HEALTH ASSESSMENT
What is the correct sequence for performing an abdominal assessment?
Inspection, Auscultation, Percussion, and Palpation
Rationale: Palpation and percussion can stimulate bowel activity and alter bowel sounds; therefore, auscultation must occur immediately after inspection.
The first action a nurse should take when a patient’s oxygen saturation drops suddenly.
What is Elevate the Head of the Bed (Fowler’s Position)?
Rationale: This is a non-invasive nursing intervention that uses gravity to allow for maximum chest expansion and improved gas exchange.
The classic triad of symptoms for Diabetes Mellitus.
What are Polyuria, Polydipsia, and Polyphagia?
• Rationale: Excessive urination, thirst, and hunger result from hyperglycemia and the resulting osmotic diuresis.
The priority assessment to perform before administering Digoxin.
What is the Apical Pulse?
• Rationale: Digoxin is a negative chronotrope; it should be held (usually if <60 bpm) to prevent dangerous bradycardia.
The "Five Rights" of Delegation include Right Task, Right Circumstance, Right Person, Right Direction, and this.
What is Right Supervision and Evaluation?
• Rationale: The RN is always responsible for following up and ensuring the task was completed correctly.
This heart sound, often called a "ventricular gallop," is heard early in diastole and can be a sign of heart failure in adults.
What is S3?
Rationale: S3 occurs during the rapid ventricular filling phase and is often associated with fluid volume overload or decreased ventricular compliance.
These "standard precautions" must be used for every patient, regardless of their diagnosis.
What is Hand Hygiene and Gloves?
Rationale: Standard precautions are based on the principle that all blood and body fluids are potentially infectious.
A patient with a DVT suddenly develops shortness of breath and chest pain; the nurse suspects this complication.
What is a Pulmonary Embolism (PE)?
• Rationale: A thrombus that detaches from the leg (DVT) and travels to the pulmonary artery obstructs blood flow to the lungs.
This class of antibiotics is associated with "Red Man Syndrome" if infused too quickly.
What is Vancomycin?
Rationale: Rapid infusion causes a histamine release; it is not a true allergy and is managed by slowing the infusion rate.
This ethical principle refers to the nurse's obligation to "do no harm."
What is Nonmaleficence?
• Rationale: It is the foundational duty of healthcare providers to protect patients from harm or injury.
What is a localized, purple-colored area of intact skin that indicates damage to underlying soft tissue from pressure or shear?
Deep Tissue Pressure Injury (DTPI)
Rationale: Unlike Stage 1 (non-blanchable redness), a DTPI indicates deeper tissue damage that may evolve rapidly into an open ulcer.
The primary goal of "Primary Prevention" in the levels of health care.
What is Health Promotion and Disease Prevention?
Rationale: Primary prevention aims to prevent a disease or injury before it ever occurs (e.g., immunizations, nutrition education).
This cardiac rhythm is characterized by a "sawtooth" P-wave pattern.
What is Atrial Flutter?
• Rationale: This occurs due to a re-entry circuit in the atrium, creating a rapid, regular atrial rate that looks like teeth on a saw.
The pharmacological antagonist (antidote) for Warfarin.
What is Vitamin K?
Rationale: Warfarin works by inhibiting Vitamin K-dependent clotting factors; Vitamin K directly reverses this effect.
In ABG interpretation, if the pH is 7.25 and the PaCO_2 is 50, the patient is in this state.
What is Respiratory Acidosis?
• Rationale: A low pH (<7.35) and high CO_2 (>45) indicates the lungs are retaining acid.
When assessing the lower extremities, the nurse notes an indentation of 6mm that remains for several seconds after pressing. This is documented as what grade of edema?
3+ Pitting Edema
Rationale: Pitting edema is graded 1+ (2mm) to 4+ (8mm). A 6mm indentation that remains for a short time is classified as 3+.
This type of transmission-based precaution requires a private room with negative airflow and the use of an N95 respirator.
What is Airborne Precautions?
• Rationale: Airborne precautions are used for small-particle pathogens (like TB, Varicella, or Measles) that remain suspended in the air.
The priority nursing assessment for a patient in the immediate postoperative period following a thyroidectomy.
What is Assessment for Respiratory Distress/Stridor?
• Rationale: Swelling or laryngeal nerve damage can cause airway obstruction; the nurse must also keep a tracheostomy tray at the bedside.
A patient receiving Magnesium Sulfate for preeclampsia shows a respiratory rate of 10 and absent deep tendon reflexes; the nurse should prepare this antidote.
What is Calcium Gluconate?
Rationale: Calcium Gluconate is the direct antagonist for Magnesium toxicity, which causes CNS and respiratory depression.
When providing care to a patient who does not speak the same language as the nurse, this is the only appropriate person to use for medical interpretation.
What is a Certified Medical Interpreter?
• Rationale: Family members may misinterpret clinical terms; a certified interpreter ensures accuracy and confidentiality.
During a cranial nerve assessment, the nurse asks the patient to shrug their shoulders and turn their head against resistance to test this specific nerve.
What is Cranial Nerve XI (Spinal Accessory)?
Rationale: CN XI controls the trapezius and sternocleidomastoid muscles; inability to shrug or turn the head indicates a deficit in this nerve.
According to Maslow’s Hierarchy of Needs, after physiological needs are met, this is the next priority for the nurse to address.
What is Safety and Security?
• Rationale: Once survival needs (oxygen, fluid, nutrition) are stable, the nurse must ensure the patient's physical safety and psychological security.
In a patient with Cirrhosis, the accumulation of ammonia in the blood can lead to this type of brain dysfunction, characterized by asterixis (hand flapping).
What is Hepatic Encephalopathy?
• Rationale: When the liver cannot detoxify ammonia, it crosses the blood-brain barrier, causing altered mental status and neuromuscular changes.
This life-threatening side effect of ACE inhibitors involves rapid swelling of the lips, tongue, and airway.
What is Angioedema?
Rationale: Angioedema is a medical emergency that can lead to total airway obstruction; it is a known adverse reaction to drugs ending in "-pril."
The legal term for a nurse performing a procedure on a patient without their informed consent.
What is Battery?
Rationale: Battery is the intentional and unwarranted touching of another person without consent.