Vital signs & Assessment
This is the normal pulse range for adults and adolescents in beats per minute.
What is 60 to 100 beats per minute?
Explanation: Normal adult/adolescent pulse range is 60-100 bpm. Below 60 = bradycardia; above 100 = tachycardia.
According to the WHO, hand hygiene should be performed at this many moments during patient care.
What is 5 (five) moments?
Explanation: WHO "5 Moments for Hand Hygiene":
1 Before touching a patient
2 Before clean/aseptic procedure
3 After body fluid exposure risk
4 After touching a patient
5 After touching patient surroundings
This type of data includes what the patient tells you about their symptoms and experiences.
What is subjective data?
Explanation:
• Subjective = what the patient TELLS you (symptoms, feelings, pain)
• Objective = what you OBSERVE/MEASURE (vital signs, lab values, physical findings)
On the pulse amplitude scale, this number (0-4+) indicates a bounding, increased pulse that is stronger than normal.
What is 3+?
Explanation: Pulse amplitude scale:
• 0 = Absent
• 1+ = Weak, thready
• 2+ = Normal
• 3+ = Bounding, increased
• 4+ = Very bounding
This surface of the hand is used to assess a patient's body temperature during palpation.
What is the dorsal surface (or back of the hand)?
Explanation: Dorsal surface = temperature; Palmar surface = general palpation; Ulnar surface = vibration.
When caring for a patient with C. difficile, you must use this method for hand hygiene instead of alcohol-based hand rubs.
What is soap and water (for at least 20 seconds)?
Explanation: Alcohol does NOT kill C. diff spores. Must use soap and water to mechanically remove spores. This is a critical exception to the usual preference for alcohol-based hand rubs.
This therapeutic communication technique involves summarizing the main themes of what the patient has communicated.
What is reflection?
Explanation:
• Reflection = summarizing main THEMES (emotional content and overall meaning)
• Restatement = repeating back the CONTENT
• Elaboration = asking patient to describe more completely
• Clarification = asking questions when meaning is unclear
A patient has a WBC count of 16,000/mm³ and an elevated erythrocyte sedimentation rate. These two laboratory findings indicate this condition.
What is infection (or possible/active infection)?
Explanation:
• Elevated WBC (normal is 5,000-10,000) = body producing more white blood cells to fight infection
• Elevated ESR (erythrocyte sedimentation rate) = indicates inflammation/infection
• Both together strongly suggest active infection
When assessing the abdomen, you must perform this technique BEFORE palpation to avoid creating false findings.
What is auscultation?
Explanation: The abdomen is the EXCEPTION to the typical assessment order. You must listen to bowel sounds BEFORE touching the abdomen because palpation/percussion can stimulate bowel sounds. Order: Inspection → Auscultation → Percussion → Palpation.
This stage of infection is when the patient is MOST contagious, even though symptoms are vague and nonspecific.
What is the prodromal stage?
Explanation: During the prodromal stage, early symptoms are present but vague, so patients often don't realize they're sick and continue spreading infection. This makes it the most dangerous/contagious stage.
Nurses should avoid asking this type of question during interviews because it can make patients feel defensive and judged.
What are "why" questions?
Explanation: "Why" questions (like "Why did you wait so long?") make patients feel they need to justify their actions and can seem judgmental. This is a nontherapeutic response. Better to ask "What prevented you from..." or "Tell me about..."
Patients have the right to obtain, review, and do THIS to their medical record, but they cannot do THIS to existing documentation.
What is update (and cannot) revise (or change existing documentation)?
Explanation: Patients can:
• Obtain (get copies) ✓
• Review (read/see) ✓
• Update (add NEW information) ✓
But patients CANNOT:
• Revise (change EXISTING documentation) ✗
Key difference: Update = add new info; Revise = change what's already there
A patient's temperature fluctuates between 100°F and 103°F throughout the day but never returns to normal. This is the term for this fever pattern.
What is remittent fever?
Explanation:
• Remittent = does NOT return to normal, fluctuates a few degrees
• Intermittent = returns to normal at least once per 24 hours
• Sustained = stays constantly elevated with minimal variation
• Relapsing = normal for one or more days between fever episodes
For patients on transmission-based precautions, PPE should be donned at this time and removed at this time.
What is before entering the room and when leaving the room (or upon exit)?
Explanation: 2007 CDC guidelines: Don PPE BEFORE entering, remove ONLY when leaving the room. This prevents contamination of the environment outside the isolation room.
This documentation method is unique because it incorporates the care plan into progress notes and identifies problems by number.
What is PIE charting (Problem, Intervention, Evaluation)?
Explanation: PIE is unique - it does NOT develop a separate care plan but incorporates it into progress notes with numbered problems.
This anatomical location is where you place the stethoscope to assess the apical pulse: the fifth intercostal space at this line.
What is the left midclavicular line?
Explanation: Apical pulse location = 5th intercostal space, left midclavicular line (apex of the heart, point of maximal impulse).
These three types of transmission-based precautions can be used alone or in combination with standard precautions.
What are airborne, droplet, and contact precautions?
Explanation:
• Airborne = TB, measles, varicella (N95, negative pressure room)
• Droplet = Influenza, meningitis (surgical mask)
• Contact = MRSA, C. diff (gloves + gown) These are used IN ADDITION TO standard precautions.
In the ISBARR communication format, these six components are presented in this specific order.
What is Identity/Introduction, Situation, Background, Assessment, Recommendation, Read back (I-S-B-A-R-R)?
Explanation: ISBARR standardized communication tool ensures all critical information is communicated in logical sequence:
• I = Identity/Introduction (who you are, who the patient is)
• S = Situation (what's happening now)
• B = Background (relevant history/context)
• A = Assessment (your clinical assessment)
• R = Recommendation (what you think should be done)
• R = Read back (verify orders/response)