Exam #1 (40 questions / 60 minutes)
Weekly Lecture Outline and Topics
Please note that this is a not a template of the exam.
Overall areas covered will include: lectures week 1, 2, and 3. Please consult your course
syllabus/weekly schedule for the corresponding chapters in your textbooks, CoursePoint, Kaplan
resources, and other assigned videos and reading
Lecture Topics (week 1, 2 and 3):
Foundations of Professional Nursing Practice
 Paradigm of Nursing
o Person. Recipient of care. Physical, spiritual, emotional, and social dimensions)
o Environment. Internal and external factors
o Health. Defined by the person
o Nursing. Nursing actions
 Scope and standards of practice
o allow nurses to carry out professional roles, serving as protection for the nurse, the
patient, and the institution where health care is provided. Each nurse is accountable for
his or her own quality of practice and is responsible for the use of these standards to
ensure knowledgeable, safe, and comprehensive nursing care
 Code of ethics
o Developed as a guide for carrying out nursing responsibilities in a manner consistent
with quality in nursing care and the ethical obligations of the profession.
 Nursing practice acts
o Provides parameters for practice
o It contains 17 national standards of Practice and performance which define the Who,
What, Where, When, Why, and How of nursing practice.
o It outlines key aspects of nursing’s professional role and practice for any level, setting,
population focus, or specialty.
o Nursing practice acts define nursing, set standards for the nursing profession and give
guidance regarding scope of practice issues. As such, the state nursing practice act is
the single most important piece of legislation affecting nursing practice.
o Laws established in each state in the United States to regulate the practice of nursing
 Nursing process
o Purpose: a nurse follows the nursing process to organize and deliver nursing care.
o Assessment, diagnosis, planning, implementation, evaluation
 Nursing theory
o Provides nurse with a distinct health care identity when collaborating with other
healthcare professionals
o Informs nursing practice
o Ensures consistent and constancy of professional nursing practice across clinical
settings
o Nursing theory builds upon theories in other disciplines i.e. psychology, sociology
o Nursing theories are;
o Central focus of nursing is the client
o Goal of nursing is to promote and maintain health
 Health and wellness
o Health is the state of optimal functioning or well being
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o Wellness
Model of health promotion and illness prevention
o Health promotion is the increasing of a person’s well-being and health potential
o Preventing illness: The objectives of disease prevention activities are to reduce the risk
of illness, to promote good health habits, and to maintain optimal functioning. Nurses
prevent illness primarily by teaching and by personal example.
Never Events
o The objectives of disease prevention activities are to reduce the risk of illness, to
promote good health habits, and to maintain optimal functioning. Nurses prevent illness
primarily by teaching and by personal example.
HIPAA
o Respect patient information and privacy
Vital Signs
 Measuring vital signs
o Check vital signs for patient condition and to acquire a baseline
o Access airway, breathing, and circulation
 Temperature
o Temperature range is between 96.4- and 100.4-degrees F. Do an intervention if above
100.4.
o Age, physical activity hormonal activity, circadian rhythm, environment, and
temperature alterations affect body temperature
o Febrile = fever, afebrile = no fever
o High temperature = more metabolic activity
 Pulse
o Normal pulse rate is 60 to 100 beats per minute
o Increased pulse rate = tachycardia (>100 beats per minute)
o Decreased pulse rate = bradycardia (<60 beats per minute
o Doppler used to access pulses that aren’t easy to palpate or auscultate
o S1 is the lub sound. Closure of mitral (left heart) and tricuspid (right) valves
o S2 Is dub sound. Closure of aortic (left) and pulmonary valves (right)
o Age, sex, physical activity, fever, stress, medications, disease, and decreased stroke
volume affect pulse
o 0 pulse absent, +1 faint, +2 normal, +3 bounding
 Respiration
o The exchange of gases in and out of the lungs (ventilation)
o Diffusion = exchange of oxygen and CO2
o Perfusion = exchange of oxygen and co2 between the alveoli and blood
o Environmental factors include wind, cold, fear, pain exertion
o Assess by inspection, stethoscope, monitoring arterial gas results, and using pulse
oximeter
o Normal rate is eupnea (12-20 breaths per minute)
o Tachypnea is a higher rate > 24 breaths per minute
o Bradypnea is a lower rate < 10 breaths per minute
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Blood pressure
o Force of blood against arterial walls
o Sphygmamometer used or electronic blood pressure machine
Health Assessment: Health history and Physical exam
 Overview of assessment
o Systematic and continuous Collection, analysis, validation, and communication of patient
data
 2 Components of Health assessment
o Health history. Interview the patient
o Physical assessment. Head to toe sequence, system sequence, review of system
 Type of assessments
o Medical assessment = target data pointing to pathological conditions
o Nursing assessment = Focus on the patient’s response to health problems
 Assessment data
o Objective data= observable data that can be seen, felt, or heard by someone other than the
patient
o Subjective data = information perceived by the patient
 Performing physical assessment
o Appraisal of health status
o Identification of health problems
o Establishment of data base for nursing intervention
 IPPA
o Inspect-access size, color, shape, position, and symmetry
o Palpation-access temperature, turgor, texture, moisture, vibrations, and shape
o Percussion-access location, shape, size, and density of tissues
o Auscultate-access sound (pitch, loudness, quality, and duration
 Documentation
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o Identify actual and potential health problems
o Make nursing diagnoses
o Plan appropriate care
o Evaluate patient’s response to treatment
Assessment of Integument
o Health history
 Rashes, lesions, color changes, itchiness, bruising, bleeding
 Allergies to meds, plants, foods, other substances
 Piercing or tattoo
 Degree of mobility
 Cultural practices of skin
o Skin color
 Erythema, cyanosis, jaundice, pallor
 Cyanosis most severe because oxygen is lacking
o Skin vascularity and lesions
 Ecchymosis, petechiae
o Skin temperature, texture, moisture, turgor
 Diaphoresis, edema, turgor
o Nails
o Hair and Scalp
Assessment of HEENT
o Changes in vision and hearing
o Use of corrective lenses or hearing aids
o Allergies
o Visual or hearing disturbances
o Chronic illness like diabetes
o Exposure to harmful substances or loud noise
o Smoking
o Body piercing and tattoos
o Head trauma
o Dental history
Assessment of the Thorax and Lungs/Respiratory
o Tracheal deviation (can suggest of tension pneumothorax)
o Chest wall deformities
o Kyphosis - curvature of the spine - anterior-posterior
o Scoliosis - curvature of the spine - lateral
o Barrel chest - chest wall increased anterior-posterior; normal in children; typical of
hyperinflation seen in COPD
o Breath sounds
 Bronchial
 trachea and mainstem bronchi (tracheal breath sounds-tubular/harsh)
o (2nd-4th intercostal spaces either side of the sternum anteriorly &
3rd-6th intercostal spaces along the vertebrae posteriorly).
 Higher, lower, and higher pitched expiration
 Bronchovesicular (air moving through large lung airways)
 major bronchi below the clavicles in upper of the chest anteriorly.
o The sounds are described as medium-pitched and continuous
throughout inspiration and expiration.
 Equal sound between inspiration and expiration
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Vesicular
 peripheral lung. soft and low- pitched. Best heard on inspiration.
 louder, and higher pitched ,Longer
Diminished
shallow breathing; normal in obese patients with excessive adipose tissue and
during pregnancy.
 Also-obstructed airway, partial or total lung collapse, or chronic lung
disease.
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o Cough
 Dry, moist, wet, productive, hoarse, hackling, barking, whooping
 Onset, pattern, duration, wheezing
o Sputum
 Color, amount, presence of blood, odor, consistency, pattern of production
Assessment of the Abdomen
o Inspection
 Skin color, symmetry, lumps, masses, contour, pulsations
o Auscultation
 PLACE DIAPHRAGM ON LOWER RIGHT QUADRANT AND LISTEN FOR
BOWEL SOUNDS!!!
 Can listen in one area, listen for 2 minutes
 Use bell of stethoscope and place over abdominal aorta and femoral arteries and
iliac arteries for bruit
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Assessment of the Cardiac and peripheral vascular systems
o Diastole and systole
 Systole: the heart contracts to pump blood out, the period of ventricular
contraction.
 Diastole: the heart relaxes after contraction, the period of ventricular relaxation.
o Assessment for heart sounds
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o Assessment of carotid arteries
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o Inspect neck for carotid pulsations
 Press just inside the medial border of the sternomastoid muscle at the level of the
cricoid cartilage
 Don’t press on carotid sinus
 Don’t press both carotids at the same time
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o Auscultate carotid arteries
 Auscultate over both carotid arteries with the bell
 Bruits are abnormal and have a swooshing or blowing sound. This means there
is stenosis (Narrowing of artery) or occlusion of an artery
o Peripheral pulse locations
 Radial
 Ulnar
 Carotid
 Temporal
 Brachial
 Femoral
 Popliteal
 Dorsalis pedis
 Posterior tibial
o Assessment of peripheral pulse sounds
 Sites
 Use of stethoscope or doppler
 Rate
 Quality of pulse and rhythm of pulse
 Pulse grade
o 0 absent
o +1 weak, diminished
o +2 normal, brisk
o +3 bounding
o Capillary refill
 Test peripheral perfusion and cardiac output
 Press on nail bed on hand or foot until color is pale. Should refill and color should
be normal in less than three seconds
o Assessment of edema
 Generalized edema implies renal or cardiac insufficiency
 Localized edema found in specific areas like the ankles, hands, or feet
Assessment of the Musculoskeletal systems
o Compare symmetry in muscle pairs
o Ask patient to flex muscle and resist when applying force
o Grading scale is 0-5 with 0 being no muscle contractions and 5 being full power
o GALS assessment
 Gait, arms, legs, spine
 1–2-minute assessment that is highly effective in finding abnormalities
 Inspect joints for swelling, posture, and normal movement
Assessment of Neurological system
o Ask for patient orientation. Ask for date, name, place, time etc.
o Levels of consciousness
 Awake and alert = person is fully aware of the place, date, and time. Aware of
orientation
 Lethargy = patient is sleepy but can be awaken by shaking or calling patient name.
Spontaneous movements made
 Stuporous = patient not conscious most of the time. No spontaneous movements
but responds to painful stimuli
 Comatose = patient doesn’t respond to painful stimuli. Cannot be arouse
o Assessment of Motor and Sensory function
 Balance and gait
 Motor function and coordination
 Sensory assessment
 Neurovascular assessment
 Pain
 Peripheral pulses
 Sensation
 Paralysis
 Movement
Please keep in mind this is a guide for reviewing weekly lecture topics and it does not determine
the material on the exam. I recommend you reviewing PowerPoint slides, chapters in the
textbooks, Kaplan resources, CoursePoint, and assigned videos and readings.
Exam 1 Review
Breath sounds
 Which can heard the best inspiration and expiration
o Bronchiovascular
 Which can be heard best at inspiration
o Vesicular
 Wheezing airway
o Asthma
o Narrow airway
o Bronchodilator
 Rhonchi
o Secretions in the airway
o Suctioning
o COPD
 Crackles
o Fluid in airways
o Pneumonia, inflammation
o Heart failure
o Give antibiotic for pneumonia
o For heart failure, give diuretic
 Stridor
o Allergic reaction
o Anaphylactic shock
o Foreign bodies in the airway
o Obstructed airway
o Give EpiPen
 Rubbing
o Lungs rubbing on the chest wall
Standards and Scope of practice
 What the nurses can do. What is expected
 Bigger umbrella
Nursing practice act
 By state law.
Code of ethics
 Morals towards patients
Leaders in Nursing