ASSESSMENT & CLINICAL JUDGEMENT
A patient refuses care. What is your BEST response?
Respect their autonomy and educate on risks and benefits
Unilateral weakness and slurred speech suggest this
Stroke
Scale used to assess level of consciousness
What is Glasgow Coma Scale
High pitched wheezing indicates this
Airway narrowing such as asthma
Best area to check skin turgor in elderly patients
Sternum or forehead
A coworker ignores your concerns about a deteriorating patient. What is your next step?
Escalate to charge nurse or supervisor
Findings: BP 88/60, HR 114, cool clammy skin indicates this
Shock or hypovolemia
A&O x4 means this
Alert and oriented to person, place, time and situation
What are normal heart sounds?
S1 and S2
What is a priority intervention for pressure injury prevention?
Repositioning every 2 hours
You assess a patient and note jugular vein distention at 45 degrees. What does this indicate?
What is fluid overload or right-sided heart failure?
Why should you not massage a reddened pressure area?
Risk of tissue damage
A patient becomes suddenly lethargic and difficult to arouse. What is your priority?
Assess LOC (level of consciousness) and check vital signs immediately
Crackles, edema, shortness of breath indicates what?
Congested heart failure
A wound has redness, warmth, swelling, and drainage. What phase is this?
Inflammation/infection phase
A patient has bounding pulses and a BP of 168/92. What is your concern?
Hypertension with possible increased cardiac workload
A patient becomes restless, anxious, O2 saturation of 88%. What early sign is this?
Hypoxia
You note unequal pupils. What is the significance of this?
Increased intracranial pressure or neurological EMERGENCY
A patient with COPD has O2 saturation of 90%. Why should oxygen be used cautiously?
Risk of suppressing respiratory drive
Why are diabetics at higher risk for breakdown?
Poor circulation and delayed healing
During an assessment, you find unequal chest expansion. What would this suggest?
Pneumothorax or lung collapse
You are assessing a patient who suddenly becomes SOB, anxious, O2 saturation 86% on room air, BP 92/60. What are your FIRST 3 actions?
1. assess airway and breathing
2. Apply oxygen
3. Notify provider/call rapid response
A patient post-head injury begins vomiting and has a headache. what is your concern?
Increased intracranial pressure
Sudden chest pain, tachycardia, and shortness of breath may indicate this
Pulmonary embolism
A non-blanchable deep purple area indicates this type of wound
Suspected deep tissue injury