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.
This normal breath sound is low-pitched, soft, and heard best over most of the lung fields during inspiration.
What are vesicular breath sounds?
This heart sound is produced by closure of the mitral and tricuspid valves at the start of systole.
What is S1 (“lub”)?
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
This abnormal sound, often described as “crackling,” indicates fluid or secretions in the alveoli and is commonly heard in heart failure and pneumonia.
What are crackles (rales)?
This is the correct location to auscultate the apical pulse (point of maximal impulse).
What is the 5th intercostal space at the midclavicular line?
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.
A nurse observes an increased anterior-posterior chest diameter in a chronic smoker. This finding is most associated with this condition.
What is COPD (barrel chest)?
A nurse hears an extra heart sound after S2 in an adult, suggesting fluid overload and possible heart failure.
What is S3?
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.
A patient with asthma presents with high-pitched, musical sounds on expiration due to narrowed airways.
What are wheezes?
A patient reports chest pain radiating to the jaw and left arm with diaphoresis. This condition requires immediate intervention.
What is myocardial infarction?
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.
A patient develops sudden dyspnea, absent breath sounds on one side, and tracheal deviation. This is the priority emergency.
What is a tension pneumothorax?
A palpable vibration over the chest wall during cardiac assessment indicates this abnormal finding.
What is a thrill (turbulent blood flow)?