CARDIAC ASSESSMENT
The nurse palpates this pulse site during a focused cardiac assessment to assess circulation to the lower extremities.
Answer:
What is the pedal pulse?
Rationale:
Pedal pulses help the nurse evaluate peripheral circulation and tissue perfusion to the feet and legs. Weak or absent pulses may indicate decreased cardiac output or vascular disease.
Question:
This breath sound is high-pitched and commonly heard in patients with asthma.
Answer:
What are wheezes?
Rationale:
Wheezes occur when air moves through narrowed airways and are common in asthma and bronchospasm.
Question:
This scale is used to assess a patient’s level of consciousness after a head injury.
Answer:
What is the Glasgow Coma Scale?
Rationale:
The Glasgow Coma Scale measures eye opening, verbal response, and motor response to assess neurological status.
Question:
Which patient should the nurse assess first?
Answer:
What is the patient with wheezing?
Rationale:
Airway and breathing problems are always priority according to ABCs.
Question:
This documentation is most appropriate:
Answer:
What is “Patient alert and oriented x2”?
Rationale:
Objective, measurable documentation is legally and professionally appropriate.
A patient has bilateral +3 pitting edema and crackles in both lung bases. These findings may indicate this condition.
Answer:
What is heart failure/fluid overload?
Rationale:
Edema and crackles are signs of fluid retention. In heart failure, fluid backs up into the lungs and tissues due to ineffective cardiac pumping.
Question:
The nurse notes use of accessory muscles during breathing. This finding indicates this problem.
Answer:
What is respiratory distress?
Rationale:
Accessory muscle use means the patient is working harder to breathe and may not be oxygenating effectively.
Question:
The nurse asks a patient their name, location, and date. The nurse is assessing this.
Answer:
What is orientation?
Rationale:
Orientation assesses cognitive function and awareness of person, place, and time.
Question:
Which patient finding is highest priority?
Answer:
What is O2 sat 84%?
Rationale:
Severe hypoxia threatens life immediately and requires urgent intervention.
Question:
The nurse documents crackles in the lower lung bases bilaterally. This documentation is considered this type of data.
Answer:
What is objective data?
Rationale:
Objective data are measurable or observable findings obtained during assessment.
Question:
The nurse notes jugular vein distention while the patient is sitting upright. This finding should cause the nurse to suspect this problem.
Answer:
What is fluid volume overload/right-sided heart failure?
Rationale:
Jugular vein distention indicates increased venous pressure and is commonly seen in right-sided heart failure and fluid overload states.
Question:
Which assessment finding requires immediate follow-up?
Answer:
What are absent breath sounds on the left side?
Rationale:
Absent breath sounds may indicate pneumothorax, severe obstruction, or lung collapse and require urgent assessment.
Question:
The nurse notes facial droop, slurred speech, and unilateral weakness. Which action is priority?
Answer:
What is activate stroke response/notify provider immediately?
Rationale:
These are classic stroke symptoms. Rapid intervention improves patient outcomes and may preserve brain tissue.
Question:
The nurse enters a room and finds a patient unresponsive. What is the FIRST action?
Answer:
What is assess responsiveness and breathing?
Rationale:
The nurse must first determine if the patient is responsive and breathing before initiating further interventions.
Question:
The nurse receives a verbal order from the provider over the phone. What action should the nurse take to ensure accurate documentation and patient safety?
Correct Response:
What is read back the order to the provider before documenting it?
Rationale:
Reading back verbal orders helps prevent communication errors and ensures the order is documented accurately before implementation.
Question:
The nurse is assessing a patient with a history of heart failure. Which finding requires immediate follow-up?
• BP 128/76
• HR 88
• New crackles in bilateral lung bases
• Trace pedal edema
Correct Response:
What are new crackles in bilateral lung bases?
Rationale:
New crackles may indicate worsening fluid overload and pulmonary edema, which can quickly impair oxygenation and respiratory status in patients with heart failure.
Question:
The nurse is caring for a patient with crackles and shortness of breath. Which intervention is priority?
Answer:
What is raise the head of the bed?
Rationale:
High Fowler’s position improves lung expansion and decreases work of breathing.
Question:
Which assessment finding is most concerning?
Answer:
What are unequal pupils?
Rationale:
Unequal pupils may indicate neurological deterioration or increased intracranial pressure.
Question:
Which patient should the nurse see first?
Answer:
What is the patient with new confusion?
Rationale:
Acute mental status changes may indicate hypoxia, stroke, or neurological decline.
Question:
A nurse documents “patient resting comfortably” after administering pain medication. Which additional documentation is most important?
Correct Response:
What is reassessment of the patient’s pain rating after the medication?
Rationale:
Pain reassessment is required after interventions to evaluate whether the medication was effective and to support appropriate clinical judgment and documentation.
Question:
The nurse is assessing a patient with chest pain. Which finding requires immediate intervention?
Answer:
What is O2 sat 89%?
Rationale:
An oxygen saturation below 90% indicates hypoxemia and impaired oxygen delivery to tissues, requiring immediate intervention.
Question:
A patient with COPD becomes restless and confused. Which action should the nurse take first?
Answer:
What is assess oxygenation/O2 saturation?
Rationale:
Restlessness and confusion are early signs of hypoxia and require immediate oxygenation assessment.
Question:
A patient suddenly becomes difficult to arouse after a head injury. Which nursing action takes priority?
Answer:
What is assess airway and neurological status immediately?
Rationale:
A decreased level of consciousness after head injury may indicate worsening brain injury and threatens airway protection.
Question:
A patient with chest pain suddenly becomes short of breath and diaphoretic. What is the priority nursing action?
Answer:
What is assess airway, breathing, circulation, and notify rapid response/provider?
Rationale:
These findings may indicate cardiac instability requiring immediate intervention.
Question:
A nurse is preparing to delegate vital signs to an unlicensed assistive personnel (UAP). Which patient should the nurse assess personally instead of delegating?
• Stable patient awaiting discharge
• Patient admitted for routine observation
• Post-op patient with new onset chest pain
• Patient scheduled for physical therapy
Correct Response:
What is the post-op patient with new onset chest pain?
Rationale:
The nurse should personally assess unstable patients or those with new symptoms requiring nursing judgment and critical thinking. Delegation is appropriate only for stable patients with predictable outcomes.