Prioritization & Clinical Judgment
What does the ABC framework stand for, and which patient would you see first using this method?
Airway, Breathing, Circulation. First see the patient with airway issues (e.g., trouble breathing).
Why is silence sometimes more therapeutic than speaking?
It gives the client space to reflect and shows presence without pressure.
How often should a nurse perform a head-to-toe assessment on a stable client during a 12-hour shift?
Minimum of once at the start of the shift, hourly round, and reassess every 4 hours or more often based on condition changes and medication administrations using focused assessments.
Where should the pulse ox sensor be placed for the most accurate reading?
On a clean, warm finger or earlobe, away from nail polish.
A patient has otitis media. What would the tympanic membrane look like?
Red, bulging, and possibly purulent tympanic membrane.
A confused patient has lost their ID band. What should the nurse do first?
Verify the patient's identity using the EHR and obtain a new ID band immediately.
What is the correct way to validate a patient’s feelings when they’re in pain but refusing medication?
Acknowledge their fear/pain and explore their concerns respectfully.
What is BMI of a 42 yr old male weighing 230 lbs and 70 inches.
The BMI of a 42-year-old male weighing 230 lbs and standing 70 inches tall is 33.00.
Square the height in inches: 702=4900702=4900
Divide the weight by the squared height: 2304900≈0.046944900230≈0.04694
Multiply by 703 to get the BMI: 703×0.04694≈33.00703×0.04694≈33.00
What actions could lead to false low pulse ox readings?
Cold fingers, poor perfusion, movement, bright lights, nail polish.
What does the presence of jugular vein distention indicate?
Right-sided heart failure or fluid
Name two examples of when a nurse would initiate a focused assessment and why.
Chest pain or acute distress; after intervention, reassess to evaluate response.
Why is “Don’t worry, everything will be fine” a nontherapeutic response?
It's false reassurance, which invalidates the client’s emotions.
Why is it important to document assessment findings immediately?
So findings are accurate, not forgotten, and care is timely.
Describe the difference between a normal and abnormal precordium assessment.
Normal: No lifts/heaves/thrills. Abnormal: presence of lifts/heaves/thrills withvisible pulsations or abnormal PMI (Point of Maximal Impulse).
Identify the landmarks for auscultating heart valves (A, P, E, T, M).
Aortic-2nd intercostal space, right sternal border. , Pulmonic-2nd intercostal space, left sternal border., Erb’s point-3rd intercostal space, left sternal border., Tricuspid-4th intercostal space, left sternal border., Mitral-5th intercostal space, midclavicular line. (APET To Monkey).
A client reports joint pain and fear about movement worsening it. Which part of the nursing process is this, and how should the nurse respond?
Implementation requires action but first use therapeutic communication and validate the client's fears.
What does active listening look like in a nurse-patient interaction?
Eye contact, nodding, summarizing; fully engaged listening.
What is the correct patient positioning for assessing jugular vein distention?
Supine with the head of bed at 30–45 aka semi-fowlers.
What is the significance of an S1 heart sound, and where is it best heard?
Marks beginning of systole; best heard at apex (mitral area).
Which cranial nerve would affect hearing loss, and how would you test it?
Cranial Nerve VIII; test with whisper or tuning fork tests.
A carotid bruit is heard—what does this mean and what is the priority nursing action?
It indicates turbulent blood flow due to narrowing; notify the provider.
Provide an example of a therapeutic statement a nurse could say to a client dealing with chronic illness and anxiety.
“I hear that you’re feeling overwhelmed. Let’s talk through it together.”
What are red flags that a lesion may indicate skin cancer?
Asymmetry, irregular border, color variation, diameter >6mm, evolution.
Define bruit and where it would most commonly be assessed.
A vascular sound indicating partial artery obstruction; commonly carotid.
A patient presents with poor circulation in the hands. How would you educate them on follow-up care?
Explain need to see a provider for further circulation evaluation.