Vital Signs
What is a normal respiratory rate for an adult patient?
12-20 breaths/min
What is the purpose of assessing a patient's nutritional status?
To identify nutritional risks, assess dietary intake and needs, and support individualized care planning.
What is the purpose of therapeutic communication?
To establish a therapeutic relationship, support patient expression, gather information, and promote patient-centered care.
Name one aspect of care that may be influenced by a patient's cultural preferences.
Examples include dietary practices, personal space, eye contact, touch, family involvement, and communication preferences.
What is one common intervention to reduce the risk of patient falls?
Keep the call light within reach, maintain a clear environment, and implement individualized fall precautions.
What does the "P" in OPQRSTUV stand for?
Provocation/Palliation — what makes the pain better or worse.
What is the term used to describe a respiratory rate below the normal adult range?
bradypnea
Name one assessment finding that may indicate fluid volume deficit.
Examples include dry mucous membranes, decreased urine output, tachycardia, hypotension, or dizziness. Findings must be interpreted in context.
Identify the communication technique demonstrated when the nurse repeats the patient's words to encourage further discussion.
Reflection
Why should nurses avoid making assumptions about a patient's cultural practices?
Individual preferences and beliefs vary. Asking respectful questions helps the nurse provide individualized care and avoid stereotyping.
What does the term "never event" refer to in patient safety?
A serious, preventable healthcare event that should not occur under appropriate safety systems. Your presentation includes retained surgical objects as an example.
Which person is the primary source of information about their subjective pain experience?
The patient, when able to self-report. The nurse should assess the patient's report and consider other clinical findings.
A patient's respiratory rate is 28/min, and the patient is restless. What should the nurse do first?
Answer: Assess the patient's respiratory status, including airway, breathing effort, oxygen saturation, and other relevant findings. Escalate promptly if respiratory compromise is suspected.
Teaching point: Restlessness and tachypnea can be concerning signs of impaired oxygenation.
A client receiving enteral feeding develops abdominal distention and vomiting. What should the nurse do?
Stop the feeding and assess the client. Follow facility protocols and notify the appropriate healthcare professional about concerning findings.
What communication technique involves allowing a patient time to gather their thoughts without immediately filling the silence?
Silence.
A patient prefers that a family member be present during healthcare discussions. What should the nurse do?
Ask about the patient's preferences, obtain appropriate consent for sharing information, and facilitate family involvement when consistent with the patient's wishes and privacy requirements.
What is the purpose of a culture of safety in healthcare?
To promote patient safety, identify risks, and support practices that reduce preventable harm
A patient rates their pain as 8/10 but is smiling and talking with family. Should the nurse assume the pain is mild?
No. The nurse should take the patient's report seriously and perform a comprehensive pain assessment. A patient's appearance alone does not establish the severity of their pain.
A nurse uses a blood pressure cuff that is too small for the patient's arm. How might this affect the reading?
Answer: It may produce a falsely elevated blood pressure reading.
Teaching point: An appropriate cuff size is necessary for accurate measurement.
Why is monitoring intake and output important for a patient at risk for fluid imbalance?
It provides information about fluid intake and losses, supports evaluation of fluid status, and helps identify changes that may require further assessment.
A nurse says, "Everything will be fine. You have nothing to worry about." What communication barrier is demonstrated?
False reassurance.
A patient avoids eye contact while speaking with the nurse. What should the nurse consider?
Eye contact preferences can vary across cultures and individuals. The nurse should avoid assumptions and assess the patient's communication preferences.
A nurse notices a wet floor in the hallway near a patient's room. What action should be taken?
Address the immediate hazard according to facility procedures, protect patients and others from the area, and arrange for the spill to be cleaned promptly.
Name two nonpharmacologic interventions that may help promote comfort for a patient experiencing pain.
Examples include repositioning, relaxation techniques, guided breathing, reducing environmental stimuli, and applying heat or cold when appropriate and safe.
A patient has a heart rate of 124/min, blood pressure of 86/52 mmHg, pale skin, and new confusion. What is the nurse's priority?
Answer: Recognize possible hemodynamic instability and impaired perfusion. Perform an immediate focused assessment, initiate appropriate emergency interventions within scope, and call for assistance/escalate promptly.
Teaching point: Hypotension and altered mental status with tachycardia are concerning findings that require urgent attention.
A patient has had persistent vomiting and diarrhea. The nurse notes decreased urine output, dizziness, and tachycardia. What is the priority nursing concern?
Possible fluid volume deficit with impaired perfusion. The nurse should promptly assess the patient, monitor relevant findings, and communicate concerns for appropriate intervention.
A patient has limited English proficiency and needs to understand a complex treatment plan. What should the nurse do to support safe communication?
Use a qualified medical interpreter according to facility policy, communicate in plain language, and assess understanding. Avoid relying on unqualified individuals for complex medical interpretation when an appropriate interpreter is available.
A patient declines a particular meal because it conflicts with their dietary practices. What is the most appropriate nursing approach?
Respectfully assess the patient's dietary preferences and nutritional needs, communicate with dietary services and the care team, and collaborate on appropriate alternatives.
A patient at high risk for falls is found on the floor. What should the nurse do first?
Assess the patient for immediate injury and clinical stability, call for assistance, and follow facility post-fall procedures. Avoid automatically moving the patient before assessing for possible injury unless an immediate environmental danger requires movement.
A patient reports new severe abdominal pain. The nurse observes abdominal rigidity and the patient appears pale. What should the nurse do?
Answer: Perform an immediate assessment, recognize the potentially serious findings, and escalate promptly for medical evaluation. Do not dismiss the symptoms or delay care solely to administer routine comfort measures.
Teaching point: Pain assessment includes recognizing concerning associated findings and prioritizing possible acute deterioration.