Neuro
What does “A&O ×4” stand for?
Alert & oriented to person, place, time, and situation.
What is the normal respiratory rate for an adult?
12–20 breaths per minute.
Where is the apical pulse located?
Left chest, 5th intercostal space, mid‑clavicular line.
In what order do you "assess" the abdomen?
(percuss, palpate, inspect, auscultate....)
Inspect (look)
Auscultate (listen)
Percuss
Palpate (feel)
When checking the skin, what does “warm and dry” usually indicate?
A normal skin finding.
What tool is used to assess level of consciousness in more complex cases?
Glasgow Coma Scale (GCS).
What position helps patients breathe easier?
Sitting upright (High Fowler’s).
What should a normal heart rate be for an adult?
60-100 bpm
What are "normoactive" bowel sounds?
5-30 sounds per minute
Normal bowel sounds are called "active bowel sounds"
(May be documented as BS+x4quads)
Gently pinching the skin on the forearm or chest checks for what?
Skin turgor (hydration status).
What does PERRLA measure?
Pupils equal, round, reactive to light and accommodation.
Which lung sound is described as tiny popping noises, like rubbing hair between your fingers?
Crackles
If capillary refill takes longer than 3 seconds, what could that mean?
Poor circulation or decreased perfusion.
If a patient hasn’t urinated all shift, what is your first action?
Ask when they last voided / monitor for retention.
If you press on a patient’s lower leg and an indentation stays, what is this called?
Pitting edema.
When you ask the patient to squeeze your hands, what are you checking?
Their muscle/motor strength, and is it equal bilaterally?
Which lung sound is high‑pitched and whistling, often heard when the airways are tight?
What does a nurse feel for when checking a peripheral pulse?
Rate, rhythm, and strength.
What should you check for before assuming a catheter is “not draining”?
Kinks in the tubing (simple but often forgotten!).
When you check the skin for cuts, bruises, redness, or open areas, what are you checking?
Skin integrity
You rub the patient’s sternum and they do not wake up. What does this tell you?
They are not responding to painful stimulus (decreased level of consciousness).
Which lung sound is low‑pitched, rumbling, or snoring‑like, caused by mucus in the larger airways
Rhonchi
Why does the nurse check pulses on both sides of the body?
To make sure circulation is equal on both sides.
What order do you auscultate bowel sounds?
Start in RLQ and move clockwise
RLQ-RUQ-LUQ-LLQ
When observing the patient walking a few steps, what are you monitorng?
Gait & Mobility, how they move