NRS 204 WEEK 3 EXAM QUESTIONS ANSWERED CORRECTLY LATEST UPDATE 2026

NRS 204 WEEK 3 EXAM QUESTIONS ANSWERED CORRECTLY LATEST UPDATE 2026 Parts of life threat scan - Answers 1) Brief assessment 2) Within defined limits 3) Clinical triggers 4) Red flags 5) Focused assessment 6) Nursing diagnosis 7) Safest first actions How long should the brief assessment take? - Answers Less than 60 seconds Airway brief assessment - Answers "Is the airway open and clear?" Can the patient speak, are there any abnormal sounds? Breathing brief assessment - Answers "Is breathing adequate?" Rate, effort, SpO2, skin color Circulation brief assessment - Answers "Is circulation sufficient?" Pulse, skin Disability brief assessment - Answers "Is neurological status intact?" AVPU, pupils, glucose Exposure brief assessment - Answers "Any hidden findings?" Full body check, temperature WDL statement (Life threat scan) - Answers "Airway patent with clear vocalization, breathing unlabored with a RR 12-20 + Sp02 94% on room air. Circulation adequate with palpable radial pulse, skin warm and dry with brisk cap refill, alert and oriented, pupils equal and reactive, no obvious bleeding or injuries noted." Airway clinical triggers - Answers Hoarse voice, difficulty swallowing, noisy breathing, drooling, coughing Breathing clinical triggers - Answers Outside of 12-20 RR, SpO2 less than 94%, shortness of breath, increased effort, abnormal sounds Circulation clinical triggers - Answers HR outside of 60-100, irregular pulse, increased capillary refill time, pale/cool skin/dizziness Disability clinical triggers - Answers Drowsiness, confusion, slurred speech, weakness, unequal pupils, diabetes Exposure clinical triggers - Answers Fever, chills, wounds, swelling, bruising, pain with movement Airway red flags - Answers Stridor, gurgling, choking, unable to speak, severe swelling Breathing red flags - Answers RR less than 8 or more than 30, SpO2 less than 88%, apnea, severe accessory muscle use, tripod position, cyanosis, agonal respirations Circulation red flags - Answers No pulse, HR less than 40 or greater than 150, SBP less than 90, active uncontrolled breathing, ashen skin, unusual chest pain Disability red flags - Answers Unresponsive (APVU=U), sudden severe headache, one-sided weakness, seizure activity, fixed/dilated pupils, blood glucose less than 40 or more than 500 mg/dl Exposure red flags - Answers Temp greater than 95F or more than 104F, petechial rash, major trauma/burns, anaphylactic signs Airway focused assessment - Answers -Full sentences? -Visible obstructions? -Abnormal sounds? -Drooling or facial/throat swelling? Airway immediate interventions - Answers -Positon patient -Suction visible secretions -If choking and conscious, encourage coughing and prepare for thrusts -Call rapid response if airway cannot be maintained Breathing focused assessment - Answers -Rate -Rhythm (Reg or irregular) -Depth (Shallow, normal, deep) -Effort (Accessory muscle use, contractions, nasal flaring) -SpO2 (Normal is greater than 94% or 88% if chronic COPD) -Color (Central cyanosis indicates severe hypoxia) Breathing immediate interventions - Answers -Sit patient upright -Apply 02 -Stay with patient and reassess frequently -Call if distressed or worsening Circulation focused assessment - Answers -Pulse rate -Quality (Strong, weak, thready, pulsing) -Blood pressure -Skin: color, temperature, moisture -Cap refill time (Should be less than 3 seconds) -Bleeding (active hemorrhage?) Circulation immediate intervention - Answers -If no pulse, code blue and begin CPR -Active bleeding: Apply pressure -Hypotensive: Lay patient flat (legs elevated if no breathing problems) call for help -Prep for IV and fluids Disability focused assessment - Answers -APVU -Pupils (equality, size, reactivity to light) -Blood glucose: Check if altered mental status (70-100 mg/dl) -Motor function (Move all extremities and equal strength) AVPU - Answers Alert, Verbal, Pain, Unresponsive AVPU alert - Answers Awake, eyes open spontaneously, interacts appropriately APVU verbal - Answers Eyes open or responds only when spoken to; may be confused AVPU pain - Answers Responds only to painful stimuli (sternal rub, nail bed pressure) AVPU Unresponsive - Answers No response to verbal or painful stimuli= Emergency! Disability immediate interventions - Answers -If AVPU= P or U, call for help, ensure airway is protected -If blood glucose less than 70 mg/dl, give oral tablets or IV dextrose -If stroke suspected, note onset and call stroke alert -If seizure, protect from injury, place on side, time (don't restrain) Safest first actions order - Answers ABCDE Independent nursing safest first actions - Answers -Position -Apply 02 via protocol -Apply direct pressure to bleeding -Check blood glucose for altered mental status -Stay with patient and reassess continuously -Call for help When to escalate (safest first actions) - Answers -Airway obstruction you cannot clear -RR is less than 8 or greater than 30 -SpO2 not improving with O2 -No pulse or severe hemodynamic instability -Unresponsive (APVU=U) -Anytime you feel the patient deteriorating Symptom analysis guide - Answers 1) Chief complaint 2) OPQRST framework 3) detailed assessment questions Chief complaint - Answers the main reason for the patient's visit (In their own words) -Use quotes, keep it brief, avoid med terms, do not interpret OPQRST - Answers Onset, Provocation, Quality, Region/Radiation, Severity, Timing. OPQRST: onset - Answers What were you doing when the pain began? OPQRST: provocation/palliation - Answers Does anything make the symptoms better or worse? How are you most comfortable? OPQRST: quality - Answers Can you describe the pain? OPQRST: region/radiation - Answers Where do you feel the symptom? Does it move anywhere? OPQRST: Severity - Answers pain scale 1-10 OPQRST: timing - Answers Constant or intermittent Pain assessment red flags - Answers -Abdominal pain w/ rigid abdomen/rebound tenderness -Chest pain w/ shortness of breath, diaphoresis, nausea -Sudden severe headache -Pain 10/10 -Pain with signs or poor perfusion -Sudden onset of weakness, numbness, speech change General survey guide steps - Answers 1) Brief assessment 2) WDL 3) Red flags for immediate escalation 4) Orientation assessment 5) Nursing diagnosis What is a general survey? - Answers The first impression of the patient Brief assessment categories - Answers -Appearance -Affect/behavior -Alertness/cognition -Acuity/distress Appearance (Brief assessment) - Answers -Stated vs apparent age -Skin color -Body build and nutritional status