PCA Patient Observation & Documentation 2 — Questions and Answers
Question 1: A patient's urine appears dark amber and has a strong odor. What should the PCA do first?
- Encourage the patient to drink more water immediately
- Report the observation to the supervising nurse (Correct answer)
- Ignore it unless the patient complains
- Document it and wait until end of shift to report
Correct 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.
Question 2: Which of the following is the correct way to document a patient's refusal to eat lunch?
- 'Patient was uncooperative at lunch'
- 'Patient refused lunch — stated not hungry' (Correct answer)
- 'Patient did not eat because of bad attitude'
- 'Lunch was offered but ignored'
Correct 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.
Question 3: What does it mean when a patient's skin appears cyanotic?
- The skin is dry and flaking
- The skin has a bluish discoloration indicating poor oxygenation (Correct answer)
- The skin is unusually pale from anemia
- The skin is red and inflamed from an allergic reaction
Correct 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.
Question 4: A PCA notices a patient is having difficulty swallowing during a meal. What is the priority action?
- Offer smaller bites and continue feeding
- Stop the meal and notify the nurse immediately (Correct answer)
- Give the patient water to help wash down food
- Document it and report at the next shift change
Correct 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.
Question 5: When documenting vital signs, a PCA records a blood pressure of 180/110. What should happen next?
- Record it and recheck in one hour
- Report it to the supervising nurse immediately (Correct answer)
- Ask the patient if they feel okay and leave it at that
- Discard the reading and retake it until a normal result appears
Correct 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.
Question 6: Which observation about a patient's wound should be reported to the nurse?
- The wound dressing appears clean and dry
- The wound site shows new redness, warmth, and yellow drainage (Correct answer)
- The wound is healing and the scab is forming
- The wound dressing was changed yesterday as scheduled
Correct 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.
Question 7: A PCA observes a patient is holding their abdomen and grimacing but denies pain when asked. How should this be documented?
- 'Patient has abdominal pain but is lying about it'
- 'Patient denies pain but was observed grimacing and holding abdomen' (Correct answer)
- 'Patient appears fine; no complaints noted'
- 'Patient may be in pain — needs further investigation'
Correct 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.
PCA Patient Observation & Documentation 2
A patient's urine appears dark amber and has a strong odor.
What should the PCA do first?