NURS 301 EXAM GUIDE 2022/2023 UPDATE WITH
COMPLETE SOLUTION PACK A+
Vital Signs:
1. Temperature: Thermometer
• Axillary (97.6)
• Oral (96.6 - 99.5 F) Standard: 98.6
• Rectal (99.6 = 0.7 - 1 Degree higher than Oral): Babies
2. Pulse
• Radial (60 - 100): Most common pulse site.
0 = No pulse
+1 = Weak
+2 = Normal
+3 = Bounding
3. Respirations: Chest movement (Rise/ Fall, Asthmatic)
• (12 - 20)
• Bradypnea/ Tachypnea
4. Blood pressure
• 120/80
• Right size cuff: 2 finger breaths
• 80% coverage circumference when wrapping arm - 20% not overlapping
5. Pain (“The fifth vital sign”)
• COLDSPA: Character, Onset, Location, Duration, Severity, Pattern, & Associated factors
• FACES (Creator = Wong Baker)
• FLACC: Babies
• NRS (Numeric Rating Scale 0-10): Patient’s +6
* Capillary Refill Time: Less than 3 seconds
* Diaphragm: High-pitched sounds; Bells: Low-pitched sounds
Chapter 1: Nurse’s Role in Health Assessment: Collecting and Analyzing Data
,NURS 301 EXAM GUIDE 2022/2023 UPDATE WITH
COMPLETE SOLUTION PACK A+
Nurses are needed in all care units and have a dramatic impact on assessment role of the nurse:
• Acute care (Hospital)
• Critical care: (ICU - Closer to death, need more care & management. Nurse ratio: 2-1 Peds:
4- 1)
• Ambulatory care (Outpatient services)
• Home health
• Holistic nursing assessment: Collects holistic subjective & objective data to determine
client’s overall level of functioning in order to make professional clinical judgement.
(Looking at whole body & how they interact)
• Physical medical assessment: Focuses primarily on client’s physiologic development status.
Phases of Nursing Process: ADPIE
Assessment: Collecting subjective & objective data
Diagnosis: Make professional judgement after analyzing data
Planning: Determining outcome & plan of care
Implementation: Carrying out plan
Evaluation: Assessing if plan of care was efficient
Steps of Health Assessment:
1. Preparing for assessment: Patient’s records, status, medication, educate about diagnosis
& tests performed. (Education is key!)
2. Collecting Subjective data (What the subject tells you - All verbal)
• Biographical information
• History of present health concern; physical symptoms related to each body part.
• Past health history
• Family history
• Health & lifestyle practices
3. Collecting Objective data (What YOU SEE in the object - Inspecting, touching, smelling)
• Physical characteristics: Dislocation/ abnormal posture
• Body functions: Constipation/ Diarrhea
• Appearance: Clothing appropriate for weather
• Behavior: Making eye contact/ looking away/ laughing after hearing bad news
,NURS 301 EXAM GUIDE 2022/2023 UPDATE WITH
COMPLETE SOLUTION PACK A+
• Measurements: Height/ weight/ temperature
• Results of lab tests
4. Steps of Health Assessment:
• Validation of assessment data
• Documentation of data
• Analysis of data
* Are the patient’s telling you something different than what you see? VALIDATE!
5. Analysis phase of Nursing Process:
• Identify abnormal data & strengths
• Cluster data (Taking all the clues you need)
• Draw inferences & Identify problems
• Purpose possible nursing diagnosis
• Check for defining characteristics of those diagnoses
• Confirm/ rule out nursing diagnosis
• Document conclusions
Types of assessment:
1. Initial comprehensive: Collection of subjective data about client’s perception of health of all
body parts/ systems, past medical history, family history, and lifestyle/ health practices.
(Full documentation. Name, address, whole history)
2. Ongoing/ partial assessment: Data collection that occurs gayer comprehensive database is
established. (Doing problem areas you need to assess)
3. Focused/ problem-oriented: Thorough assessment of particular client problem, which
doesn’t cover areas not related to the problem.
4. Emergency: Very rapid assessment performed in life-threatening situations. (Doing
subjective & objective very quickly. Doing vital assessments but focusing more
on saving life. Determine ABCs first!)
Evolution of the Nurse’s Role in Health Assessment:
PAST:
• Physical assessment integral part of nursing
• Nurses relied on natural senses
• Palpation
, NURS 301 EXAM GUIDE 2022/2023 UPDATE WITH
COMPLETE SOLUTION PACK A+
• Movement of health care from acute care setting to community care & proliferation
of baccalaureate & graduate education
• Advanced practice nurses
PRESENT:
Managed care & internal case management has impact on assessment role of nurse:
• Acute care nurses
• Critical care outreach nurses
• Ambulatory care nurses
• Home health nurses
• Public health nurses
• School & hospice nurses
Chapter 2: Collecting Subjective Data: Interview & Health History:
Interviewing: Introduction, Working, Summary & Closing
I. Introductory phase: Introducing self
• Introduction
• Explain purpose of interview
COMPLETE SOLUTION PACK A+
Vital Signs:
1. Temperature: Thermometer
• Axillary (97.6)
• Oral (96.6 - 99.5 F) Standard: 98.6
• Rectal (99.6 = 0.7 - 1 Degree higher than Oral): Babies
2. Pulse
• Radial (60 - 100): Most common pulse site.
0 = No pulse
+1 = Weak
+2 = Normal
+3 = Bounding
3. Respirations: Chest movement (Rise/ Fall, Asthmatic)
• (12 - 20)
• Bradypnea/ Tachypnea
4. Blood pressure
• 120/80
• Right size cuff: 2 finger breaths
• 80% coverage circumference when wrapping arm - 20% not overlapping
5. Pain (“The fifth vital sign”)
• COLDSPA: Character, Onset, Location, Duration, Severity, Pattern, & Associated factors
• FACES (Creator = Wong Baker)
• FLACC: Babies
• NRS (Numeric Rating Scale 0-10): Patient’s +6
* Capillary Refill Time: Less than 3 seconds
* Diaphragm: High-pitched sounds; Bells: Low-pitched sounds
Chapter 1: Nurse’s Role in Health Assessment: Collecting and Analyzing Data
,NURS 301 EXAM GUIDE 2022/2023 UPDATE WITH
COMPLETE SOLUTION PACK A+
Nurses are needed in all care units and have a dramatic impact on assessment role of the nurse:
• Acute care (Hospital)
• Critical care: (ICU - Closer to death, need more care & management. Nurse ratio: 2-1 Peds:
4- 1)
• Ambulatory care (Outpatient services)
• Home health
• Holistic nursing assessment: Collects holistic subjective & objective data to determine
client’s overall level of functioning in order to make professional clinical judgement.
(Looking at whole body & how they interact)
• Physical medical assessment: Focuses primarily on client’s physiologic development status.
Phases of Nursing Process: ADPIE
Assessment: Collecting subjective & objective data
Diagnosis: Make professional judgement after analyzing data
Planning: Determining outcome & plan of care
Implementation: Carrying out plan
Evaluation: Assessing if plan of care was efficient
Steps of Health Assessment:
1. Preparing for assessment: Patient’s records, status, medication, educate about diagnosis
& tests performed. (Education is key!)
2. Collecting Subjective data (What the subject tells you - All verbal)
• Biographical information
• History of present health concern; physical symptoms related to each body part.
• Past health history
• Family history
• Health & lifestyle practices
3. Collecting Objective data (What YOU SEE in the object - Inspecting, touching, smelling)
• Physical characteristics: Dislocation/ abnormal posture
• Body functions: Constipation/ Diarrhea
• Appearance: Clothing appropriate for weather
• Behavior: Making eye contact/ looking away/ laughing after hearing bad news
,NURS 301 EXAM GUIDE 2022/2023 UPDATE WITH
COMPLETE SOLUTION PACK A+
• Measurements: Height/ weight/ temperature
• Results of lab tests
4. Steps of Health Assessment:
• Validation of assessment data
• Documentation of data
• Analysis of data
* Are the patient’s telling you something different than what you see? VALIDATE!
5. Analysis phase of Nursing Process:
• Identify abnormal data & strengths
• Cluster data (Taking all the clues you need)
• Draw inferences & Identify problems
• Purpose possible nursing diagnosis
• Check for defining characteristics of those diagnoses
• Confirm/ rule out nursing diagnosis
• Document conclusions
Types of assessment:
1. Initial comprehensive: Collection of subjective data about client’s perception of health of all
body parts/ systems, past medical history, family history, and lifestyle/ health practices.
(Full documentation. Name, address, whole history)
2. Ongoing/ partial assessment: Data collection that occurs gayer comprehensive database is
established. (Doing problem areas you need to assess)
3. Focused/ problem-oriented: Thorough assessment of particular client problem, which
doesn’t cover areas not related to the problem.
4. Emergency: Very rapid assessment performed in life-threatening situations. (Doing
subjective & objective very quickly. Doing vital assessments but focusing more
on saving life. Determine ABCs first!)
Evolution of the Nurse’s Role in Health Assessment:
PAST:
• Physical assessment integral part of nursing
• Nurses relied on natural senses
• Palpation
, NURS 301 EXAM GUIDE 2022/2023 UPDATE WITH
COMPLETE SOLUTION PACK A+
• Movement of health care from acute care setting to community care & proliferation
of baccalaureate & graduate education
• Advanced practice nurses
PRESENT:
Managed care & internal case management has impact on assessment role of nurse:
• Acute care nurses
• Critical care outreach nurses
• Ambulatory care nurses
• Home health nurses
• Public health nurses
• School & hospice nurses
Chapter 2: Collecting Subjective Data: Interview & Health History:
Interviewing: Introduction, Working, Summary & Closing
I. Introductory phase: Introducing self
• Introduction
• Explain purpose of interview
