CARDIAC ASSESSMENT
The nurse palpates this pulse site during a focused cardiac assessment to assess circulation to the lower extremities.
Answer:
What is the pedal pulse?
Rationale:
Pedal pulses help the nurse evaluate peripheral circulation and tissue perfusion to the feet and legs. Weak or absent pulses may indicate decreased cardiac output or vascular disease.
Question:
This breath sound is high-pitched and commonly heard in patients with asthma.
Answer:
What are wheezes?
Rationale:
Wheezes occur when air moves through narrowed airways and are common in asthma and bronchospasm.
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This assessment evaluates a patient’s level of consciousness.
Answer:
What is the Glasgow Coma Scale?
Rationale:
The Glasgow Coma Scale measures eye opening, verbal response, and motor response to assess neurological status.
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Which patient should the nurse assess first?
Answer:
What is the patient with wheezing?
Rationale:
Airway and breathing problems are always priority according to ABCs.
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This documentation is most appropriate:
Answer:
What is “Patient alert and oriented x2”?
Rationale:
Objective, measurable documentation is legally and professionally appropriate.
A patient has bilateral +3 pitting edema and crackles in both lung bases. These findings may indicate this condition.
Answer:
What is heart failure/fluid overload?
Rationale:
Edema and crackles are signs of fluid retention. In heart failure, fluid backs up into the lungs and tissues due to ineffective cardiac pumping.
Question:
The nurse notes use of accessory muscles during breathing. This finding indicates this problem.
Answer:
What is respiratory distress?
Rationale:
Accessory muscle use means the patient is working harder to breathe and may not be oxygenating effectively.
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The nurse asks a patient their name, location, and date. The nurse is assessing this.
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What is orientation?
Rationale:
Orientation assesses cognitive function and awareness of person, place, and time.
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Which patient finding is highest priority?
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What is O2 sat 84%?
Rationale:
Severe hypoxia threatens life immediately and requires urgent intervention.
Question:
The nurse documents crackles in the lower lung bases bilaterally. This documentation is considered this type of data.
Answer:
What is objective data?
Rationale:
Objective data are measurable or observable findings obtained during assessment.
Question:
The nurse notes jugular vein distention while the patient is sitting upright. This finding should cause the nurse to suspect this problem.
Answer:
What is fluid volume overload/right-sided heart failure?
Rationale:
Jugular vein distention indicates increased venous pressure and is commonly seen in right-sided heart failure and fluid overload states.
Question:
Which assessment finding requires immediate follow-up?
Answer:
What are absent breath sounds on the left side?
Rationale:
Absent breath sounds may indicate pneumothorax, severe obstruction, or lung collapse and require urgent assessment.
Question:
The nurse notes facial droop, slurred speech, and unilateral weakness. Which action is priority?
Answer:
What is activate stroke response/notify provider immediately?
Rationale:
These are classic stroke symptoms. Rapid intervention improves patient outcomes and may preserve brain tissue.
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The nurse enters a room and finds a patient unresponsive. What is the FIRST action?
Answer:
What is assess responsiveness and breathing?
Rationale:
The nurse must first determine if the patient is responsive and breathing before initiating further interventions.
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Which documentation entry is best?
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What is “Lungs clear bilaterally, respirations even and unlabored”?
Rationale:
Clear and specific documentation improves communication and patient safety.
Question:
During assessment, the nurse notes chest pain rated 8/10, diaphoresis, and nausea. What is the nurse’s priority action?
Answer:
What is notify the provider/rapid response and assess vital signs and oxygenation?
Rationale:
Chest pain with diaphoresis and nausea may indicate myocardial infarction. Immediate assessment and intervention are necessary to prevent cardiac damage.
Question:
The nurse is caring for a patient with crackles and shortness of breath. Which intervention is priority?
Answer:
What is raise the head of the bed?
Rationale:
High Fowler’s position improves lung expansion and decreases work of breathing.
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Which assessment finding is most concerning?
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What are unequal pupils?
Rationale:
Unequal pupils may indicate neurological deterioration or increased intracranial pressure.
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Which patient should the nurse see first?
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What is the patient with new confusion?
Rationale:
Acute mental status changes may indicate hypoxia, stroke, or neurological decline.
Question:
The nurse identifies abnormal findings and immediately notifies the provider using this communication method.
Answer:
What is SBAR?
Rationale:
SBAR promotes organized and effective communication between healthcare providers.
Question:
The nurse is assessing a patient with chest pain. Which finding requires immediate intervention?
Answer:
What is O2 sat 89%?
Rationale:
An oxygen saturation below 90% indicates hypoxemia and impaired oxygen delivery to tissues, requiring immediate intervention.
Question:
A patient with COPD becomes restless and confused. Which action should the nurse take first?
Answer:
What is assess oxygenation/O2 saturation?
Rationale:
Restlessness and confusion are early signs of hypoxia and require immediate oxygenation assessment.
Question:
A patient suddenly becomes difficult to arouse after a head injury. Which nursing action takes priority?
Answer:
What is assess airway and neurological status immediately?
Rationale:
A decreased level of consciousness after head injury may indicate worsening brain injury and threatens airway protection.
Question:
A patient with chest pain suddenly becomes short of breath and diaphoretic. What is the priority nursing action?
Answer:
What is assess airway, breathing, circulation, and notify rapid response/provider?
Rationale:
These findings may indicate cardiac instability requiring immediate intervention.
Question:
A nurse documents “patient tolerated assessment well.” Which additional focused assessment information is MOST important to include?
Answer:
What are objective assessment findings/vital signs?
Rationale:
Objective assessment findings provide evidence of the patient’s actual condition and response to care.