Pre-Assessment Week 3
1. 12 oz (water) = 360 mLs
360 mLs x 3 (3 meals: breakfast, lunch, dinner) = 1080 mLs
1080 mLs + 50 mLs = 1130 mLs is the total intake for this 12 hour shift
2. There is an I&O balance because the input equaled the output. The input was
1130 mLs and the output was 1130 mLs.
3. A routine urinalysis uses a specimen “hat” that collects 120 mL urine under a
toilet seat. A culture and sensitivity is used to identify if bacteria is present and
how to treat it with antibiotics. Instead of using a “hat” under the toilet seat, you
must collect it with a clean-voided midstream or a urinary catheter.
4. This is not the correct process as the patient is supposed to void into the
specimen cup during the midstream not the initial stream. This is because the
initial stream flushes out microorganisms from the urinary meatus. The specimen
that this nurse collected is contaminated with microorganisms and is not the
correct process.
5. A blood pressure reading of 180/110 is considered abnormally high. You can get
another blood pressure reading on another limb such as the other arm. After the
second measurement, you can compare the findings. Another intervention would
be to make sure you used the correct placement and size of the blood pressure
cuff. You may have received an abnormally high reading due to an error in the
size or placement of the cuff.
6. Before entering a patient’s room to check the blood glucose level, you will need a
cotton ball, blood glucose meter, clean gloves, an antiseptic swab, lancet device,
blood glucose test strips, and a paper towel
7. A blackened big toe can be defined as eschar. Eschar is dead and decaying
tissue found in a wound.
8. The main difference between a stage 1 and 2 pressure injury is the presence of
intact skin. A stage 1 pressure injury still has intact skin while a stage 2 injury has
an exposed dermis. Also, a stage 2 pressure injury may be wet or moist due to a
ruptured blister. Stage 1 pressure injury has a nonblanchable erythema which
means that when you press your finger against it, the skin stays red and blood
does not leave the capillaries.
9. No, these findings are not normal. A loud, low pitched sound can be described as
an adventitious breath sound which is an abnormal breath sound. The sound
being described is a rhonchi or sonorous wheeze. It is caused by mucus in
airways which causes turbulence.
10. A single beat or pulse is the combination of both S1 and S2. S1 is the closing of
tricuspid and mitral valves and S2 is the pulmonic and aortic valves closing.
Once you hear S1 and S2, you count for 30 seconds and multiply it by two which
will give you your heart rate.