Assessment Basics
What is the first step of the nursing process?
Assessment.
What is the normal adult pulse range?
60-100 bpm
What are the 5 basic vital signs taught in this course? What is the 6th vital sign?
Temperature, pulse, respirations, blood pressure, O2 saturation, and the sixth is pain.
What is normal oxygenation at baseline?
What is normal oxygenation for someone with COPD?
95-100%.
85-90% (hopefully we can keep it as high as possible during treatment for COPD but it naturally declines the longer they have the disease.)
Who is the most reliable source for determining a patient's pain?
The patient.
A nurse is gathering information from the patient's spouse because the patient is unconscious. Is this a primary or a secondary source?
Secondary.
A patient's initial vital signs are obtained when they arrive on the unit. What is the purpose of this first set?
Establishing a baseline.
When auscultating lung sounds, should you listen to the entire right side and then the entire left side?
No. Compare side-to-side as you move from top to bottom.
What does the "O" in OPQRST stand for?
What is Onset?
The nurse notices that a patient is grimacing while being repositioned. Is this subjective or objective data?
Objective (remember, it is observable).
What are the two normal heart sounds commonly described as "lub-dub"?
S1 and S2.
A patient has a recorded body temperature of 94F. Is this considered hypothermia or hyperthermia?
Hypothermia.
When listening to lung sounds, what three things should the nurse evaluate?
presence, quality, and symmetry
A patient says, "My pain is a 7 out of 10." Is that subjective or objective data?
subjective data
A patient says, "My stomach hurts and feels like it is burning." What type of data is this?
Subjective.
When auscultating a patient's heart tones, the nurse notices a "whoosing" sound between S1 and S2. What should the nurse document this as?
This is turbulent blood flow and should be documented as a systolic murmur.
A patient has an abnormal temperature, tachycardia, flushed skin, and intense thirst. What condition is suspected?
Hyperthermia.
A patient has crackles in the lungs. Is this an expected normal lung sound?
If not, what could it indicate?
No. Crackles are an abnormal/adventitious lung sound that indicate fluid in the lungs.
In SOAP charting, the nurse documents: "RR 26/min, SpO₂ 90% on room air, patient using accessory muscles." Which section does this belong in?
Objective (O)
A nurse obtains a blood pressure reading that is significantly different from the patient's baseline. What should the nurse do before documenting the finding as an accurate change in condition?
Reassess the patient and verify the accuracy of the measurement
Yourself and a fellow nurse are performing a 2 person head to toe. You notice your coworker checks for the carotid pulse by placing their fingers on both sides of the patient's neck at the same time. What should you do?
Tell them that this is inappropriate, palpating the carotid pulse bilaterally at the same time can restrict blood flow to the brain and cause loss of consciousness.
A patient has a new set of vital signs that is significantly different from their baseline. Should the nurse simply document the numbers and move on?
No. The nurse should assess the patient and consider what the change means.
A patient reports shortness of breath. The nurse documents: "Patient states, 'I feel short of breath.'" Where does this belong in SOAP?
S — Subjective
A patient reports severe abdominal pain but is resting quietly with stable vital signs. The nurse documents, “Patient appears to be resting comfortably; pain rated 8/10.” What is the most important problem with this documentation?
The nurse should document the patient's reported pain without allowing their own observation to invalidate the patient's subjective pain report.