Vital signs
What is the normal adult heart rate?
60-100 beats per minute.
What is a chief complaint?
The main reason the patient is seeking medical care
What does the A in SAMPLE stand for?
Allergies
Why is accurate documentation important?
It keeps patient records correct and supports safe patient care.
A patient’s oxygen level is 84%. Is that normal?
No.
What is the normal oxygen saturation range?
95-100%.
What question should you ask first when a patient says they have pain?
Ask where the pain is and when it started
What does the Q stand for in OPQRST?
Quality
When should patient information be documented?
As soon as possible after the assessment.
What should you do if a patient becomes dizzy while you are taking vital signs?
Keep the patient safe, stop the assessment if needed, and notify the healthcare provider
A patient has a blood pressure of 180/110 mmHg. What should you do?
Report it immediately because it is dangerously high.
A patient says “I’ve had chest pain for 20 minutes”. Which assessment tool should you use?
OPQRST.
Name all six parts of SAMPLE
Signs & symptoms, Allergies, Medications, Past medical history, Last oral intake, Events leading up
Name two things that should be documented after taking vital signs
Any two: Temperature, Pulse, Respirations, BP, Oxygen saturation, Patient complaints
A patient has:
Temperature of 102 F
Pulse of 118 BPM
Respirations of 24/min
What could these vital signs suggest?
A fever and possible infection
What are the five vital signs?
Temperature, Pulse, respirations, Blood pressure, Oxygen Saturation
Why is asking follow up questions about a chief complaint important?
It helps find the cause, severity, and best treatment
What does the R in OPQRST stand for?
Region/Radiation
Should you document opinions or only facts?
Only facts and observations
A patient says they have severe chest pain and trouble breathing. What should you do first?
Notify the provider immediately and follow emergency procedures.
A patient has:
Temperature: 103 F
Pulse: 125 BPM
Respirations:28/min
BP: 90/60 mmHg
Oxygen saturation: 89%
What do these vital signs suggest?
The patient is seriously ill and needs immediate medical attention
A patient says “I’ve been short of breath since yesterday”. Name three follow up questions you should ask.
Examples: When did it start? Does anything make it better or worse? How severe is it? Do you have chest pain? Have you had this before?
A patient says “My stomach pain started this morning, it’s sharp, it’s an 8 out of 10, and it spreads to my back.” Which parts of the OPQRST have already been answered?
O-Onset
Q-Quality
R- Region/RadiationS-Severity
Which note is written incorrectly?
A.) “patient looks really sick”
B.)”Patient seems lazy”
C.) “Patient reports pain 8/10 in the lower back that started this morning”
D.) “ Patient is probably exaggerating”
C
A patient suddenly becomes pale, sweating, confused, and says they feel faint while standing. What is your first action?
Help the patient sit or lie down, stay with them, and notify the healthcare provider immediately.