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Basic Nursing Exam 3
Vital Signs - Adult
Temperature (96.8-100.4 Degrees F) (36-38 Degrees C)
Rectal
Tympanic
Oral
Axillary
Temporal
Respiration (12-20)
Oxygen Saturation (94%-100%)
Pulse (60-100)
Blood Pressure (<120/80)
Pain
2 mins
Pain Assessment
Types of Pain
Acute Pain
Chronic Pain
OPQRST Mnemonic
Onset
Provoking or Palliative
Quality
Radiation
Severity
Timing
Nursing Considerations
Subjective Findings
Objective Findings
Reassessment of Pain
2 mins
Child and Elder Physical Abuse Assessment
Physical Abuse
Inconsistent Injuries
Delay in Treatment
Various Stages of Healing
Child Abuse
Symmetrical Burns
Sexually Transmitted Infection
Bloody/Torn Undergarments
Shaken Baby Syndrome
Elder Abuse
Poor Hygiene
Overmedication
2 mins
Lung Sounds - Wheezes
Location
Throughout Lung
Description
High Pitched
Sounds Like
Musical
Cause
Air Moving through Narrowed Airways
38 secs
Lung Sounds - Crackles
Location
Lower Lobes
Description
Fine/Coarse
Sounds Like
Fine: Twisting Hair through Fingers
Coarse: Velcro
Cause
Collapsed Small Airways and Alveoli "Popping Open"
1 min
Lung Sounds - Rhonchi
Location
Trachea and Bronchi
Description
Low Pitched Rumbling
Sounds Like
Gurgling
Cause
Narrowed Airway
Secretions or Bronchospasm
49 secs
Lung Sounds - Pleural Friction Rub
Location
Anterior Lateral Lung
Description
Dry, Rubbing, or Squeaking
Sounds Like
Rubbing a Balloon with Finger
Cause
Inflamed Pleura
50 secs
Lumbar Puncture
Indications
CSF Sample
CSF Pressure
Considerations
Empty Bladder
Side-lying Position
Between 3rd and 4th Lumbar Vertebrae
Number Tubes
Supine Position After Procedure
Contraindications
Increased ICP (Intracranial Pressure)
Infection at Puncture Site
2 mins
Normal Electrolyte Lab Values
Potassium (K+)
3.5 to 5.0 mEq/L
Calcium (Ca2+)
8.5 to 10.5 mg/dL
Phosphate (PO43–)
2.5 to 4.5 mg/dL
Magnesium (Mg2+)
1.5 to 2.5 mEq/L
Sodium (Na+)
135 to 145 mEq/L
Chloride (Cl–)
95 to 105 mEq/L
2 mins
Potassium (K+) Lab Value
3.5 to 5.0 mEq/L
20 secs
Sodium (Na+) Lab Value
135-145 mEq/L
24 secs
Chloride (Cl-) Lab Value
95-105 mEq/L
28 secs
Calcium (Ca2+) Lab Value
8.5 to 10.5 mg/dL
26 secs
Phosphate (PO43-) Lab Value
2.5 to 4.5 mg/dL
29 secs
Magnesium (Mg2+) Lab Value
1.5 to 2.5 mEq/L
28 secs
BUN (Blood Urea Nitrogen) Lab Values
10-20 mg/dL
40 secs
Creatinine Lab Values
Measures Renal Function
0.6 - 1.3 mg/dL
1 min
Bilirubin Lab Value
0.2-1.2 mg/dL
Increased Bilirubin Causes Jaundice
54 secs
Albumin Lab Value
3.5 - 5.5 g/dL
49 secs
Total Protein Lab Values
6.4 - 8.3 g/dL
1 min
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