Assessment Cues
What abnormal lung sounds indicate fluid buildup in this patient?
Coarse crackles and diminished breath sounds bilaterally, more on the left.
Which problem should be addressed first: impaired gas exchange, fluid overload, or infection?
Impaired gas exchange - airway and breathing take top priority.
Mr. A needs help turning in bed every two hours to prevent skin breakdown. Who can safely perform this task?
Nurses and Care Aids
Mr. A’s O2 is 94 %. What is your first nursing action?
Apply O2 2 L/min via nasal prongs
Why does Mr. A’s CKD affect medication safety?
↓ renal clearance → drug accumulation risk (e.g., ramipril)
What cue suggests gastrointestinal bleeding has improved?
The patient no longer has nausea or bloody emesis.
Which problem should be prioritized first: pain, constipation, or fluid/electrolyte imbalance?
Fluid and electrolyte imbalance - essential for perfusion and kidney function.
Your patient’s blood pressure is 88/50 mmHg. What is your responsibility as a student nurse?
Reassess the blood pressure, report findings to the primary nurse/instructor, and monitor for symptoms.
Patient D coughs during meals, what is your priority intervention?
Sit him upright ≥ 45°, stop feeding, assess for aspiration
If the patient’s sodium drops from 134 to 130 mEq/L, what is your first nursing response?
Notify the primary nurse/physician, assess for neurological changes (LOC), and review IV fluid orders.
Which new finding suggests possible cellulitis in Patient D
Red, swollen, painful area on the right leg.
Which problem should be addressed first: pain, dehydration, or worsening infection (sepsis)?
Infection. It’s the underlying cause of sepsis and can rapidly worsen.
While assessing a post-stroke patient, you notice coughing and a wet voice during meals. Which inter-professional referral should you anticipate?
Speech-Language Pathologist (SLP) for a swallowing assessment.
What nursing action helps relieve abdominal distension related to constipation and NG tube use?
Verify NG tube function and promote repositioning/ambulation to encourage bowel movement.
What nursing action helps improve oxygenation and reduce fluid accumulation in the lungs?
Encourage upright HOB positioning (semi-Fowler’s/high Fowler’s) to promote lung expansion.
You notice your patient’s respiratory rate has increased from 18 to 28 breaths/min and they appear restless. What is your immediate nursing action?
Assess oxygen saturation, assess pain and record any abnormal data and notify the primary nurse (possible early sign of hypoxia)
You are caring for four patients. Who should you see first?
A patient with a dressing that needs changing
A patient requesting pain medication
A patient with O₂ saturation of 89 % on room air
A patient needing discharge teaching
The patient with O2 89 % - airway and breathing are top priority.
The physiotherapist asks you to help mobilize a patient who just had a dose of IV hydromorphone. What is your best response?
Inform the PT that the patient recently received narcotics, assess sedation level, and ensure it’s safe before assisting.
Which healthcare provider is most appropriate to delegate performing a swallow assessment before starting oral intake post-stroke?
Speech-Language Pathologist
If breath sounds suddenly decrease and O₂ drops to 88%, what should you do first?
Assess airway and chest tube patency, then notify the primary nurse/physician immediately.