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Basic Nursing Skills Chapter 14 Workbook
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Basic Nursing Skills Chapter 14 Workbook

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Questions and Answers

What might changes in vital signs indicate?

The resident's condition is worsening.

Which changes should be immediately reported to the nurse? (Select all that apply)

  • Pain is worse or not relieved (correct)
  • Blood pressure changes (correct)
  • Has a fever (correct)
  • Respiratory or pulse rate that is too rapid or slow (correct)

    • What are five sites for measuring body temperature?

    The mouth (oral), rectum (rectal), armpit (axilla), ear (tympanic), temporal artery.

    Name seven conditions that indicate a person's temperature should not be taken orally.

    <p>Unconscious, has facial/oral surgery, younger than 5 years old, is confused or disorientated, heavily sedated, likely to have a seizure, is coughing, is using oxygen.</p> Signup and view all the answers

    A rectal thermometer is usually color coded.

    <p>Red or orange.</p> Signup and view all the answers

    Which temperature site is another word for the armpit area?

    <p>Axilla.</p> Signup and view all the answers

    Which temperature site is considered to be the most accurate?

    <p>Rectum.</p> Signup and view all the answers

    How long do digital thermometers take to display a person's temperature?

    <p>2 to 60 seconds.</p> Signup and view all the answers

    How are temporal artery thermometers used to measure body temperature?

    <p>The thermometer is scanned across the forehead.</p> Signup and view all the answers

    Where is the apical pulse located?

    <p>On the left side of the chest just below the nipple.</p> Signup and view all the answers

    Which pulse is most often used for measuring pulse rate?

    <p>Radial pulse.</p> Signup and view all the answers

    The medical term for difficulty breathing is?

    <p>Dyspnea.</p> Signup and view all the answers

    Which of the following is an instrument that can listen to sounds within the body?

    <p>Stethoscope.</p> Signup and view all the answers

    Inhaling air into the lungs is also called?

    <p>Inspiration.</p> Signup and view all the answers

    Exhaling air out of the lungs is also called?

    <p>Expiration.</p> Signup and view all the answers

    The normal respiration rate for adults ranges from?

    <p>12 to 20 breaths per minute.</p> Signup and view all the answers

    Why is it important for the nursing assistant to observe respirations without letting the resident know what she is doing?

    <p>People may breathe more quickly if they know they are being observed.</p> Signup and view all the answers

    Blood pressure measurement that reflects the phase when the heart relaxes?

    <p>Diastolic phase.</p> Signup and view all the answers

    The medical term for high blood pressure is?

    <p>Hypertension.</p> Signup and view all the answers

    The medical term for low blood pressure is?

    <p>Hypotension.</p> Signup and view all the answers

    Abbreviation for millimeters of mercury?

    <p>mmHg.</p> Signup and view all the answers

    Device that measures blood pressure?

    <p>Sphygmomanometer.</p> Signup and view all the answers

    Blood pressure measurement that reflects the phase when the heart is at work?

    <p>Systolic phase.</p> Signup and view all the answers

    If a resident complains of pain, what questions should the nursing assistant ask to get the most accurate information?

    <p>Where, when, rate on scale of 0-10, what they were doing when it started, how long pain lasts, how often, what makes it better/worse.</p> Signup and view all the answers

    What are barriers to managing pain?

    <p>Fear of addiction to meds, feeling that pain is normal part of aging, worrying about constipation/fatigue from meds, feeling that caregivers are too busy to deal with pain, feeling that too much meds will cause death.</p> Signup and view all the answers

    One benefit of cold applications is that they can bring this down.

    <p>Fever.</p> Signup and view all the answers

    Type of application that helps stop bleeding.

    <p>Cold application.</p> Signup and view all the answers

    A warm soak of the perineal area to clean perineal wounds and reduce pain is called?

    <p>Sitz bath.</p> Signup and view all the answers

    A condition that could cause a person to be unable to feel or notice damage occurring from a warm or cold application is?

    <p>Paralysis.</p> Signup and view all the answers

    Numbness, pain, blisters, or skin that is this color should be reported to the nurse.

    <p>Red.</p> Signup and view all the answers

    Type of application that increases blood flow to an injured area is?

    <p>Heat.</p> Signup and view all the answers

    Moisture reduces the effects of heat and cold.

    <p>False</p> Signup and view all the answers

    Dry applications are more likely to cause injury than moist applications.

    <p>False</p> Signup and view all the answers

    Redness, pain, blisters, and numbness are signs that an application may be causing tissue damage.

    <p>True</p> Signup and view all the answers

    A disposable warm pack is a type of dry application.

    <p>True</p> Signup and view all the answers

    Circulation to the perineal area is decreased when having a sitz bath.

    <p>False</p> Signup and view all the answers

    Sitz baths may stimulate voiding (urination).

    <p>True</p> Signup and view all the answers

    Residents may feel weak or dizzy after a sitz bath.

    <p>True</p> Signup and view all the answers

    Sterile dressings cover new, ____ or ____ wounds.

    <p>Open, draining.</p> Signup and view all the answers

    A ____ changes sterile dressings.

    <p>Nurse.</p> Signup and view all the answers

    Non-sterile dressings are applied to dry, ____ wounds that have less chance of ____.

    <p>Closed, infection.</p> Signup and view all the answers

    What are the supplies that may be needed for a sterile dressing change?

    <p>Sq gauze dressing, adhesive tape, scissors, gloves, plastic bag.</p> Signup and view all the answers

    What should a nursing assistant observe and report about the wound site during sterile dressing changes?

    <p>Skin color change; scabs that have come off; bleeding; swelling; odor; drainage.</p> Signup and view all the answers

    Elastic bandages are also known as?

    <p>Non-sterile bandages.</p> Signup and view all the answers

    One purpose of elastic bandages is to?

    <p>Hold a dressing in place.</p> Signup and view all the answers

    Elastic bandages should be applied snugly enough to control ____ and prevent movement of ____.

    <p>Bleeding, dressings.</p> Signup and view all the answers

    How soon should an NA check on a resident after applying a bandage?

    <p>10 minutes.</p> Signup and view all the answers

    IV therapy allows direct access to?

    <p>The bloodstream.</p> Signup and view all the answers

    What is the nursing assistant's responsibility for IV care?

    <p>Documenting observations.</p> Signup and view all the answers

    If the fluid in an IV bag is nearly gone, the NA should?

    <p>Notify the nurse.</p> Signup and view all the answers

    Which of the following is a box-like device that changes air in the room into air with more oxygen?

    <p>Oxygen concentrator.</p> Signup and view all the answers

    When should the nursing assistant administer a resident's oxygen?

    <p>Never.</p> Signup and view all the answers

    What is the purpose of a nasal cannula?

    <p>To provide concentrated oxygen through a resident's nose.</p> Signup and view all the answers

    Liquid oxygen can cause which of the following?

    <p>Frostbite.</p> Signup and view all the answers

    What kind of water is used in the humidifying bottles for oxygen concentrators?

    <p>Distilled water.</p> Signup and view all the answers

    What is the purpose of a humidifier?

    <p>To put warm or cool moisture in the air.</p> Signup and view all the answers

    Study Notes

    Vital Signs and Their Implications

    • Changes in vital signs can indicate a worsening condition.
    • Immediate reporting of specific changes is crucial, including fever, abnormal respiratory or pulse rates, blood pressure changes, and worsening pain.

    Body Temperature Measurement

    • Common sites for measuring body temperature include oral, rectal, axillary (armpit), tympanic (ear), and temporal artery.
    • There are conditions under which temperature should not be taken orally: unconsciousness, facial/oral surgery, age under 5, confusion, heavy sedation, seizure risk, coughing, or oxygen use.

    Thermometers

    • Rectal thermometers are typically color-coded red or orange.
    • The rectum is considered the most accurate site for temperature measurement.
    • Digital thermometers provide readings in 2 to 60 seconds, and temporal artery thermometers scan across the forehead for quick measurements.

    Pulse Measurement

    • The apical pulse is located on the left side of the chest, just below the nipple.
    • Radial pulse is the most commonly used site for measuring pulse rate.

    Respiratory Terms

    • Dyspnea refers to difficulty breathing, with respiration rates for adults ranging from 12 to 20 breaths per minute.
    • Observing respiration without the resident's knowledge is important as awareness can alter breathing patterns.

    Blood Pressure Basics

    • Diastolic pressure reflects the heart's relaxation phase, while systolic pressure reflects when the heart is active.
    • Hypertension indicates high blood pressure, and hypotension indicates low blood pressure.
    • Blood pressure is measured in millimeters of mercury (mmHg) using a sphygmomanometer.

    Pain Assessment

    • Key questions for accurate pain assessment include location, timing, intensity (0-10 scale), activity during onset, duration, frequency, and relieving/worsening factors.
    • Barriers to effective pain management can include fear of addiction, misconceptions about aging, concern over medication side effects, and caregivers' perceived busyness.

    Heat and Cold Applications

    • Cold applications can reduce fever and control bleeding, while heat can increase blood flow to an injured area.
    • Sitz baths are used to clean perineal wounds and alleviate pain, but may cause weakness or dizziness.

    Dressings and Wound Care

    • Sterile dressings are used for open or draining wounds and should be changed by a nurse.
    • Non-sterile dressings apply to closed wounds with lower infection risks.
    • Supplies for sterile dressing changes include gauze dressings, adhesive tape, scissors, gloves, and a plastic bag for disposal.

    Bandaging Techniques

    • Elastic bandages help hold dressings in place and should be applied tightly enough to control bleeding.
    • Residents should be monitored within 10 minutes after applying a bandage.

    IV Therapy and Oxygen Administration

    • IV therapy provides direct access to the bloodstream, with assistants responsible for documenting observations.
    • Oxygen concentrators enhance air oxygen levels and nasal cannulas deliver concentrated oxygen.
    • Humidifiers add moisture to the air, using distilled water for humidifying bottles with oxygen concentrators.

    Safety Precautions

    • Never administer a resident's oxygen; trained personnel should handle such duties.
    • Liquid oxygen can potentially cause frostbite if mishandled.

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    Description

    Test your knowledge on vital signs and basic nursing skills with these flashcards from Chapter 14 of the workbook. Learn the crucial indicators to observe in patient assessment and what vital changes necessitate immediate reporting. This quiz will reinforce your understanding of monitoring patient conditions effectively.

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