Vital Signs
What is the normal range for adult respiratory rate?
12–20 breaths per minute
What does PERRLA stand for?
A: Pupils Equal, Round, Reactive to Light and Accommodation
Name a lung sound that may indicate fluid in the lungs.
A: Crackles (rales)
What part of the stethoscope is used for low-pitched sounds like bruits?
A: Bell
What does SBAR stand for?
A: Situation, Background, Assessment, Recommendation
Which pulse site is used for assessing circulation to the lower extremities?
A: Dorsalis pedis
When auscultating lungs, how many sites should be assessed anteriorly?
A: At least 6 (3 per side)
What skin color might you expect in a patient with hypoxia?
A: Cyanosis (bluish discoloration)
You notice the patient’s abdomen is tender in the RLQ. What organ might be involved?
A: Appendix
What’s the correct abbreviation for “as needed”?
A: PRN
A patient has a BP of 89/60 mmHg. This is considered:
A: Hypotension
What is the sequence of physical assessment techniques (except abdomen)?
A: Inspect, Palpate, Percuss, Auscultate
Which cranial nerve is affected if the patient cannot smile symmetrically?
A: Cranial Nerve VII (Facial)
You’re checking capillary refill. What is a normal finding?
A: Less than 2 seconds
You document a patient’s pain as 9/10. What type of data is this?
A: Subjective
The best method to take a temperature for an unconscious patient is:
A: Rectal (if not contraindicated)
What sound is heard over the lungs during percussion?
A: Resonance
If a patient has unequal pupil sizes, it may indicate:
A: Neurological injury (e.g., stroke, brain trauma)
What do you ask the patient to do during auscultation of carotid arteries to reduce noise?
A: Hold their breath
A nurse notes "clear breath sounds bilaterally." Is this objective or subjective?
A: Objective
Define systolic vs. diastolic blood pressure.
A: Systolic = pressure during heart contraction; Diastolic = pressure during heart relaxation
When assessing for edema, what does “+2 pitting edema” mean?
A: Moderate indentation that rebounds in 10–15 seconds
A bounding pulse (4+) could be a sign of:
A: Fluid overload or high cardiac output
Define orthostatic hypotension.
A: A drop in BP of ≥20 systolic or ≥10 diastolic when standing from sitting/lying
What’s wrong with this charting? "Patient seems fine, probably just tired."
A: Vague and subjective; "seems" and "probably" are not appropriate in charting