Nursing Primary Assessment Process

Choose a study mode

Play Quiz
Study Flashcards
Spaced Repetition
Chat to Lesson

Podcast

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What is the first step that nurses should undertake in every encounter with patients?

  • Administer medication
  • Perform a focused assessment
  • Take vital signs
  • Complete a primary assessment (correct)

What should nurses do if a patient is not responding and they hear stridor during the assessment?

  • Insert nasopharyngeal airways
  • Administer oxygen
  • Send for immediate help (correct)
  • Check for a pulse

What should be used to clear the airway if there is nothing visible when trying to manage a compromised airway?

  • Geudels
  • Yankeer sucker (correct)
  • Oxygen mask
  • Nasopharyngeal airway

When should airway adjuncts like geudels or nasopharyngeal airways be inserted according to the text?

<p>If the patient is unconscious (B)</p> Signup and view all the answers

What is the first indication of a patient exhibiting moderate to severe respiratory distress?

<p>Speaking in broken sentences (A)</p> Signup and view all the answers

Which of the following is NOT a sign of respiratory distress?

<p>Speaking in full sentences (A)</p> Signup and view all the answers

What muscle groups can be involved when a patient is using accessory muscles for breathing?

<p>Intercostal muscles and abdominal wall muscles (C)</p> Signup and view all the answers

What does cyanosis indicate in terms of a patient's respiratory function?

<p>Severe respiratory distress (C)</p> Signup and view all the answers

Which of the following is a sign of haemodynamic compromise in a patient?

<p>Complaining of dizziness (C)</p> Signup and view all the answers

If a patient has no radial pulse, what does this suggest about their blood pressure?

<p>&lt;80 mmHg systolic BP (C)</p> Signup and view all the answers

What is one of the first signs to look for to assess if a patient is in respiratory distress?

<p>Speaking in broken sentences (D)</p> Signup and view all the answers

Which of the following is a clear indicator of moderate to severe respiratory distress in a patient?

<p>Use of accessory muscles for breathing (C)</p> Signup and view all the answers

What does a patient speaking in single words suggest about their respiratory function based on the text?

<p>They are exhibiting signs of respiratory distress (C)</p> Signup and view all the answers

Which of the following is a sign that a patient might be 'tiring' in terms of their respiratory function?

<p>Decrease in respiratory rate without improvement in vital signs (B)</p> Signup and view all the answers

Why is it crucial to observe for paradoxical breathing in a patient showing signs of respiratory distress?

<p>It can help identify specific muscle groups involved in breathing (A)</p> Signup and view all the answers

In assessing breathing, what does the presence of cyanosis typically indicate?

<p>Signs of severe respiratory distress (C)</p> Signup and view all the answers

If a patient is using shoulder shrugging as an accessory muscle while breathing, what does this suggest?

<p>'Tiring' in their respiratory function (C)</p> Signup and view all the answers

Why is it important to monitor the work of breathing in a patient exhibiting respiratory distress?

<p>To evaluate the effectiveness of interventions and prevent respiratory fatigue (A)</p> Signup and view all the answers

What is the purpose of a primary assessment for nurses?

<p>To identify and correct threats to patient safety (B)</p> Signup and view all the answers

Which abnormal sound should nurses be concerned about when assessing a patient's airway?

<p>Snoring (occlusion of the pharynx by the tongue or palate) (C)</p> Signup and view all the answers

What action should be taken if a patient is unconscious and has a compromised airway?

<p>Immediately send for help by pressing the emergency buzzer (B)</p> Signup and view all the answers

Which position can be used to maximize airway capacity in patients on spinal precautions?

<p>Head tilt 'sniff position' (C)</p> Signup and view all the answers

What should nurses do if they hear gurgling sounds during the assessment of a patient's airway?

<p>Attempt to clear the airway by using appropriate techniques (A)</p> Signup and view all the answers

When should nurses insert airway adjuncts like nasopharyngeal airways according to the text?

<p>If the patient is unconscious (C)</p> Signup and view all the answers

Which action should nurses take if a patient is not responding during the airway assessment?

<p>Listen for abnormal sounds indicating potential issues (A)</p> Signup and view all the answers

What do stridor, snoring, wheezing, and gurgling sounds indicate in a patient's airway?

<p>Possible blockages or obstructions at different levels (A)</p> Signup and view all the answers

What should nurses do if they hear hoarseness in a patient's voice during an airway assessment?

<p>Investigate further as it could be related to airway issues (C)</p> Signup and view all the answers

What technique can be used by nurses to clear a compromised airway when no obstructions are visible?

<p>Head tilt 'sniff position' (B)</p> Signup and view all the answers

What immediate action should be taken if a patient exhibits stridor during an airway assessment?

<p>Send for help by pressing the emergency buzzer (B)</p> Signup and view all the answers

Flashcards are hidden until you start studying

More Like This

Use Quizgecko on...
Browser
Browser