Patient Observation & Documentation Flashcards
7 cards from real PCA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Observation & Documentation flashcards as text
A patient's urine appears dark amber and has a strong odor. What should the PCA do first?
Answer: Report the observation to the supervising nurse
Unusual changes in urine color or odor may indicate dehydration or infection and must be reported promptly to the supervising nurse.
Which of the following is the correct way to document a patient's refusal to eat lunch?
Answer: 'Patient refused lunch — stated not hungry'
Documentation must be objective, factual, and include the patient's own words when relevant, avoiding subjective or judgmental language.
What does it mean when a patient's skin appears cyanotic?
Answer: The skin has a bluish discoloration indicating poor oxygenation
Cyanosis is a bluish tint to the skin or lips caused by insufficient oxygen in the blood and requires immediate reporting.
A PCA notices a patient is having difficulty swallowing during a meal. What is the priority action?
Answer: Stop the meal and notify the nurse immediately
Difficulty swallowing (dysphagia) is a safety risk for aspiration and must be reported to the nurse immediately rather than managed independently.
When documenting vital signs, a PCA records a blood pressure of 180/110. What should happen next?
Answer: Report it to the supervising nurse immediately
A blood pressure of 180/110 is critically elevated and must be reported to the nurse immediately for timely medical intervention.
Which observation about a patient's wound should be reported to the nurse?
Answer: The wound site shows new redness, warmth, and yellow drainage
Redness, warmth, and yellow drainage are signs of possible infection and must be reported to the nurse for evaluation.
A PCA observes a patient is holding their abdomen and grimacing but denies pain when asked. How should this be documented?
Answer: 'Patient denies pain but was observed grimacing and holding abdomen'
Objective documentation records what is observed and what the patient states, without drawing conclusions or making judgments.