PCCN: Chapter 1 - Assessment of
Progressive Care Patients and Their
Families
1. A difference of how many mmHg between a cuff BP and an arterial line
pressure, require a decision to be made as to which pressure is the most
accurate and will be followed for future treatment decisions? -- Correct
Answer ---10 - 15 mmHg
2. Admission of an acutely ill pt can be chaotic and staff must be cognizant
of: -- Correct Answer ---accurate assessments & data gathering to ensure
the pt is cared for safely with appropriate interventions.
3. Arterial Blood Gases (ABG's) are used to assess: -- Correct Answer –
1. -oxygenation
2. -ventilatory status
3. -acid-base balance
4. Assessment of the progressive care patient begins (2) -- Correct Answer
–
1. -moment nurse aware of pending admission/transfer
2. -continues until transitioning to next phase of care
,5. Assessments should first focus on (2): -- Correct Answer –
1. -patient (focal point of practitioner's attention)
2. -technology (augments info obtained from direct
3. assessment)
6. At what time does the comprehensive assessment begin? -- Correct
Answer ---after completion of the "ABCDE's"
7. AUSCULTATE heart sounds for: -- Correct Answer –
-S1 and S2
-quality, intensity and pitch
-presence of extra heart sounds (murmers, clicks, rubs)
-any changes with RR or pt position
8. Auscultate the chest for: -- Correct Answer –
-presence of bilateral breath sounds
-quality of breath sounds
-bilateral chest expansion
9. AUSCULTATION of the abdomen includes: -- Correct Answer –
-bowel sounds in all four quadrants
-characteristics and frequency
, -adventitious sounds (friction rubs, bruits, hums)
10. Before noting ABSENT bowel sounds, a quadrant should be auscultated
for how long? -- Correct Answer –
-60 - 90 seconds
11. Brain tissue atrophy results in the following: -- Correct Answer ---
stretching parasagittal bridging veins (making them more
susceptible to rupture
-additional space in cranial vault (that allows bleeding to
accumulate before S/Sx of increased ICP present)
-higher incidence of chronic subdural hematomas
12. Cognitive impairments are exacerbated during an acute illness due to: --
Correct Answer –
-physiologic changes
-Rx
-environmental changes
13. Collection of assessment data is obtained in: -- Correct Answer –
-phased or staged manner
-consistent with pt care priorities
, 14. Define mnemonic: DOPE -- Correct Answer –
-D = Dislodgement
-O = Obstruction
-P = Pneumothorax
-E = Equipment functioning properly
15. Define mnemonic: FOCA -- Correct Answer –
-F = Fluid fluctuation with respirations
-O = Output
-C = Color of drainage (amount and character)
-A = Air leak
16. Define mnemonic: SBAR -- Correct Answer –
-S = Situation
-B = Background
-A = Assessment
-R = Recommendations
17. Define the elements assessed in evaluating the gross LOC. -- Correct
Answer –
-Alert
-Aware of surroundings
-Type of stimulus required to obtain a response ( verbal or
Progressive Care Patients and Their
Families
1. A difference of how many mmHg between a cuff BP and an arterial line
pressure, require a decision to be made as to which pressure is the most
accurate and will be followed for future treatment decisions? -- Correct
Answer ---10 - 15 mmHg
2. Admission of an acutely ill pt can be chaotic and staff must be cognizant
of: -- Correct Answer ---accurate assessments & data gathering to ensure
the pt is cared for safely with appropriate interventions.
3. Arterial Blood Gases (ABG's) are used to assess: -- Correct Answer –
1. -oxygenation
2. -ventilatory status
3. -acid-base balance
4. Assessment of the progressive care patient begins (2) -- Correct Answer
–
1. -moment nurse aware of pending admission/transfer
2. -continues until transitioning to next phase of care
,5. Assessments should first focus on (2): -- Correct Answer –
1. -patient (focal point of practitioner's attention)
2. -technology (augments info obtained from direct
3. assessment)
6. At what time does the comprehensive assessment begin? -- Correct
Answer ---after completion of the "ABCDE's"
7. AUSCULTATE heart sounds for: -- Correct Answer –
-S1 and S2
-quality, intensity and pitch
-presence of extra heart sounds (murmers, clicks, rubs)
-any changes with RR or pt position
8. Auscultate the chest for: -- Correct Answer –
-presence of bilateral breath sounds
-quality of breath sounds
-bilateral chest expansion
9. AUSCULTATION of the abdomen includes: -- Correct Answer –
-bowel sounds in all four quadrants
-characteristics and frequency
, -adventitious sounds (friction rubs, bruits, hums)
10. Before noting ABSENT bowel sounds, a quadrant should be auscultated
for how long? -- Correct Answer –
-60 - 90 seconds
11. Brain tissue atrophy results in the following: -- Correct Answer ---
stretching parasagittal bridging veins (making them more
susceptible to rupture
-additional space in cranial vault (that allows bleeding to
accumulate before S/Sx of increased ICP present)
-higher incidence of chronic subdural hematomas
12. Cognitive impairments are exacerbated during an acute illness due to: --
Correct Answer –
-physiologic changes
-Rx
-environmental changes
13. Collection of assessment data is obtained in: -- Correct Answer –
-phased or staged manner
-consistent with pt care priorities
, 14. Define mnemonic: DOPE -- Correct Answer –
-D = Dislodgement
-O = Obstruction
-P = Pneumothorax
-E = Equipment functioning properly
15. Define mnemonic: FOCA -- Correct Answer –
-F = Fluid fluctuation with respirations
-O = Output
-C = Color of drainage (amount and character)
-A = Air leak
16. Define mnemonic: SBAR -- Correct Answer –
-S = Situation
-B = Background
-A = Assessment
-R = Recommendations
17. Define the elements assessed in evaluating the gross LOC. -- Correct
Answer –
-Alert
-Aware of surroundings
-Type of stimulus required to obtain a response ( verbal or
