DHA Nursing Patient Assessment and Clinical Skills — Questions and Answers
Question 1: According to DHA nursing standards, what is the correct order for physical assessment?
- Palpation, inspection, percussion, auscultation
- Inspection, palpation, percussion, auscultation (Correct answer)
- Auscultation, inspection, palpation, percussion
- Percussion, palpation, auscultation, inspection
Correct 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.
Question 2: What is the normal range for adult blood pressure according to DHA clinical guidelines?
- 140/90 to 160/100 mmHg
- Less than 120/80 mmHg (Correct answer)
- 100/60 to 110/70 mmHg
- 160/100 to 180/110 mmHg
Correct 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.
Question 3: How should a DHA-licensed nurse document a wound assessment?
- Note only the wound size
- Document wound location, size, depth, color, drainage type and amount, surrounding skin condition, and odor (Correct answer)
- Write 'wound present' in the chart
- Only photograph the wound
Correct 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.
Question 4: What is the purpose of the Braden Scale used in DHA healthcare facilities?
- To measure pain levels
- To assess a patient's risk for developing pressure injuries (Correct answer)
- To calculate medication doses
- To evaluate fall risk
Correct 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.
Question 5: What must a DHA nurse assess before administering an enteral feeding?
- Only the feeding rate
- Tube placement verification, residual volume, patient positioning at 30-45 degrees, and tube patency (Correct answer)
- Only the patient's appetite
- Only the feeding temperature
Correct 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.
Question 6: What is the recommended frequency for neurological observations using the Glasgow Coma Scale in DHA acute care settings?
- Once daily
- Every 15 minutes to 4 hours depending on patient acuity and clinical condition (Correct answer)
- Only on admission
- Once per nursing shift
Correct 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.
DHA Nursing Patient Assessment and Clinical Skills
According to DHA nursing standards, what is the correct order for physical assessment?