Patient Assessment and Clinical Skills Flashcards

According to DHA nursing standards, what is the correct order for physical assessment?

Answer: Inspection, palpation, percussion, auscultation

DHA nursing standards follow the systematic approach of inspection (visual observation), palpation (touch), percussion (tapping), and auscultation (listening), except for abdominal assessment where auscultation precedes palpation.

What is the normal range for adult blood pressure according to DHA clinical guidelines?

Answer: Less than 120/80 mmHg

DHA guidelines align with international standards defining normal blood pressure as less than 120/80 mmHg. Readings above this require monitoring and potential intervention.

How should a DHA-licensed nurse document a wound assessment?

Answer: Document wound location, size, depth, color, drainage type and amount, surrounding skin condition, and odor

DHA documentation standards require comprehensive wound assessment including exact location, measurements (length x width x depth), wound bed color, exudate characteristics, periwound skin condition, and any odor.

What is the purpose of the Braden Scale used in DHA healthcare facilities?

Answer: To assess a patient's risk for developing pressure injuries

The Braden Scale assesses six risk factors (sensory perception, moisture, activity, mobility, nutrition, friction/shear) to predict pressure injury risk, guiding preventive interventions in DHA facilities.

What must a DHA nurse assess before administering an enteral feeding?

Answer: Tube placement verification, residual volume, patient positioning at 30-45 degrees, and tube patency

Before enteral feeding, DHA nurses must verify tube placement (aspiration of gastric contents, pH testing), check residual volume, position the patient upright at 30-45 degrees to prevent aspiration, and confirm tube patency.

What is the recommended frequency for neurological observations using the Glasgow Coma Scale in DHA acute care settings?

Answer: Every 15 minutes to 4 hours depending on patient acuity and clinical condition

DHA protocols require neurological observations at frequencies determined by patient acuity: every 15 minutes for acute neurosurgical patients, progressing to 1-4 hourly as the patient stabilizes.