient is allergic to the medication
2. Whether the patient is becoming addicted to the medication
3. Whether the patient would respond to a different type of medication

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4. Whether the patient is experiencing an increased respiratory rate because of the medication

Question 9 of 10
A nurse is caring for a 12-month old child who is recovering from surgery. Which of the following
principles should the nurse implement when managing pain in a patient who cannot communicate
with words? Select all that apply.
1. Check for an elevated pulse or respiratory rate
2. Administer pain medication on a scheduled basis to prevent pain as ordered if indicated
3. Ask a close family member to assist in pain assessment
4. Look for behaviors such as crying or grimacing that would indicate pain
5. Check if the patient is in a situation that would cause pain

Question 10 of 10
A nurse prepares a dose of medication that is a controlled substance to give to a patient for pain.
When the nurse takes the medication into the room, the patient refuses it. What action of the nurse
is most appropriate?
1. Discard the medication according to facility policy and document the Patient’s refusal
2. Label the medication for use and return it to the locked cupboard so that someone else may use it
3. Return the medication to its former packaging
4. Encourage the patient to take the medication and explain that it has already been signed out to
him

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Hygiene
Overview
1. Hygiene

a. Hygiene considerations

b. Systems

c. Nursing care

Nursing Points
General

1. Hygiene considerations

a. Beliefs

i. Culture

b. Personal preferences

i. Does preference create a conflict with care?

c. Fragrance and allergies

d. Body image

2. Systems

a. Skin, hair and nails

i. Bathing

1. Chlorhex/Wipes

2. Bed bath

ii. Shaving

1. Preference vs need for care

iii. Foot care

1. Nail considerations

2. Skin integrity

b. Oral

i. Regular oral care

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1. Prevents infection

2. Pneumonia avoidance

c. Pericare

i.

1. Dignity

2. Safety

a. Skin integrity

b. Reduction in irritation

3. Use of appropriate products

3. Nursing care

1.

i. Encourage autonomy

1. Encourages independence

b. Provide education

1. Fill knowledge gaps and clarify information

c. Encourage family participation

1. Identify caregiver role

2. Educate family
Nursing Concepts

1. Tissue/Skin Integrity

2. Safety

3. Professionalism

4. Health Promotion

Patient Education
1. Educate patient on hygiene goals

a. Provide evidence to dispel myths or misinformation

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QUIZ
Question 1 of 8
A nurse is providing a complete bed bath for a patient who is in the hospital. Which of the following
steps would be included as part of a complete bed bath? Select all that apply.
1. Position the bed flat, if possible
2. Start at the Patient’s lower legs and move toward the head
3. Remove only one piece of clothing or jewelry at a time
4. Protect the Patient’s privacy by closing the door
5. Cover the patient with a bath blanket

Question 2 of 8
While caring for a patient in a rehabilitation center who has self-care deficit related to bathing and
hygiene, the nurse assists the patient by finding loose clothing to wear that snaps easily in the front.
Which of the following best describes the rationale for this?
1. Loose clothing is easier to remove so the patient may be more likely to change clothes
2. Tight clothing restricts blood flow and the patient may develop hypotension
3. Wearing loose clothing helps the Patient’s disturbed body image
4. The patient would be more comfortable wearing these types of clothes
Question 3 of 8
A public health nurse is teaching a seminar about hygiene promotion. Which best describes the
difference between health education and health promotion?
1. Health education is administered in a traditional classroom or conference setting, while health
promotion is administered in the community
2. Health education is directed by members of the community to support public health, while health
promotion typically has financial backing to provide guidance for individuals
3. Health education involves teaching others about their conditions and diagnoses, while health
promotion focuses on prevention of illness
4. Health education involves increasing others' awareness of their health while health promotion
involves supporting measures that encourage healthy activities

Question 4 of 8
A nurse is getting ready to perform oral hygiene for an unconscious patient. Which of the following
principles would the nurse follow that are associated with oral hygiene in an unconscious patient?
Select all that apply.
1. If the nurse does not perform oral hygiene, the Patient’s mouth may crack and bleed
2. An unconscious patient may mouth breathe, further indicating the need for oral hygiene
3. When performing oral hygiene, the nurse should keep the head of the bed flat
4. The nurse should brush and floss the Patient’s teeth every two hours
5. After cleaning the mouth, the nurse can apply moisturizer to the Patient’s lips

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Question 5 of 8
A patient with insulinoma is suffering from mental confusion and cognitive impairment. Which
action of the nurse best demonstrates respecting the Patient’s dignity?
1. Ask a family member to hold the patient down during a procedure
2. Tell the patient that the nurse will take care of everything the patient needs
3. Allow the patient to make choices such as what to eat or what to wear
4. Do not force the patient to take necessary medications

Question 6 of 8
A nurse overhears two employees talking about a Patient’s poor hygiene in a derogatory way.
Which of the following actions should the nurse take first?
1. Walk away and not participate
2. Indicate to the employees that it is not appropriate to discuss
3. Tell the patient
4. Tell the charge nurse

Question 7 of 8
A nurse is helping a patient with his oral hygiene after eating breakfast in the morning. The nurse
assesses the Patient’s ability to brush teeth and knows that lack of oral hygiene affects the Patient’s
health. Which of the following situations is a risk for a patient with poor oral hygiene?
1. The patient will be at increased risk of diarrhea
2. The patient is at risk for endocarditis
3. The patient may be more likely to develop an autoimmune disorder
4. The patient will have glucose control problems
Question 8 of 8
A nurse is caring for an older adult patient with dentures. The patient needs assistance to brush his
dentures and put them back in his mouth. Which action indicates that the nurse is performing this
appropriately? Select all that apply.
1. Rinse the dentures well before putting them back in the Patient’s mouth
2. Use hot water when rinsing dentures
3. Remove the lower denture before the upper
4. Soak stained dentures in a solution of commercial denture cleaner
5. Break the seal on the upper denture before trying to remove it

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Intake and Output (I&O)

Overview
1. Intake and output

1. Importance

2. Considerations

3. Intake

4. Output

5. Nursing tasks

Nursing Points
General

1. Intake and output importance

a. Determines fluid imbalance

b. Identifies current status vs potential risks

i. Fluid volume deficit

c. 1 kg of body weight = 1 liter of fluid

2. Intake and output considerations

a. Fluid restriction

b. Renal or cardiac patients

c. Critical or unstable patients

d. Patients on diuretics or IV fluids

3. Intake

a. Anything by mouth

i. Fluids, ice cream, soup, juice water

1. Ex: Coffee cup – 180-200 mL; Juice – 120 mL

2. Check container for fluid volume

ii. Ice chips

iii. Tube feedings

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iv. IV Fluids

1. Blood transfusions

4. Output

a. Urine

b. Diarrhea

i. Stool measurements

c. Emesis

d. Gastric contents

e. Drainage from wounds

f. Output from drains

5. Nursing tasks

a. Obtain weights daily

b. Measure EVERYTHING

i. Lines

ii. Drains

iii. Pumps

c. Instruct patients to eliminate in the appropriate receptacle

i. Hats

ii. Bedpan and measure with graduated cylinder

d. Strict I&O

i. ICU Requirements

1. Measure all I&O on every patient

ii. Strict I&O order

1. Measure EVERYTHING

2. Usually not common in Med-Surg, unless an order is

present
Nursing Concepts

1. Fluid & Electrolyte Balance

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2. Nutrition

3. Elimination

Patient Education
1. Educate patient on fluid balance

a. Especially in renal and cardiac patients

b. Consider strict I&O order

c. Educate patient on needs of fluid restriction

STUDY TOOLS:

QUIZ
A patient with a paralytic ileus has an order to insert an NG tube and set to low-intermittent
suction. Which of the following steps would be included as part of inserting an NG tube? Select all
that apply.
1. Check the Patient’s coagulation studies prior to insertion
2. Test the gag reflex by asking the patient to swallow two cups of water
3. Insert air into the NG tube with a syringe and auscultate with a stethoscope to verify placement
4. Measure the tube from the tip of the nose to the xiphoid process
5. Inspect the Patient’s nares for polyps

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Glucose Monitoring
Overview
1. Glucose monitoring

1. When to use blood glucose monitoring

2. Glucose monitoring pro-tips

3. Nursing considerations

Nursing Points
General

1. When to use glucose monitoring

1. Patient condition

1. Diabetes

2. Surgical patients

3. Infection

4. Trauma

5. When it’s ordered

6. When there’s a suspicion

1. High blood sugars

2. Low blood sugars

3. Non-classic symptoms

2. Glucose monitoring pro-tips

1. Glucose monitoring controls

1. When ordered

2. Keeps compliance

3. Reduces errors

2. Use proper PPE

1. Use gloves

3. Use alcohol swabs

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1. Swab and then prick with lancet

2. Use gauze to wipe away first drop

3. Then use second drop to measure

4. Trust your gut

1. High and low results should be retested for accuracy

2. If results don’t correspond to patient symptoms, retest

3. Nursing considerations

1. High results

1. Recent food intake

2. Does the patient know how to properly give insulin, if diabetic?

1. Is the patient compliant with insulin and testing?

3. Drugs causing resistance

4. How high is it?

1. Is it an emergency?

2. Low results

1. Recent food intake

2. Recent insulin vs food

3. How low is it?

1. Less than 70 mg/dL

2. Is it an emergency?

4. 15-15 Rule

1. If CBG is low, give 15 grams of carbs and recheck

blood sugar in 15 minutes

Nursing Concepts

1. Glucose Metabolism

2. Hormone Regulation

3. Safety

4. Nutrition

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Patient Education
1. Educate patient on proper way to conduct glucose monitoring at home

1. Follow CDC recommendations for reducing infection

2. Educate patient on following manufacturers instructions for any equipment that they may be

using to monitor their blood sugar

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STUDY TOOLS:
Diabetes Mellitus Type 1- Signs & Symptoms
The 3 Ps

• P-Polyuria (excessive urination)

• P-Polydypsia (excessive thirst)

• P-Polyphagia (excessive hunger)

In type 1 diabetes mellitus a patient does not produce insulin. Insulin allows glucose to go from the blood

into the cells for energy. When glucose does not get into the cell, glucose levels in the blood rise. The

body tries to remove excess glucose by producing extra urine. The body then requires more water. We get

hungry because our cells are starving for energy.

Diabetes Patho Chart

PATHOPHYSIOLOGY
When the body does not have glucose to fuel cells properly. Can be because insulin isn't being produced
to take the sugar from the blood stream into the cells, Could also be because the pancreas isn't producing
enough insulin leaving the cells still very hungry, or the body isn't recognizing insulin as a vehicle to get
the glucose into the cells (this is called insulin resistance). Type I diabetes is when the pancreas isn't
producing insulin. Type II diabetes is when the pancreas doesn't produce enough insulin or resistance
occurs. If the body doesn't get the glucose it needs to produce energy, it will start to break down fat to get
the energy, If this happens for long enough, the body goes into a state of ketosis/acidosis and the patient
can become altered, dehydrated, and have electrolyte imbalances.

ASSESSMENT FINDINGS
• Elevated glucose, 3 P's (polydipsia, polyuria, and polyphagia), blurred vision, non-healing
wounds, neuropathy, poor circulation, HTN, retinopathy; Check their feet, inspect their skin for
wounds, get their HbA1C results, assess their insulin schedule and their understanding of the
schedule.

DIAGNOSTICS
• Fasting blood sugar tests results greater than 100
• Chronic abnormal POC glucose and HbA1C

NURSING PRIORITIES
• Monitor blood glucose levels
• Promote optimal electrolyte balance
• Prevent or manage infection

THERAPEUTIC MANAGEMENT
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• Diet changes
• Insulin therapy (rotate sites to avoid lipoatrophy)
• Close BG monitoring
• Because of difficulty healing wounds and neuropathy monitor skin closely especially the feet
• Use the rule of 15 for low BG - 15 g sugar, recheck in 15 minutes
• Lots of patient education about diet and insulin and skin care.

MEDICATION THERAPY
• Insulin
• Oral anti-diabetic medications such as metformin

Glucose Monitoring in Gestational Diabetes

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QUIZ
Question 1 of 9
A nurse is assessing a diabetic patient at the healthcare clinic who has a log of glucose levels and
insulin dosages for the past month. The nurse notes that the patient has had high levels of blood
glucose every morning, requiring increased dosages of insulin first thing in the morning when
compared to other times of day. Which of the following suggestions would most likely assist the
patient to have better readings of morning blood glucose levels?
1. Avoid carbohydrates near bedtime
2. Adjust the insulin dose time from bedtime to dinnertime
3. Increase the amount of exercise per day
4. Ask the provider to add daily cortisol to the medication regimen

Question 2 of 9
A patient is being seen in the emergency department for anxiety, confusion, and behavioral
changes. The Patient’s heart rate is elevated, and the blood glucose is 48 g/dL. The nurse
administers a dose of glucagon and a continuous infusion of IV dextrose. Which of the following
interventions should the nurse perform next?
1. Suction the Patient’s mouth
2. Provide oxygen and elevate the head of the bed
3. Recheck the glucose level in 15 minutes
4. Administer pain medication

Question 3 of 9
The nurse is admitting a diabetic patient. The nurse asks questions about diet and discovers that
the patient avoids sugary foods but eats rolls and bread at every meal. Which of the following
responses by the nurse is correct?
1. We'll check your A1C because it sounds like you're in trouble with glucose control
2. Avoiding sugary foods is the right thing to do. Keep up the good work
3. You need to avoid the foods that cause gluconeogenesis in the body
4. Since bread and rolls turn into glucose in the body, you must limit these

Question 4 of 9
A 44-year-old diabetic patient is undergoing surgery for a hysterectomy. The patient is a type 1
diabetic who requires regular monitoring of blood glucose levels and insulin administration on a
sliding scale. Which information should be given to the patient about controlling blood glucose
levels throughout surgery?
1. The patient will receive dextrose through the IV but will need to take oral diabetic agents on the
day of the surgery

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2. The patient will receive IV fluids with dextrose and should still receive insulin throughout the
perioperative period
3. The patient will have no dextrose in the IV and should not take any insulin throughout the
perioperative period
4. The patient will have no dextrose in the IV but should still take insulin throughout the
perioperative period

Question 5 of 9
A 65-year-old patient is in the hospital for surgery for a colon resection. The patient requires total
parenteral nutrition, which is administered through a central venous catheter. The nurse notes that
the patient has a red area of induration around the catheter exit site. The Patient’s latest blood
glucose result is 176 mg/dL and a current temperature of 38 degrees celsius. Which of the following
conditions should the nurse suspect?
1. Sepsis
2. Hematoma
3. Hyperosmolar hyperglycemic non-ketotic syndrome
4. A blood clot in the central catheter

Question 6 of 9
A patient uses Novolin R, a short-acting insulin, to control his blood glucose levels. The patient is
reviewing the principles of glucose control with the nurse and asks about when he should take his
insulin in relation to meals. Which response from the nurse is most accurate?
1. "This type of insulin should be taken with meals."
2. "You should only take this insulin once a day; it does not coincide with your meals."
3. "Give yourself a dose of this insulin about 30 minutes after you have started eating."
4. "Take this insulin about a half hour before you eat."

Question 7 of 9
A patient who is in the hospital requires total parenteral nutrition for management of malnutrition.
After two days on the TPN solution, the nurse checks the patients blood glucose levels and the
result is 181 mg/dL. Which action of the nurse is most appropriate?
1. Continue to monitor and recheck the blood glucose in four hours
2. Turn down the rate of the TPN and recheck the glucose in one hour
3. Contact the physician for an order to start insulin therapy
4. Turn off the TPN infusion for one hour, then restart, advancing the rate slowly

Question 8 of 9
A 41-year-old patient has been diagnosed with type 2 diabetes. The nurse is teaching the patient
about how to perform self-monitoring of blood glucose (SMBG) at home. The nurse instructs the
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patient about how to use a lancet to obtain a blood sample. Which technique would the nurse most
likely include?
1. Use the same two fingers to check glucose to provide consistency in blood samples
2. Use the lancet on the tip of the finger to provide the most blood
3. Use the lancet to puncture deep enough to reach the subcutaneous tissue
4. Use the lancet on the side of the pad of the finger

Question 9 of 9
A nurse is assessing a patient with a history of diabetes. The patient tells the nurse that she does not
feel well. The nurse checks her blood glucose levels and gets a result of 51 mg/dL. What signs or
symptoms would the nurse expect to see with this blood glucose level? Select all that apply.
1. Weakness
2. Anxiety
3. Bradycardia
4. Hot, dry skin
5. Tremor

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Specialty Diets (Nutrition)

Overview
1. Diet Orders

1. Diet types

2. Indications for use

3. Foods to be included or excluded within each diet

Nursing Points
General

1. NPO (nothing by mouth)

1. Used for:

1. Surgery

2. Dysphagia (swallowing)

3. GI patients

2. Cannot have ANY food or liquid by mouth

2. Clear liquid

1. Foods include

1. Liquids that are transparent at room temperature

2. Used for:

1. Patients that have been NPO

2. Advancing from an NPO diet

3. Full liquid

1. Used for

1. Progression between clear liquid and soft or regular diet

2. Liquids at room temperature, but do not have to be transparent

1. These foods include dairy

1. These foods contain protein and fat

4. Soft/Low Fiber/Low Residue

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1. Includes

1. Soft foods

2. Less than 10 grams of fiber per day

2. Used in patients with

1. Chewing issues

2. GI patients

3. Foods must exclude

1. Raw fruits and vegetables

2. No nuts or seeds

3. No whole wheats or grains

5. High Fiber/High Residue

1. Used for patients with constipation

2. Includes foods with

1. Whole wheats

2. Whole grains

3. Fruits

4. Vegetables

5. Nuts

6. Dysphagia diets

1. Pureed

1. Blended and then passed through a sieve

2. Mechanical soft ground/chopped

1. Soft foods that require less chewing

1. Ground/chopped meat

2. Soft fruits and vegetables

3. Soft breads

7. Carbohydrate Consistent

1. Used for diabetic patients or patients with elevated blood sugar

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2. Limit foods

1. With added sugar

2. Limit meals to 3 to 5 carbohydrate servings per meal

8. High Protein

1. Used for patients that have high protein needs

1. Dialysis patients

2. Patients who have severe wounds

2. Increased protein

1. Meat

2. Dairy

3. Nuts

4. Seeds

5. Beans

9. Renal diet

1. Used for patients with renal disease

1. Include foods with

1. Low sodium

2. Low potassium

3. Low phosphorus

4. Protein dependent on patient needs

2. Limit these foods:

1. Dairy

2. Meat

3. Beans

4. Nuts

5. Potatoes

6. Chocolate

7. Bananas

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8. Melons

10. Low Sodium

1. Monitor for less than 2000 mg of sodium consumption per day

2. Used in renal, heart failure and hypertension patients

3. Avoid foods high in sodium

1. Processed foods

2. Added salt

3. Canned foods

11. Cardiac Diet

1. Used for patients with heart disease

2. Reduce fat and sodium in diet

12. Low Fat

1. Less than 50 gm of fat per day

2. Used in patients with high cholesterol and GI patients

3. Include these foods

1. Lean meats

2. Low fat dairy

3. Limit butter and added oils

13. Vitamin K/Coumadin Diet

1. Used in patient on Coumadin

2. Vitamin K counteracts Coumadin

1. Therefore, avoid eating large amounts of

1. Dark, green leafy vegetables

2. Kale

3. Broccoli

4. Brussel sprouts

5. Cabbage

6. Cauliflower

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14. Other diets

1. Food allergies

1. Avoid certain foods based on individual allergies

2. Food requests

1. Cultural or Religious requests

1. Kosher

2. Vegan

3. Vegetarian

4. Pescatarian

2. Delivered on request

3. Fluid restriction

1. Limit fluid intake per order

2. Used in renal and heart patients

4. Thickening

1. Honey or nectar thickened

2. Used in dysphagia, due to aspiration risk

STUDY TOOLS:
THERAPEUTIC DIETS
• NPO (nil per os):
Nothing by mouth

• CLEAR LIQUID:
✓ transparent to light and liquid at body temperature
✓ water
✓ fruit juice
✓ broth
✓ hard candy
✓ gelatin
✓ popsicles
✓ coffee
✓ tea

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• FULL LIQUID:
✓ clear and opaque liquid foods at body temperature
✓ all clear liquid items
✓ ice cream
✓ sherbet
✓ breakfast drinks
✓ fat free & 1% milk
✓ pudding
✓ thin hot cereals (cream of wheat)

• PUREED DIET:
✓ foods that require no chewing
✓ all full liquid items
✓ mashed potatoes
• MECHANICAL DIET:
✓ foods that require less chewing
✓ chopped, ground, & pureed foods
✓ tender fruits and vegetables
✓ tender meats
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• LOW RESIDUE/ LOW FIBER:

✓ limit fiber intake to 10g a day
✓ white bread
✓ refined cereals and pastas
✓ white rice
• HIGH RESIDUE/ HIGH FIBER:
✓ high fiber intake 20-35g a day
✓ whole-grain products
✓ fruits and vegetables
• CONSISTENT CARB (diabetic diet):
✓ limited starches, juice, fruit, milk, and sugars
✓ control carbohydrate intake
• CARDIAC:
✓ restrict fat and sodium intake
• SODIUMRESTRICTED:
✓ limit sodium intake to set amount (4g, 3g, 2g, 1g, 500mg)
✓ avoid canned, frozen, boxed, smoked, salted foods
• RENAL:
✓ Low sodium, phosphorous, potassium and protein.
✓ High-quality protein and usually limiting fluids

Gluten Free Diet

BROW

• B-Barley

• R-Rye

• O-Oats

• W-Wheat

Gluten is a protein found in wheat, barley and rye. People with gluten allergies can be affected by even

trace amount of gluten in foods. If they don't feel good, they'll furrow their BROW. Oats do not contain

gluten, but they are often milled in the same factories as wheat. Always check food labels to make sure

a product is gluten free.

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Pureed Diet

QUIZ
Question 1 of 10
An older adult patient is having difficulty getting enough to eat to maintain proper nutrition.
Which nursing care strategies could the nurse employ that would promote proper nutrition in this
patient? Select all that apply.
1. Assess the oral health of the patient
2. Encourage the patient to drink 2 to 4 L of water daily
3. Refer the patient to a dietitian
4. Provide food options the patient enjoys
5. Offer the patient spicy foods to stimulate saliva production

Question 2 of 10
A nurse is caring for a patient who has a nasogastric tube in place and is receiving enteral feedings.
The nurse must administer formula to the patient that has been prepared by the hospital dietary
staff and consists of milk-based, blenderized foods. This type of formula is known as:
1. Polymeric formula
2. Specialized formula
3. Modular formula
4. Elemental formula

Question 3 of 10
A patient on chemotherapy has arrived for an appointment. Upon assessment, the nurse notes that
the patient has lost 20 pounds. The patient denies nausea and vomiting, and says she is following the

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same diet as before. Which of the following dietary recommendations should the nurse give this
patient?
1. Increased protein consumption
2. Increased fat consumption
3. Eat two large meals per day
4. Add protein and calorie-rich snacks between meals

Question 4 of 10
A patient has been taking 60 grams of fiber every day as a dietary supplement. The patient tells the
nurse that she suffers from irritable bowel syndrome and hopes that the fiber will help. Which sign
or symptom should the nurse look for that would indicate that this patient is taking too much fiber?
1. The patient has constipation
2. The patient has bloody stools
3. The patient has low blood pressure
4. The patient has frequent diaphoresis

Question 5 of 10
A nurse is educating a diabetic patient about their diet. Which information should the nurse
include in dietary teaching?
1. Glucose control is best achieved by eating three large meals each day
2. Carbohydrate counting is focused on the total grams of carbohydrates eaten per meal
3. There is not a restriction on eating fruits, because they contain naturally occurring fructose
4. It is ok for the patient to indulge in a normal portion of sugary dessert if they have 'saved' their
carbohydrates through the day

Question 6 of 10
The nurse is ordering from the cafeteria for a patient who is on clear liquids. Which of the
following would be appropriate to order for the patient? Select all that apply.
1. Ice cream
2. Milk
3. Coffee
4. Broth
5. Tea

Question 7 of 10
A nurse is assessing the dietary intake of an 80-year-old patient who is in the healthcare clinic.
Which of the following is related to changes associated with eating that contribute to impaired
nutrition?

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1. Increased risk of diarrhea from changes in nutrient absorption

2. Decreased blood pressure that makes it difficult to sit for long periods
3. Decreased intake of fiber because of difficulties chewing these foods
4. Increased intake of fluids due to an increased thirst mechanism

Question 8 of 10
A 71-year-old patient in the rehabilitation facility has dysphagia and must have food consistencies
altered before eating. He is on the dysphagia diet, at level 1: dysphagia pureed. Which of the
following foods would it be most appropriate for the nurse to serve to him?
1. Ground meat
2. Custard
3. Soft-cooked fruits
4. Pasta

Question 9 of 10
A nurse is caring for a patient who is Catholic and is NPO after abdominal surgery. The Patient’s
priest visits to offer communion. Which action of the nurse is most appropriate?
1. Tell the patient to take the communion wafer but not the wine
2. Check with the provider before letting the patient take communion
3. Allow the patient to take the communion and participate in the process
4. Tell the patient not to take the communion because of the NPO status

Question 10 of 10
A patient who has leukemia has asked the nurse about what type of foods to eat to help boost the
immune system. Which of the following supplements could the nurse suggest that would help to
boost this Patient’s immune system? Select all that apply.
1. Citrus fruits
2. Garlic
3. Red meat
4. Spinach
5. Wheat bread

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Enteral & Parenteral Nutrition (Diet, TPN)

Overview
1. Enteral & Parenteral Nutrition

1. Indications/Contraindications

2. Access

3. Formula Types & Solutions

4. Administration

5. Initiation

6. Monitoring

7. Complications

Nursing Points
General

1. Enteral Nutrition

1. Indications

1. Cannot consume food via oral route

2. Patient has a functional GI tract

2. Contraindications

1. Hemodynamically unstable

2. Risk of aspiration

3. Signs of GI distress

1. Distended abdomen

2. Increased nasogastric tube drainage >500 mL/day

3. High pitched bowel sounds

3. Enteral feeding access

1. Nasal or Oral routes

2. Short-term feeding tubes

1. Nasogastric

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2. Nasoduodenal

3. Nasojejunal

4. Orogastric

3. Gastric Access (surgical interventions)

1. Gastrotomy

2. Gastrojejunostomy

1. Accesses both stomach and jejunum

4. Jejunal Access (Jejunum)

1. Jejunostomy

2. Surgical access

4. Formula Types

1. Based on Calories (kcal) per mL

1. 1-1.2 kCal/mL

2. High fiber

1. Regulates the bowels

2. Used in malabsorption patients

3. Disease specific

1. Renal

2. Diabetes

3. Respiratory

5. Administration Types

1. Bolus

1. Delivering large quantities in short duration (given over

10-15 minutes)

2. Good for ambulatory patients

2. Intermittent feedings

1. Similar to bolus

2. Run over longer periods of time (up to one hour)

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3. Cyclic

1. Run for large portion of the day

1. Over 10-18 hours

2. Continuous through that time period

2. Good for some patients who take food my mouth

4. Continuous feeds

1. Used for patients on intestinal feeds or those that can’t

tolerate bolus feedings

2. Continuous rate delivered over 24-hour period

6. Initiation of Enteral Feedings

1. Confirm tube placement

1. Per policy

2. Elevate head of bed

1. At least 30 degrees

3. Begin feedings at 10-40 ml/hr or per order

4. Advance feedings per policy or 10-10 ml/hr every 8-12 hours

1. Until reached goal rate

2. Unless contraindicated

5. Monitor for tolerance

6. Wean tube feedings

1. Hold feedings 1 hour prior to meal

2. Initiate 6 small meals per day as ordered or per policy

7. Monitoring

1. I&O (ins and outs)

1. Monitor total volumes in versus volume out

1. Important in renal patients

2. Gastric residuals

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1. Gastric residual = the amount of tube feedings

remaining in stomach during assessment

2. Gastric residuals should never exceed 500 mL

3. Weigh patients daily

4. Monitor lab values

5. Oral Care

1. Patients can be forgetful or oral care

2. Can lead to bad hygiene and complications

6. Bowel Health

1. Assess abdomen regularly or per policy

7. Tube site

1. Assess skin at site for skin breakdown and tube

functionality

8. Medication administration

1. Stop tube feeding prior to administration

2. Flush tube per policy

3. Administer medications per policy

4. Flush tube after administration

5. Resume feeding

8. Complications

1. GI intolerance

1. Some patients cannot tolerate tube feedings

2. Monitor case-by-case basis

2. Tube placement site

1. Monitor for skin breakdown

3. Tube clogging

1. Refer to policy for unclogging tube

2. Use medically approved unclogging agent

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3. Flush tube frequently

4. DO NOT USE SODA

4. Bacterial contaminations

1. Wash hands

2. Follow policy

5. Metabolic complications

1. Elevated blood sugars and electrolyte imbalances can

occur

2. Monitor patient lab values

2. Parenteral Feeding

1. Indications

1. Inability to take food orally

1. GI Disorders

1. Obstruction

2. Extended bowel rest

3. GI Fistula

4. Short bowel syndrome

2. Inadequate food intake

2. Contraindications

1. Functional GI tract

1. GI nutrition should always be first choice

2. Inability to gain venous access

1. Ideally should be placed centrally (PICC line, Central

Line)

2. Check policy

3. Hemodynamically unstable

4. Short-term nutritional supplemental use

3. Access

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1. Peripheral Access

1. Short term

2. Nutrition must be isotonic

2. Central Access

1. Longer term

2. Nutrition can be hypertonic

3. Considerations

1. When submitting labs drawn from a central line, you

must waste at least 10 mLs of blood before submitting a

sample

2. TPN/PPN can alter lab results

4. Solutions

1. Total Parenteral Nutrition (TPN)

1. Hypertonic solution

2. Dextrose >10%

2. Peripheral Parenteral Nutrition (PPN)

1. Isotonic

2. Dextrose < or = 10%

3. Consider total volume the patient can have

3. TPN & PPN

1. Can both contain

1. Lipids

2. Amino Acids

3. Heparin

4. Insulin

5. Electrolytes

6. Multivitamins

7. Other trace elements

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4. Always verify order!

5. Administration

1. Continuous

1. Lower rate

2. Over 24 hour

2. Cyclic

1. Higher rate

2. Better for ambulation

3. Consideration

1. If discontinuing parenteral nutrition, notify dietician

because of pausing of caloric intake

6. Monitoring

1. I&O

1. Monitor for total intake and output

2. Daily Weight

1. Monitor for changes

3. Vital Signs

1. Monitor for vital signs (increased potassium can cause

EKG changes, etc).

4. Lab Values

1. Monitor for electrolyte depletions and increases in

glucose

5. Sterile Techniques

1. Because the line is going centrally in most cases, all

lines must be treated as sterile lines

6. Flow Rate

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1. If you run out of TPN/PPN, you must have D5 available

because stopping the TPN/PPN abruptly is

contraindicated

7. Precipitation

1. Follow policy and monitor for precipitation when

administering drugs through another lumen of a central

or peripheral line

2. Not all drugs are compatible with TPN/PPN

1. As a precaution, generally try to use other

access for administering drugs

7. Complications

1. Infection

1. All PPN/TPN is administered through a venous access

1. Consider the sterility of the line when

changing dressings and administering any

TPN/PPN

2. Mechanical Complications

1. Obstruction

2. Air embolism

3. Metabolic Complications

1. Patient is at risk for

1. Electrolyte imbalance

2. Fluid imbalances

3. Hyperlipidemia

4. Nutrition deficiency

5. Liver disease or complication

Nursing Concepts

1. Nutrition

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2. Patient Education

3. Fluid & Electrolyte Balance

STUDY TOOLS:
NG Tube

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Central Line
This image displays the placement of a central line (Tunneled vs non-Tunneled)

Reference: https://www.uptodate.com/contents/central-venous-access-devices-and-approach-to-device-and-site-selection-in-adults/print

Tunneled vs Non-Tunneled Central Venous Catheter

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Enteral vs Parenteral Feeding

Enteral Feeding Parenteral Feeding

Indications Indications
• Functional GI tract • Non-Functional GI tract
Contraindications Contraindications
• Hemodynamically unstable • Hemodynamically unstable
• Risk of aspiration • Inability to gain venous access
Access Access
• Nasogastric tube (NGT) • Peripherally Inserted Central Catheter
• Orogastric tube (OGT) (PICC)
• Gastrojejunostomy tube • Central Venous Catheter (CVC)
• Jejunostomy Tube
Types Types
• Based on caloric needs • Total Parenteral Nutrition (TPN)
o Based on ability to eat and take in nutrition o Hypertonic solution
via the GI tract (can be affected by diseases) o Given via Central Line
• Peripheral Parenteral Nutrition (PPN)
o Isotonic solution
o Given via peripheral line
o Can be given peripheral IV
Monitoring Monitoring
• I&O • I&O
• Tube site (for skin breakdown) • Flow rate
• Lab values • Lab values
• Gastric residuals • Precipitation of solution
• Daily Weight • Daily Weight

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QUIZ
Question 1 of 10
A patient has developed hypocalcemia as a result of using TPN. Which of the following nursing
interventions are most appropriate in managing this situation? Select all that apply.
1. Increase vitamin D intake
2. Assess for refeeding syndrome
3. Administer loop diuretics
4. Assess renal function
5. Remove excess phosphate intake

Question 2 of 10
A nurse suspects that a patient has developed an infection because of a contaminated bag of TPN
which is currently infusing. Which of the following interventions is most appropriate in this
situation? Select all that apply.
1. Obtain a blood culture from the catheter site
2. Return the TPN bag to the pharmacy
3. Discontinue the TPN right away
4. Take a sample of the IV fluid for culture
5. Remove the bag and tubing at the IV hub

Question 3 of 10
A patient in the hospital has developed re-feeding syndrome. Which of the following patient
diagnoses includes the highest risk of developing re-feeding syndrome when using TPN? Select all
that apply.
1. Malnutrition
2. Anorexia
3. Prolonged fasting
4. Chronic alcoholism
5. Diabetes

Question 4 of 10
A nurse is teaching a patient who will be going home with TPN. Which information would the
nurse need to include when teaching this patient about home TPN use? Select all that apply.
1. Monitor blood glucose levels and promptly report any abnormalities
2. If particles are noted in the bag, gently rotate the bag to dissolve them
3. Record a weight in the same clothes at the same time each day
4. Warm the TPN bag in the microwave shortly before infusing
5. Always wash hands and the work area before changing TPN solution

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Question 5 of 10
A nurse is caring for a patient who is using TPN while in the hospital. Which of the following
elements would be checked on a daily basis while the patient receives TPN? Select all that apply.
1. Glucose level
2. Urinalysis
3. Intake and output
4. Magnesium level
5. Patient weight

Question 6 of 10
A patient who uses TPN has developed liver dysfunction as a result. Which of the following
elements are true regarding liver dysfunction and TPN use? Select all that apply.
1. Liver dysfunction can develop at any time after the start of TPN therapy
2. A patient who develops severe liver disease and cannot come off of TPN is at risk of developing
cirrhosis
3. The exact cause of liver dysfunction with TPN remains unknown
4. Older patients are at higher risk of liver problems from TPN than the very young
5. A patient who has a history of alcoholism is more likely to develop liver disease with TPN

Question 7 of 10
The nurse is caring for a patient with a feeding tube. Which of the following is the most appropriate
position for this patient during a feeding? Select all that apply.
1. Flat on the back
2. On the right side
3. Supine with HOB elevated 30 degrees
4. On the left side
5. Fowler's position

Question 8 of 10
A nurse is working with a patient who must start TPN therapy because of weight loss and
difficulties eating. Which of the following are aims of TPN therapy? Select all that apply.
1. Promoting a negative nitrogen balance
2. Avoiding infection
3. Increasing stores of protein in the body
4. Preventing skin breakdown
5. Preventing weight loss

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Question 9 of 10
A nurse is preparing to administer the next enteral feeding to a patient with a gastrostomy tube.
The patient complains of nausea. The nurse checks for residual before starting the feeding and
returns 200 mL. Which of the following actions of the nurse is most appropriate?
1. Get the patient out of bed to ambulate
2. Administer the feeding as ordered
3. Hold the feeding
4. Turn the patient prone

Question 10 of 10
A nurse is caring for a patient with a fluid volume deficit related to inadequate oral fluid intake
because of his medical treatment. The patient requires TPN. Which of the following nursing
interventions is most appropriate in this situation? Select all that apply.
1. Ask the patient to notify the nurse with increased thirst or weakness
2. Monitor intake and output each shift
3. Assess for situations that would cause fluid loss, such as emesis or sweating
4. Note the color and odor of stool
5. Assess skin turgor each shift

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HEAD TO TOE ASSESSMENT

(NUTSHELL) -VIEW
1. General Status

• Vital signs
• Heart rate
• Blood pressure
• Temperature
• Pulse oximetry
• Respiratory rate
• Pain

2. Head, Ears, Eyes, Nose, Throat

• Observe color of lips and moistness

• Inspect teeth and gums
• Assess buccal mucosa and palate
• Examine Tongue
• Examine at uvula
• Examine tonsils
• Palpate nose and assess symmetry
• Check Septum and inside nostrils
• Verify patency of nares
• Check patient’s sense of smell
• Palpate sinuses
• Assess patient hearing with whisper test
• Tuning Fork test (Weber’s test, Rinne test)
• Look inside ear
• Assess ear discharge and tympanic membrane
• Check conjunctive and sclera
• Assess eye symmetry
• PERRLA
• Check vision with Snellen Chart
• Check six cardinal positions of the gaze

3. Neck

• Palpate lymph nodes

• Observe and palpate trachea and neck
• Check for Jugular Venous Distention
• Check neck range of motion
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• Check shoulder shrug with resistance

4. Respiratory

• Listen to lung sounds front and back

• Assess respiratory expansion level
• Ask about coughing
• Palpate thorax

5. Cardiac

• Palpate the carotid and temporal pulses bilaterally

• Listen to heartbeat

6. Abdomen

• Inspect abdomen
• Listen to 4 quadrants of abdomen for bowel sounds
• Palpate 4 quadrants of abdomen for pain/tenderness
• Ask about problems with bowel or bladder

7. Pulses

• Check pulses in arms/legs/feet including,

o Radial
o Femoral
o Posterior tibial
o Dorsalis pedis

8. Extremities

• Assess range of motion and strength in arms/legs/ankles

• Assess sharp and dull sensation on arms/legs
• Check capillary refill on fingernails/toenails

9. Skin

• Check skin turgor

• Check for lesions, abrasions, rashes
• Check for tenderness, lumps, lesions
• Check if patient is pale, clammy, dry, cold, hot, flushed

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10. Neurological

• Oriented x3
• Assess gait
• Check coordination
• Assess reflexes
• Check Glasgow Coma Scale scor

Head to Toe Nursing Assessment (Physical

Exam) in Detail

Inspection
Begin your assessment of the skin by looking at the general color or pigmentation of the patient.
The patient’s color should be consistent with the genetic makeup of the patient, ranging from
pink to dark brown. Darker-skinned people may have areas of lighter pigmentation.

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Assess for freckles and birthmarks and use the ABCDE framework to determine abnormality of
these markers. Assess the patient’s skin color for any changes in color, also known as pallor,
cyanosis, jaundice. Darker-skinned people may be more complicated to find these skin changes
in them. The best place to look for these would be nail beds and lips.

Palpation

Palpate the skin and assess the temperature. Hypothermia versus hyperthermia. As you feel the
skin you should also assess for moisture or diaphoresis.

Assess the mucous membranes and for dehydration. The general texture of the skin should also
be smooth and firm, thickness of the skin should be uniform throughout the body. The heels and
palms may be a little bit thicker.

Assess the skin as well for edema, which would be fluid accumulation. You can assess for this
by palpating on the skin and seeing if there’s an imprint left after you lift your hand up. This is
known as pitting edema. It could be graded from a scale of +1 to + 4, with +4 being more severe.
Edema can mask other more serious signs and symptoms.

Assess the mobility and turgor of the skin. This can be done by pinching the skin up in a fold,
upon releasing the fold it should return to its normal state.

Assess the skin for vascularity and for bruising or lesions. Document their size, color, elevation,
general makeup, as well as the location, and make note of any exudate or odor coming from the
lesion.

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Abnormal Findings

Cyanosis

By James Heilman, MD (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

Rash

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Jaundice By James Heilman, MD

(Own work) [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

Macule, Patch, Papule, Plaque, Vesicles, Bulla, Fissure, Erosion, Ulcer

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By Madhero88 (Own work)

[CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

By Madhero88 (Own work)

[CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia CommonsBy Ma

dhero88 (Own work) [CC

BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

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SCALP

Inspection and Palpation

Inspect and palpate the scalp and hair. Assess for the color of the hair and scalp

Assess the texture of the hair. This can help with understanding nutritional status. Assess for
lesions on the scalp and ensure that the patient’s scalp is clean.

Reference: https://www.webmd.com/skin-problems-and-treatments/psoriasis/scalp-psoriasis-vs-dandruff

NAILS

Inspection and Palpation

Inspect and palpate the nails. Assess the shape of the nail as well as the color of the nail beds.
They should be smooth, clean, and round. Assess the surface of the nail to ensure that it is
consistent throughout and that the thickness of the nails is uniform.

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Lastly, assess for capillary refill. Press on the nail for a second or two upon removing pressure
color should return to the nail bed within 1 to 2 seconds. That would be normal capillary refill.

Abnormal Findings

Clubbing

By Desherinka (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 4.0-3.0-2.5-2.0-1.0

(http://creativecommons.org/licenses/by-sa/4.0-3.0-2.5-2.0-1.0)], via Wikimedia Commons

HEAD, FACE & NECK

Inspection and Palpation

When assessing the head, start with inspecting and palpating. Inspect the head for general
symmetry and appropriate size for the body. The skull should fill symmetrical and smooth. There
should be no tenderness on palpation.

Inspect the face for symmetry with the eyebrows, the nose, and the mouth. Make note of any
abnormal facial features or swelling or involuntary ticks of the muscles.

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Inspection and Palpation

Inspect the neck for symmetry and ensure that the neck is midline. Assess for neck range of
motion, if the patient is able to point the chin down, lift the chin up, and turn from left to right, as
well as the shoulders to the ear and extend the head backward. The motions should be smooth
and well-controlled. Palpate the temporal mandibular joint.

Palpate the lymph nodes. Use a gentle, circular motion to palpate the lymph nodes in front of the
ear and within the neck. Palpate the thyroid gland.

Abnormal Findings

Goiter

By Drahreg01 (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or

CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

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EYES

The eye is a sensory organ involved with sight. The eye is protected from external offenses like
light or dust by the upper and lower eyelid. The small open space between eyelids is known as
the palpebral fissure.

The outermost part of the eye is called the conjunctiva. It lines the inside of the eyelids and the
sclera and merges with the cornea which is the outermost covering of the iris and pupil. Behind
the cornea is the lens.

A part of the interior of the eye can be visualized with a ophthalmoscope. This area is called the
ocular fundus. In this area the optic disc and macula can be seen.

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The eye has three lays: sclera just under the conjunctiva, the choroid in the middle, and the retina
on the inside. The retina is where light waves are converted into nerve impulses.

Inspection

When assessing the eyes, inspect the pupils to insure they are equal, round, and reactive to light.

Test for visual acuity with the Snellen chart by having the patient stand 20 feet from the chart.
Remove glasses or contact lenses and cover the untested eye.

Reference: https://www.amazon.ca/Chart-Snellen-Wall-Charts-Exams/dp/B082VYXCY5

You should test the visual field. Have the patient look in all directions as you move a pencil in
those directions. Eye movement should be fluid and well-controlled.

Reference:

https://morancore.utah.edu/basic-ophthalmology-review/performing-the-confrontational-visual-field-exam/

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Inspect extraocular muscle function with the 6 cardinal positions. Move your finger in the 6
positions and have the patient move their eyes in those 6 positions.

Reference: https://www.registerednursern.com/assess-

six-cardinal-fields-gaze/

Use the confrontation test to assess visual field. Stand 2 feet away from the patient with a pencil
in each hand on either side of the patient. While moving the pencils toward midline have the
patient state when they can see them.

Assess eyebrows for symmetrical movement bilaterally.

Assess eyelids and lashes, notice any redness, swelling or discharge or lesions.

Assess the general shape of the eye. Inspect the eyeballs for any protrusion or sunken
appearance.

Inspect the conjunctiva and the sclera. Ask the patient to look up and while using your thumbs to
inspect the conjunctiva and sclera of the patient.

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Inspect the interior eyeball structures. Shine a light from side to side and check for smoothness
and clarity of the eye.

Reference:

https://www.medicinenet.com/perrla_eyes/article.htm

Inspect the iris and the pupils that the pupils can accommodate to light. You should determine
that both pupils are equal bilaterally. If the patient has 2 different-sized pupils, this is known as
anisocoria.

By Radomil talk (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-

sa/3.0/)], via Wikimedia Commons

Inspect the ocular fundus by darkening the room and having the patient remove their glasses.
Have the patient look at a specific mark with the eyes fixed while the examiner looks into the

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eyes to inspect the structures of the ocular fundus, specifically the optic disc retinal vessels, and
general background of the macula.

Reference:

https://stanfordmedicine25.stanford.edu/the25/fundoscopic.html

Inspect the color, shape, and margins of the optic disk.

Assess the retinal vessels, the number, the color, caliber.

Abnormal Findings

Pinguecula:

Pinguecula and pterygium (Surfer's Eye) are common, non-cancerous growths on the cornea

and conjunctiva likely caused by exposure to UV ...

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By Red eye2008 (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)],
via Wikimedia Commons

Xanthelasma

By Klaus D. Peter, Gummersbach, Germany

(Own work) [CC BY 3.0 de (http://creativecommons.org/licenses/by/3.0/de/deed.en)], via Wikimedia Commons

Arcus Senilis

By Loren A Zech Jr and Jeffery M Hoeg [CC BY 2.0

(http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

Ptosis

By Loren A Zech Jr and Jeffery M Hoeg [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons
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Exophthalmos

By Jonathan Trobe, M.D. – University of Michigan Kellogg Eye Center (The Eyes Have It) [CC BY 3.0
(http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

Conjunctivitis

By Joyhill09 [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia

Commons

Miosis

By Anonymous (Anonymous) [CC0], via Wikimedia Commons

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Mydriasis

By grendel|khan and Lady Byron (Own work. Also available from my flickr.) [GFDL (http://www.gnu.org/copyleft/fdl.html), CC-BY-SA-3.0
(http://creativecommons.org/licenses/by-sa/3.0/) or CC BY-SA 2.5-2.0-1.0 (http://creativecommons.org/licenses/by-sa/2.5-2.0-1.0)], via
Wikimedia Commons

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EARS

The ears are sensory organs involved with hearing and balance/equilibrium. The ear is divided
into three sections: external ear, middle ear, and inner ear.

The external ear is also known as the pinna or auricle. Sound travels into the external auditory
canal and reaches the ear drum or tympanic membrane. This thin membrane separates the
external and middle ear.

The eardrum vibrates in response to sound and the vibrations travel through the middle ear. The
middle ear contains three small bones called ossicles: incus, malleus, and stapes.

The inner ear contains the bony labyrinth which is an opening in the temporal bone that contains
the sensory organs for hearing and equilibrium.

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The bony labyrinth has three parts: semicircular canals, vestibule, and cochlea. The cochlea is
responsibly from turning the pressure from sound into impulses to communicate to the brain. The
vestibular system is responsible for balance.

Inspection and Palpation

Inspect the general size and shape of the outer ear. They should be equal bilaterally with no
obviously swelling or thickening. Assess skin condition, looking for lumps, lesions or
tenderness. Palpating the patient’s ear and mastoid process should be painless.

Inspect the external auditory meatus, there should be no swelling or redness. Most patients will
have some cerumen, but excessive cerumen would be abnormal.

Inspection of the interior of the ear is called the otoscopic examination. Choose the largest
speculum that fits inside the patient’s ear comfortably. For adults, pull the pinna up and back.
This helps straighten out the ear canal.

Hold the otoscope upside down with the dorsum of your hand along the person’s cheek. Inspect
the external canal, notice any redness, swelling, discharge, or any foreign bodies within the ear
canal.

Reference:

https://oxfordmedicaleducation.com/clinical-examinations/ear-examination/

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Assess the tympanic membrane by assessing the color and characteristics. It should be
translucent with a pearly grey color. The ear drums should be flat and slightly pulled in at the
center. The tympanic membrane should be completely intact.

Assess hearing acuity by beginning with the whisper voice test. Stand about 2 feet away and
whisper 2 syllable words into the patient’s ear while asking them to repeat the words they hear.

Reference:

https://geekymedics.com/hearing-ear-examination-osce-guide/

Assess air and bone conduction with tuning forks. The Webber test involves striking a tuning
fork and placing it midline on the patient’s skull. The patient should hear the sound equally
bilaterally.

The Rinne test compares air conduction versus bone conduction. Place the tuning fork midline
on the patient’s skull and ask them to state when they stop hearing the sound.

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Conductive hearling loss, SEnsorineural hearing loss

Reference: https://twitter.com/davidando98/status/1275560837973970946?lang=es

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Abnormal Findings

Eardrum Retraction

By Adrian L James (Own work) [CC BY-SA 3.0

(http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

Otitis Media

By http://www.sharinginhealth.ca (http://www.sharinginhealth.ca) [CC BY-SA 2.5

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Otitis Externa: Otitis externa is a condition that causes inflammation (redness and swelling)
of the external ear canal, which is the tube between the outer ear and eardrum. Otitis externa is
often referred to as "swimmer's ear" because repeated exposure to water can make the ear canal
more vulnerable to inflammation

By Klaus D. Peter, Gummersbach, Germany (Own work) [CC BY 3.0 de

(http://creativecommons.org/licenses/by/3.0/de/deed.en)], via Wikimedia Commons

Cauliflower Ear: Cauliflower ear is the result of a direct blow to the outer ear. Blood or other
fluids fill the space in between and disrupts normal blood flow. The skin on the surface of the ear
is the only blood supply for the cartilage. Without adequate blood flow, the cartilage is starved of
vital nutrients.

By Drvikram008 [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 3.0

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NOSE, MOUTH & THROAT

Inspection and Palpation

Begin your assessment of the nose, mouth, and throat by inspecting and palpating the nose.
Inspect the nose. It should be symmetric and midline on the face. There should be no deformities
or inflammation or skin lesions. Test the patency of the nostrils to reveal any obstruction in the
nasal cavity.

Inspect the nasal cavity using an otoscope and a wide-tip speculum. Inspect the nasal mucosa
noting its normal color and assess for any swelling or discharge.

Inspect the two turbinates, the bony ridges coming down the lateral walls of the nose and also
note any polyps or benign growths within the nose.

Reference: https://musculoskeletalkey.com/ear-nose-throat-and-mouth/

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Palpate the sinus area. You should palpate the frontal sinus, which is directly below the
eyebrows and the maxillary sinus right below the cheek bones. The patient will feel pressure, but
they should not feel pain.

References: https://www.entkidsadults.com/sinus-allergy/sinusitis-and-allergies/Abnormal Findings

Deviated Septum

By Mike Gerkin (Own work) [CC BY-SA 3.0

(http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

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Nasal Polyp

By MathieuMD (Own work) [CC BY-SA 3.0

(http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

Inspection

Reference: https://geekymedics.com/oral-cavity-examination-osce-guide/

Inspect the mouth. Inspect the lips for their color, moisture, notice any lesions or discoloration.

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Inspect the teeth. The teeth should be straight and evenly spaced. There should not be any absent
or loose teeth or abnormally positioned teeth. Ask the patient to bite and note the alignment of
the jaw.

Inspect the gums. The gums should look pink. Check for swelling or any gingival margins, any
bleeding or discoloration.

Inspect the tongue. The tongue is pink. It should be even. Some patients may have a thin, white
coating on their tongue. To inspect the area beneath the tongue, have the patient touch the roof of
their mouth with their tongue. Make note of any ulcerations or nodules.

Inspect the buccal mucosa, which should be soft and pink and smooth. The Stensen’s duct is the
opening of the parotid salivary gland.

Reference:

https://www.uptodate.com/contents/images/PC/115303/Anatomyofthesalivaryglandsandducts.jpg

Inspect the palate. The anterior palate is hard with rugae. The posterior palate is soft. Ask the
patient to say “ah” which will cause the soft palate and the uvula to rise which aids in testing
cranial nerve X, the vagus nerve.

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Abnormal Findings

Cheilitis: Cheilitis is an inflammation of the lips, which could be acute or chronic. The

inflammation primarily arises in the vermilion zone but may extend to surrounding skin and less

commonly, to the oral mucosa.

By Lesion (Own work) [CC BY-SA

3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

Herpes

Aphthous Ulcer: Canker sores, also called aphthous ulcers, are small, shallow lesions that

develop on the soft tissues in your mouth or at the base of your gums. Unlike cold sores, canker

sores don't occur on the surface of your lips, and they aren't contagious. They can be painful,

however, and can make eating and talking difficult

By Photographer: User: TheBlunderbuss (Own work. Published under GFDL in

English Wiki) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)], via
Wikimedia Commons

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Torus Palatinus: Torus palatinus is a harmless, painless bony growth located on the roof of

the mouth (the hard palate). The mass appears in the middle of the hard palate and can vary in

size and shape. About 20 to 30 percent of the population has torus palatinus. It occurs most

frequently in women and those of Asian descent.

http://commons.wikimedia.org/wiki/User:Dozenist [GFDL (http://www.gnu.org/copyleft/fdl.html), CC-BY-SA-3.0

(http://creativecommons.org/licenses/by-sa/3.0/) or CC BY-SA 2.5-2.0-1.0 (http://creativecommons.org/licenses/by-sa/2.5-2.0-1.0)], via
Wikimedia Commons

Inspection

Inspect the throat. Inspect the tonsils by having the patient open their mouth. Tonsils are graded
on their size with one plus being visible, two plus halfway between the tonsillar pillars and
uvula, three plus touching the uvula, and four plus touching each other. Many patients will have
one plus or two plus as a normal finding.

1+: Visible

2+: Extend to Pillars

3+: Touching the uvula

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4+: Touching each other

Inspect the posterior throat for exudate or lesions. Use a tongue blade to elicit a gag reflex.
Testing the gag reflex helps with assessing cranial nerves IX and X . Assess cranial nerve XII,
the hypoglossal nerve, by asking the patient to stick their tongue out. The tongue should protrude
midline with no deviation from side-to-side.

Reference: https://slidetodoc.com/a-good-nights-sleep-is-important-overcoming-sleep/

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Abnormal Findings

Tonsillitis

By Nick Berman (Own work) [CC

BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons

THORAX and LUNGS

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Inspection

Inspect the posterior chest, the spine, spinal process which straight and midline. The thorax
should be symmetric. The neck and trapezius muscles should be developed normally for the age
and lifestyle of the patient. The patient’s skin color should be consistent with the patient’s
background with no abnormal coloring or lesions.

Palpation

Palpate the posterior chest. Confirm symmetric chest expansion. Place your hands on the
posterior chest wall between level T9 and T10. Ask the patient to take a deep breath while
watching your hands, they should move apart symmetrically.

Palpate for fremitus, which is a palpable vibration. This is done by placing the ball of the fingers
on the patients while having them repeat the “ninety-nine”. Assess areas of the chest noting that
vibration is equal corresponding areas. Fremitus will decrease as you move down.

Palpate the chest wall. Notice any areas of tenderness or decreased temperature or moisture or
lesions.

Percussion

Percuss of posterior chest. This is done by starting at the apex and percussing down in the
intercostal spaces. Avoid bony processes like the scapula and ribs. Resonance should be heard in
healthy lung tissue.

Assess diaphragmatic excursion, which is the movement of the thoracic diaphragm during
breathing. This is done by percussing to map out the lower lung border during inspiration and
expiration. Normal diaphragmatic excursion should be three to five centimeters.

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Auscultate

Auscultate the posterior chest. Begin at the apex, around C7 and proceed to the bases around
T10. Begin at C7 and move horizontally across the posterior chest. Three types of normal breast
sounds will be heard, bronchial, bronchovesicular, and vesicular. Bronchial breath sounds are
high pitched, and inspiration is shorter than expiration. Bronchovesicular is moderately pitched,
and inspiration is equal to expiration. Vesicular breath sounds are low pitched, and inspiration is
longer than expiration. While auscultating breath sounds, be cautious to note any adventitious
breath sounds which are abnormal breath sounds.

Reference: https://www.facebook.com/themedicopage/photos/pcb.764421263906960/764421183906968/

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INTEGUMENTARY

Inspection

Inspect the shape and configuration of the anterior chest noting that the ribs slope downward and
are symmetric, and intercostal spaces are symmetric as well. The patients’ abdominal muscles
should be appropriately developed for the age and activity level. The patient’s face should be
relaxed, and they should not be showing any signs of tension.

Assess the patient’s skin color and condition and assess the quality of respirations. Normal
breathing should be relaxed, regular, and effortless, and should produce no noise. Assess the
patient’s respiratory rate and ensure that it is within normal limits.

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Percussion

Percuss the anterior chest by beginning at the apex and percussing the intercostal spaces from
one side to the other in a descending motion. Dullness is heard over the heart tissue near the fifth
intercostal space. In the right midclavicular line, dullness will be heard over the liver. Tympani
will be evident over the gastric space.

Auscultation

Auscultate the anterior chest. This is done by beginning at the apex in the supraclavicular areas
and moving down from side-to-side noting the three types of breath sounds as mentioned earlier,
bronchial, bronchovesicular, and vesicular. Listen to one full respiration in each location.

HEART (CIRCULATORY SYTEM)

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Inspection and Palpation

Palpate the carotid artery. Palpate one artery at a time to avoid compressing blood flow to the
brain. Palpate for pulse strength and equality bilaterally.

Auscultate the carotid artery. This is especially indicated in older individuals and those who
demonstrate signs of cardiovascular disease. Auscultate for bruit. Listen with the bell of the
stethoscope and apply over one carotid artery at a time being cautious not to apply any direct
pressure to avoid creating an artificial bruit.

Inspect the jugular venous pulse. This is done by laying the patient at an angle from 30 to 45
degrees to avoid flexing the neck. Ask the patient to turn their head away from the examiner
while shining a bright light on the neck. This will highlight the pulsation and shadows of the
jugular venous pulse. As a person is raised to the sitting position, the jugular should flatten and
disappear usually around 45 degrees.

Inspect the anterior chest for a visible apical impulse. This is also known as point of maximum
impulse. If visible, this should be over the fifth intercostal space.

Palpate the apical pulse. This can be done with just one finger pad. Note the location, which
should be over the fifth intercostal space, the size, amplitude, and duration.The apical pulse may
not be palpable with many patients.

Palpate across the precordium. With the palms of four fingers palpate gently across the
precordium assessing for any other pulsations.

Auscultate

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By Madhero88 (Own work Reference

netter image) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

Auscultate the heart sounds. Auscultate the four valve areas. These auscultation areas are not
over the anatomical structures, but rather over the areas where sounds are most pronounced and
most easily heard. The mnemonic APE To Man is useful in recalling the order of auscultation.
APE would stand for aortic, pulmonic, and Erb’s point; To Man, tricuspid and mitral.

The aortic valve should be located over the second right intercostal space. The pulmonic valve
auscultation area should be located over the second left intercostal space. The tricuspid valve
area would be over the left lower sternal border and the mitral valve can be heard over the fifth
intercostal space around the left midclavicular line. Actual locations of heart sounds may vary
from patient to patient.

Auscultate with the bell for murmurs. Auscultate for any S3 and S4 murmur sounds. Note the
rhythm of the heart and the rate. Listen to S1 and S2 separately and listen for any sorts of
splitting or murmurs. Murmurs are classified by their timing, loudness which is graded from
grade one through six. The pitch and the pattern, the quality, location, radiation, posture.

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The peripheral vascular system is the transport system in the body. Vessels in the body contain
fluids which can carry a variety of substances throughout the body. The heart pumps blood to the
lungs where blood picks up oxygen and returns the heart.

The heart then deliveries the oxygenated blood and nutrients to the body via arteries. Once
oxygen has been picked up by cells in the body blood and waste travels back the heart via veins.

Reference: https://link.springer.com/chapter/10.1007/978-1-4471-6738-9_1

Inspection and Palpation

Inspect and palpate the arms. Note the color of the skin and the nail beds, the temperature,
texture, turgor of the skin and assess for any lesions and edema.

Assess capillary refill. This is done by depressing the nail beds and assessing how long it takes
for the color to return. This should happen within one to two seconds.

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The arms should be symmetric in size. Assess pulses in all extremities. Palpate radial pulses and
dorsalis pedis pulses. Normal would be plus two pulse and they are graded from zero, one plus,
two plus, and three plus.

Inspect and palpate the legs. Inspect color, hair growth, venous pattern, any swelling or lesions.
Inspect the hair to see if hair growth is even throughout the legs.

Legs should be symmetric in size without new swelling or atrophy. Assess calf circumference
and measure the widest part in the same on either side.

Palpate to assess the temperature. Palpate the inguinal lymph nodes and note for any unusual size
and make sure that they are non-tender.

Palpate peripheral arteries in both legs. The femoral pulse is found just below the inguinal
ligament halfway between the pubis and the anterior-superior iliac spine. Palpate popliteal
pulses. This is done with the person’s leg extended and relaxed with the examiners fingers just
underneath. Posterior tibial pulses are found along the medial malleolus. The dorsalis pedis pulse
is lateral and parallel to the big toe. Doppler may to assess these pulses if they are not easily
palpated.

Reference: https://meded.ucsd.edu/clinicalmed/extremities.html
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Assess for peripheral edema. Edema is graded from one plus, two plus, three plus, and four plus.

1+: being mild pitting and no swelling of the leg

2+: moderate: both feet plus lower legs, hands, or lower arms

3+: severe: generalized bilateral pitting edema, both feet legs, arms, and face

4+: very deep pitting and indentation lasts a long time, and the leg appears to be very swollen

Reference: https://www.grepmed.com/images/3656/physicalexam-pitting-edema-severity-diagnosis

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Abnormal Findings

Peripheral Artery Disease (Arterial Ulcer) Vs Chronic Venous Insufficency.

By Jonathan Moore [CC BY

3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

Reference: https://www.registerednursern.com/peripheral-arterial-disease-vs-peripheral-venous-disease-nclex-review/

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Pitting Edema

By James Heilman, MD (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL

(http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

Inspection

Inspect the contour of the abdomen. This is done by stooping to view across the abdomen to
determine if it is flat to slightly rounded. Assess the symmetry of the abdomen by shining a light
across and assessing for any bulging or visible masses, or asymmetry.

Assess the umbilicus, and notice any discoloration, inflammation, or hernia. There should be
none. Assess the skin texture and color. There should be no lesions or scars. If scars are present
note the length and general nature.

Assess for any pulsations or movement in the abdominal area. In some individuals, it may be
possible to see pulsations of the aorta. Respiratory movements may also be seen in patients.

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Auscultate

Auscultation comes after inspection in the abdomen so that palpation does not disrupt bowel
sounds and change your assessment.

Begin in the right lower quadrant and use the diaphragm of the stethoscope pressed lightly
against the skin. Note bowel sound characteristics and frequency. They should be anywhere from
five to 30 times per minute.

It is not necessary to count bowel sounds, but note if they are hypoactive, hyperactive, or normal.
Listen for one full minute in each abdominal quadrant to determine activity.

Auscultate vascular sounds within the abdomen. You should listen for any bruits, and you’re
going to be listening to the aorta, the left renal artery, the iliac artery and the femoral artery. You
may need to use firmer pressure to listen for these sounds.

Reference: https://meded.ucsd.edu/clinicalmed/abdomen.html
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Percussion

Percuss for tympany. Percuss to determine the location and size of the liver and the spleen.
Percuss in all four quadrants. Tympanny will be heard due to air in the intestines. A duller sound
would indicate a mass, or distended bladder, or adipose tissue.

To measure the size of the liver, begin g in the right midclavicular line. Percuss down the right
midclavicular line, listening for when lung resonance stops, the sound will change to a dull
sound. Mark that spot, which should be around the fifth intercostal space. Continue percussion
until tympany is heard once again. This indicates the lower border of the liver.

Measure the distance between the two marks. This indicates the size of the liver. It should range
from 6 to 12 centimeters in healthy adults.

To assess the spleen begin by percussing a dull tone over the ninth to eleventh intercostal space,
on the left midaxillary line.

Percussion of the kidneys aids in assess for pain and tenderness. This is done by placing the
nondominant hand over the costovertebral angle. The nondominant hand is struck with the ulnar
surface of the dominate hand made into a fist. Repeat over both kidneys.

Palpation

Begin palpation by working from light to deep palpation. You begin with light palpation with the
forefingers close together, and you should make a small circular motion. Lift the fingers between
the quadrants. As you’re moving around the patient, you should assess for any guarding and
notice if the patient is feeling pain.

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Upon completion of light palpation move on to deep palpation. To do this place two hands, one
on top of the other, the top hand pushes the bottom hand. As this is done take note of the location
size and consistency of the abdomen, as well as any tenderness.

Assess for the colon, there may be some tenderness over the colon which is a normal finding. If a
mass is felt note the location, size, consistency, and any tenderness.

Assess the location of the liver, via palpation. Place your left hand under the person’s back, and
lift up to support the abdominal contents. You should then place your right hand on the right
upper quadrant, and push deeply down and under the right costal margin. The person should take
a deep breath, and with this you should be able to feel the edge of the liver. The liver may not be
palpable.

The spleen generally is not palpable. If it is palpable, it may be due to being enlarged. Reach
your left hand over the abdomen, and behind the left side of the eleventh and twelfth ribs. You
should then place your right hand on the left upper quadrant, with the right fingers pointing
towards the left axilla. Push your hand deeply down under the left costal margin. Ask the person
to take a deep breath.

When assessing the kidneys place your hands together and position them at the person’s right
flank, and then press firmly and deeply, and ask the person to take a deep breath. You should feel
no change. You may feel the lower portion of the kidney. Do the same thing on the left side, with
the left kidney sitting about one centimeter higher than the right kidney. It should not normally
be palpable.

Palpate the aorta, use your thumbs to palpate the aortic pulsation in the upper abdomen. Assess
for costovertebral angle tenderness. Place one hand at the costovertebral angle, and the person
should feel no pain.

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Assess for rebound tenderness to identify peritoneal irritation. To do this hold your hand
perpendicular to the abdomen, and push down gently, slowly and deeply, then lift up quickly. If
the patient feels rebound tenderness, this is a sign of peritoneal inflammation. Ask where the
pain is most intense.

If the patient has a distended abdomen, testing for a fluid wave will help to distinguish between
dilated loops of bowel, fat, and free fluid. Have the patient place the ulnar edge of their hand in
the umbilical area, mid-line abdomen. You should then place your left hand on the person’s right
flank, and with your right hand reach across the abdomen and give the left flank a firm shake. If
ascites is present, this will generate a fluid wave through the abdomen. A distinct tap on your
opposite hand if ascites is present.

Reference: https://www.stepwards.com/?page_id=1275

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Abnormal Findings

Ascites

Cullen’s Sign: Cullen's sign is described as superficial oedema with bruising in the subcutaneous

fatty tissue around the peri-umbilical region. This is also known as peri-umbilical ecchymosis. It

is most often recognised because of haemorrhagic pancreatitis.

By Herbert L. Fred, MD and

Hendrik A. van Dijk (http://cnx.org/content/m14904/latest/) [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

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Inspection and Palpation

When assessing the musculoskeletal system, begin with inspection. Inspect corresponding joints,
structure, and function of each joint to determine full range of motion is present. Note the size of
each joint, color, swelling, and any masses or deformity on the joint. Palpate the joint and skin to
note temperature, as well as musculoskeletal or muscular deformations or swelling at the joints.

Assess range of motion of the joints by asking the patient to do active range of motion in the
joint corresponding to the type of joint that it is, whether it should be flexion, extension,
abduction, adduction, pronation, supination, circumduction, elevation, depression, rotation,
protraction, retraction, eversion, and inversion. Have the patient try to attempt these movements
in each of their joints.

If the patient is unable to do so, attempt passive range of motion. Assist the patient with passive
range of motion. If they are unable to complete passive range of motion exercises, do not force
any movements. You can use a goniometer to measure the angles at which the patient is able to
move. Joint motion should not cause pain or tenderness, or crepitation.

Assess the cervical spine. Inspect the spine first to see that it is aligned with the head and neck,
and that it is centered. Palpate the spine and spinal processes. They should feel firm with no
spasms or tenderness.

Ask the patient to touch chin to chest, lift their chin toward the ceiling, touch each ear toward the
corresponding shoulder without lifting the shoulder, and turn the chin toward each shoulder. The
patient should be able to do these movements equally bilaterally, without any sort of pain.

Assess the upper extremities. Inspect both shoulders, posterior and anteriorly check for the size,
and check for any atrophy, deformity or swelling. Palpate the shoulders and assess that there are
no spasms, tenderness, swelling or heat.
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To test range of motion in the upper extremities ask patient stand with arms at sides and elbows
extended. Have the patient move each arm forward in upward arcs and vertical arcs. They should
then rotate the arms internally, behind the back, and place back of hands as high as possible.

Test the strength of the shoulder by asking the person to shrug the shoulders up and place a slight
amount of resistance.

Inspect the elbow, inspect the size and contour, notice any sorts of deformity, or swelling, or
lesions. Test range of motion by asking the person to bend and straighten the elbow.

Inspect the wrist and hand, noting position, contour and shape. The fingers should lie straight
along the same axis as the forearm. There should be no swelling, redness or deformity. The skin
should be smooth, the muscle should be full. You should palpate each joint in the wrists and
hands.

There should be no bogginess. The surfaces should be smooth. Test range of motion on the
wrists and hands by having the patient bend the hand up at the wrist, bend the hand down, and
bend the fingers up and down. The patient should be able to have their palms flat, and turn them
inward and outward, spread the fingers apart and make a fist, and touch the thumb to each finger
on the hand.

Assess the lower extremities. Begin by assessing the hip and the hip joint. Assess that there is
symmetry at the level of the iliac crest, and that the patient has a smooth gait.

Lay the patient in a supine position and palpate the hip joints to test for range of motion in the
hip. Have the patient raise each leg, with knee extended, bend each knee up to the chest while
keeping the other leg straight. The patient should be able to swing the leg laterally then medially

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with the knee straight. The patient should be able to, in a standing position, swing a straight leg
back behind the body.

Next, inspect the knee. Inspect the lower ligament, and inspect the knee shape and contour.
There should be no swelling within the knee. Check the quadricep muscle and anterior thigh for
any atrophy. Assess range of motion by asking the patient to bend each knee, extend each knee.
Have the patient walk, and assess ambulation as well as range of motion during ambulation.

Assess strength by asking the person to keep the knee flexed while applying a slight amount of
pressure.

Inspect the ankle and foot. Compare both feet, the positions of toes and characteristics. Assess
for any abnormalities.

Assess the spine. The person should be standing. Place yourself far enough back so that you can
see the entire back. Note if the spine is straight by following an imaginary vertical line from
head, through the spinous processes and down to the gluteal cleft.

The person’s knees should be aligned with the trunk and should be pointing forward. From the
side, you should note a normal convex thoracic curve and a concave lumbar curve. You should
assess range of motion of the spine by asking the person to bend forward and touch the toes.
They should be able to do this in a smooth fashion.

Assess for Homans sign to identify DVT. (Lets Watch Video)

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Abnormal Findings

Kyphosis

By MusicNewz (Own work this is me) [CC0], via Wikimedia Commons

Scoliosis

By BruceBlaus. When using this image in external sources it can be cited as:
Blausen.com staff. “Blausen gallery 2014”. Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762. (Own work) [CC
BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

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Kyphosis, Lordosis, Scoliosis

By Patrick J. Lynch, medical illustrator (Patrick J. Lynch, medical illustrator) [CC BY 2.5 (http://creativecommons.org/licenses/by/2.5)], via

Wikimedia Commons

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By
Brain_human_normal_inferior_view_with_labels_en.svg: *Brain_human_normal_inferior_view.svg: Patrick J. Lynch, medical illustrator
derivative work: Beao derivative work: Dwstultz [CC BY 2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons

The central nervous system is composed of the brain and spinal column. The brain is encased by
the skull and the spinal column by the vertebrae. The primary cell of the CNS is the neuron
which has unique capabilities. The brain consists of a right and left hemisphere connected by a
group of nerves called the corpus callosum. Each hemisphere contains a frontal lobe, temporal
lobe, parietal lobe, and occipital lobe.

In the middle of the brain is the thalamus. It relays sensory signals to the cerebral cortex. It is
also involved in sleep wake cycles.

The hypothalamus located just below the thalamus plays a role in hunger, thirst, sleep, emotions,
temperature, and stimulation of the pituitary.

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Posterior to the hypothalamus is the midbrain and below that is the pons. They are involved in
motor and sensory functions.

The cerebellum is associated with balance and equilibrium, coordination, muscle tone. The
medulla helps regulate respiratory, gastrointestinal and heart functions.

Spinal cord

There are 12 pairs of cranial nerves and 31 pairs of spinal nerves. The cranial nerves originate in
the brain while the spinal nerves originate from different sections of the spinal cord. The spinal
nerves are further classified based on location: sacral spinal nerves, thoracic spinal nerves etc.

Neurons are the primary cell found in the central nervous system. They have a unique shape that
allows them to be quick and efficient communicators. This allows us to instantly sense pain in
our hand from a hot stove.
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Neurons are capable of transmitting electric impulse as well as communicating chemically via
neurotransmitters.

Level of Consciousness

When conducting the neurological system assessment, begin by assessing level of consciousness.
Is the person alert, awake and aware of the stimulus in their environment? Are they oriented to
person, time, situation and place? What’s their facial expression? What is the quality of their
speech? What is their general mood and affect?

Assess the appearance of the patient, the position and posture as well as dress and grooming.

Assess cognitive function. Is the person oriented to time, place and person? Assess attention
span. Are they able to focus on the interview? Are they able to focus on you and what is being
done at the moment? What is their recent memory? Are they able to recall why they’re in the
hospital, what happened, what brought them there?

Assess remote memory, past events, birth dates? What is their judgment? Assess thought
processes. Is the person making sense? Are they able to make sense of what is happening?
Assess their perceptions, ask them questions about their perception of the world.

Screen them for suicidal thoughts. Ask if they have any thoughts of hurting themselves.

Further assess neurological status. Are they alert? Meaning, are they awake and readily aroused?
Are they fully aware of what’s happening? Are they lethargic or somnolent, not fully alert, and
drift into sleep, and require stimulation? Are they obtunded, sleeping most of the time, very
difficult to arouse? Are they in a stupor, they respond only to vigorous shaking?

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Or are they in a coma, completely unconscious? Each institution might have different definitions
and states for level of consciousness, so it is important to understand how your hospital and your
organization determines level of consciousness.

Test cranial nerves. Test cranial nerve II the optic nerve by testing visual acuity. Assess cranial
nerves II, IV, and VI, ocular motor, trochlear and abducens nerves. Assess pupil size, the
regularity, equality, reaction to light. Are they equal round and reactive to light? This is known
as PERRLA. Assess for extra ocular movements by assessing for the six cardinal positions.

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Assess cranial nerve V, the trigeminal nerve, by assessing motor function. Palpate the temporal
masseter muscles as the person clenches their teeth. With the person’s eyes closed, test light
touch sensation by touching the forehead, cheeks and chin, and having the person state when
they feel that they’re being touched.

Test the facial nerve, cranial nerve VII, by motor function. By noting facial symmetry as the
person responds, as they smile, frown, close eyes tightly, and lift eyebrows, to show teeth.
Assess for symmetry on each side.

Inspect and palpate the motor system. Assess cerebellar function by assessing gait and balance.
Is the person able to walk in a smooth gait, is it rhythmic, effortless, and coordinated? Use the
Romberg test by asking the person to stand up with their feet together. Have the person stand
with their feet together and close their eyes, are thry able to stand in a completely balanced and
coordinated fashion for 20 seconds.

Assess the sensory system. The person needs to be alert, comfortable and cooperative in order to
do this. Assess for superficial pain by using something sharp and something dull to touch the
patient, determine is the patient is able to distinguish between sharp and dull.

Assess stereognosis by placing different objects in the patient’s hand with their eyes closed, and
determine if they can distinguish between items like paperclips, keys, and coins.

Assess reflexes. Reflexes are graded from zero to four: zero, no response, to four plus, very
brisk, hyperactive.

0: no response

1+: diminished

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2+: average or normal

3+: brisker than average

4+: very brisk, hyperactive, clonus, indicative of disease.

Assess the bicep reflex, which will test C5 and C6. Assess the tricep reflex, which would be C7
and C8. Assess patellar reflex, L2 to L4. The achilles reflex tests L5 to S2.

Assess the plantar reflex, which would be L4 to S2, with the end of the reflex hammer.

Assess for Babinski reflex by drawing a light stroke from the person’s heel to the person’s toes
in the shape of a J. The normal response is the plantar flexion of the toes, which would be
bringing the toes forward toward the stimulus. A positive Babinski reflex would indicate when
there’s upper motor neuron disease.

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Abnormal Findings

Bells Palsy

By James Heilman, MD (Own work) [CC BY-SA 3.0

(http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

Dystonia

By James Heilman, MD (Own work) [CC BY-SA 3.0

(http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

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Meningitis (neck stiffness)

Positive Babinski Sign: In adults and children over the age of 2 years, the Babinski reflex may be
a sign of an underlying central nervous system disorder or another issue in the cortical spinal
tract. Possible associated disorders include:

spinal cord injury

tumors in the spinal cord

defects in the spinal cord or spinal column

brain tumors

multiple sclerosis (MS)

Lou Gehrig disease

stroke

meningitis

cerebral palsy

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Reference: https://www.medicalnewstoday.com/articles/babinski-reflex

Inspection and Palpation

Inspect and palpate the scrotum. Scrotal size will vary depending on patient and room
temperature. Asymmetry is normal with the left scrotal half lower than the right. There should be
no lesions or cysts.

Palpate each half between your thumb and first two fingers. Testis should feel oval. They should
be freely movable and slightly tender. There should be no other scrotal content

Inspect and palpate for hernia by inspecting the inguinal region for bulge. Palpate the inguinal
canal while the patient strains down. Inspect here for inguinal lymph nodes by palpate along the
vertical chain within the upper inner thigh.

Instruct the patient to conduct a testicular self-examination once a month, the best time for this
being after a warm shower.

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Prostate Examination
Palpate the prostate gland by pressing into the gland to note the size. The size should be about
two-and-a-half centimeters long, about four centimeters wide and should not protrude more than
one centimeter into the rectum. Its shape should be heart shape and the surface should be smooth.
It should be elastic, and rubbery, and slightly movable. There should be no tenderness on
palpation. As the examination finger is withdrawn assess any signs of bright blood or mucous on
the glove. At this time test stool for occult blood.

Inspection and Palpation

When conducting the assessment of the female genital urinary system, you should note skin
color, hair distribution.

The labia majora should be symmetrical and well-formed. There should be no lesions or cysts.
With a gloved hand, separate the labia majora to inspect the clitoris. The labia minora should be
dark pink, moist and symmetric. The perineum should be smooth, the anus has coarse skin with
increase pigmentation.

Palpate the clitoral glans. Assess the urethra and Scenes glen. Insert your finger into the vagina
and apply pressure up and out. There should be no pain upon doing this.

Assess the Bartholin’s gland by palpating the posterior part of the labia majora.

Inspect the genitalia by using a speculum for examination. With the speculum inserted, inspect
the cervix. The color should be pink and even within a female who is not pregnant. The position
should be midline. The size is about two-and-a-half centimeters. The os is small and round in
women who have never been pregnant, in parous woman it is a horizontal, irregular slit. It should
be smooth.
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If there are secretions depending on menstrual cycle, they should be odorless.

Obtain cervical cultures or this is called Pap smear (Papanicolaou) to screen for cervical cancer.

Nicholasolan at en.wikipedia [CC-BY-SA-3.0

(http://creativecommons.org/licenses/by-sa/3.0/), GFDL (www.gnu.org/copyleft/fdl.html), CC-BY-SA-3.0
(http://creativecommons.org/licenses/by-sa/3.0/) or CC BY-SA 2.5-2.0-1.0 (http://creativecommons.org/licenses/by-sa/2.5-2.0-1.0)], from
Wikimedia Commons

Bimanual Examination

With the woman in a lithotomy position, one hand will be placed on the abdomen, with the other
hand insert two fingers into the vagina. Palpate the vaginal wall. It should be smooth with no
areas of induration or tenderness. It should feel consistent throughout, be evenly rounded, with
the cervix able to move from side-to-side.

With the abdominal hand push the pelvic organs closer to your intervaginal fingers to palpate.
Palpate the uterine wall. It normally feels firm and smooth. The uterus should be moved freely
and non tender.

Conduct a recto-vaginal examination to assess the recto-vaginal septum, posterior uterine wall,
cul-de-sac, and rectum. This may feel uncomfortable to the woman and feel as though she were
having a bowel movement. With one hand, insert one finger into the anus and one into the
vagina, and with the other hand will use to apply pressure to the abdomen.
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The recto-vaginal septum should feel smooth and thin. The uterine wall and fundus should feel
firm and smooth. As rectal finger is withdrawn assess for any signs of blood.

Inspection and Palpation

Inspect the breast. Note asymmetry and size. There may be a slight amount of asymmetry in the
size of the breast which is normal. The skin should be smooth. There should be no lesions, or
dimpling, or redness. There should be no edema.

There should be no bulging, discoloration or edema in lymphatic draining areas. The nipples
should be symmetrically located and should usually protrude although some may be flat or
inverted. If an inverted nipple is noted, question the patient if that is new occurrence or pre-
existing.

Assess for retraction by asking the woman to lift both arms above her head, both breasts should
move up symmetrically. Ask the patient to place her hands on her hips and push her two palms
together. There will be slight lifting of both breasts.

Inspect and palpate the axilla. Inspect the skin for any rash or infection. Lift the patients arm and
support it yourself so that her muscles relaxed. Reach your fingers into the axilla and move them
firmly down in each direction. The lymph nodes are generally not palpable and there should be
no tenderness when you palpate in there.

Palpate the breast. Ask the patient to lay in a supine position with a small pad under the side to
be palpated. Use the pads of your first three fingers and make a gentle rotation movement on the
breast. Palpate from the nipple and move outward, feeling for any nodules. Make note of any
discharge.

Note the location, size, shape, consistency, skin color and tenderness of any lumps or masses.
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Instruct the patient to conduct a breast self-examination or BSE. The best time for this is right
after the menstrual period or the fourth through seventh day of the menstrual cycle.

When assessing the male breast, inspect it and note any lumps or swelling. Gynecomastia is
enlargement of the breast tissue. There should be no nodules or swelling in the male breast.

By BruceBlaus. When using this image in external

sources it can be cited as: Blausen.com staff. “Blausen gallery 2014”. Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN
20018762. (Own work) [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

The lymphatic system is a transport system like the peripheral vascular system; however the
vessels are separate. The lymph system is composed of lymph vessels, lymph nodes, lymph
ducts, and lymph nodules.

When blood is transported throughout the body plasma from the blood flows into interstitial
spaces. To prevent excess, build up the lymph system is there to drain excess fluid and plasma
protein.

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Lymph is collected in vessels and drains into different lymph nodes in the body where it is
filtered, and microbes can be killed. Lymph is then sent to lymph ducts which deposit lymph into
veins into the body to become part of the plasma in the blood supply.

Lymph is very similar to plasma in the blood. The head and neck drain into the cervical lymph
nodes. The breast and upper arm are drained by the axillary lymph nodes. The hand and lower
arm drain into the epitrochlear lymph node, and the lower extremity drains into the inguinal
nodes. Lymph nodules like the thymus and spleen do not connect directly with rest of the lymph
system and help protect the body from external pathogens.

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STUDY TOOLS:

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QUIZ
Question 1 of 10
A patient is brought to the emergency department after being involved in a motor vehicle collision.
The patient was the restrained passenger and is conscious and alert. Vitals are as follows: HR 115,
BP 100/60, RR 26. The patient has a visible seat belt sign across the lower abdomen and is
complaining of pain in the left shoulder. The primary nurse suspects the patient might have an
injury to which of the following?
1. Spleen
2. Liver
3. Sigmoid Colon
4. Appendix

Question 2 of 10
When assessing the Patient’s abdomen, what is the first thing the nurse will do?
1. Palpation
2. Percussion
3. Auscultation
4. Inspection

Question 3 of 10

A nurse is caring for a patient in the hospital and notes these nodes on the Patient’s joints (see
image). Based on this finding, which diagnosis would the nurse expect to find in the Patient’s
medical history?
1. Osteoporosis
2. Osteoarthritis
3. Lupus erythematosus
4. Rheumatoid Arthritis

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Question 4 of 10
A patient with a history of malnutrition has skin breakdown in several areas of the body with bony
prominences. The nurse first determines the Patient’s age in the initial assessment. Which best
describes the rationale for this measure?
1. The patient is at higher risk of tissue edema with advancing age
2. An older patient is most likely incontinent of urine
3. The Patient’s age is directly associated with albumin production
4. An older Patient’s skin has a greater chance of breakdown

Question 5 of 10
A nurse is preparing to perform a physical assessment on a patient. One of the pieces of equipment
the nurse gathers is a sterile safety pin. Which best describes how the nurse would use this piece of
equipment?
1. To assess the depth of the upper layer of skin on the heel
2. To assess the Patient’s ability to feel a pin prick in the distal extremity
3. To attach a label to the Patient’s belongings
4. To pin part of the Patient’s gown to keep it out of the way

Question 6 of 10
A nurse is treating a patient in the emergency department who was severely injured after a fall.
The nurse begins the primary survey to assess for airway, breathing, and circulation. The patient is
crying and complaining of pain. Based on this information, what step must the nurse perform next
to manage the Patient’s airway?
1. Ask the patient to open his mouth
2. Continue to monitor and assess the Patient’s breathing
3. Perform a head-tilt, chin-life procedure
4. Perform a modified jaw thrust

Question 7 of 10
A nurse is performing a cardinal gaze eye assessment. The nurse knows that this tests which of the
following cranial nerves? Select all that apply.
1. IV
2. X
3. III
4. VI
5. I

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Question 8 of 10
A nurse is performing an intake assessment on a patient who has been transferred from the long-
term care facility to the hospital. The nurse knows that the patient has a history of skin breakdown
and performs a skin check as part of the initial assessment. Which best describes the rationale for
including this type of assessment during the admission process?
1. To include a head start on the discharge planning process
2. To develop a set of baseline data to use for later comparison when providing care
3. To establish the Patient’s ability to participate in his or her own care
4. To decrease the Patient’s anxiety about being transferred from the long-term care facility

Question 9 of 10
The nurse is performing an assessment of a Patient’s abdomen. Upon palpation, the nurse feels an
abnormal lump in the left upper quadrant that is extremely painful for the patient. The nurse is
likely palpating which of the following?
1. Inflamed spleen
2. Inflamed appendix
3. Bilious gallbladder
4. Enlarged liver

Question 10 of 10
A patient is brought in to the emergency department with multiple stab wounds and is at risk for
hemorrhagic shock. The nurse knows that it is best to check blood circulation through which of the
following pulse assessments?
1. Carotid
2. Popliteal
3. Radial
4. Brachial

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References

Arnold, C. & Underman Boggs, K. (2016). Interpersonal relationships: Professional

communication skills for nurses (7th ed.). St. Louis, MO: Elsevier.
Canadian Hospice Palliative Care Association. (2013a). A model to guide hospice palliative care.
Retrieved from http://www.chpca.net/media/319547/norms-of-practice-eng-web.pdf
Clayton, B & Stock, Y. (2004). Basic pharmacology for nurses (13th ed.). St. Louis, MO: Mosby.
Day, R. A., Paul, P., & Williams, B. (Eds.). (2016). Brunner & Suddarth’s textbook of Canadian
medical-surgical nursing (3rd ed.). Philadelphia: Lippincott Williams & Wilkins.
Evans, R., Evans, M., Brown, Y., & Orshan 2. (2010). Canadian maternity newborn & women’s
health nursing. Philadelphia: Lippincott, Williams & Wilkins.
Morrison-Valfre, M. (2017). Foundations of Mental Health Care (6th ed.). St. Louis, MO: Mosby.
Murray, K. (2009). Essentials in hospice palliative care. (2nd ed.). Saanichton,m BC: Life and
Death Matters
Potter, P, Perry, A., Stockert, P., & Hall, A. (Eds). (2014). Canadian fundamentals of nursing:
Concepts, process and practice (5th ed.). Toronto, ON: Mosby Inc.
World Health Organization (2013).WHO definition of palliative
care.. Retrieved from http://www.who.int/cancer/palliative/definition/en/
courtesy to nursing.com resources as well.

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THIS DOCUMENT IS THE PROPERTY OF FUTURE BUILDING NURSING PREP CENTER

(FBNPC).
RIGHTS OF THIS DOCUMENTA ARE RESERVED WITH FBNPC.
SHARING, COPYING, PRINTING, PICTURE TAKING AND FORWARDING THIS
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This document is solely developed to help students of FBNPC only and has used numerous available
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