Priority Patient Activity & Nursing Assessment
2026
, Part II: Initial Assessment/Interprofessional Communication
Herbie Saunders, 62 years old David Mueller, 71 years old Gladys Parker, 92 years old
CHF Exacerbation Below-the-Knee Amputation Weakness and Falls
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
✓ Management of Care 17-23% □
✓ Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12% □
Psychosocial Integrity 6-12%
Physiological Integrity
✓ Basic Care and Comfort 6-12%
✓ Pharmacological and Parenteral Therapies 12-18%
✓ Reduction of Risk Potential 9-15% □
✓ Physiological Adaptation 11-17% □
, It is now 7:45 am. You have received reports for each of your three patients
on the med-surg unit of Anytown General Hospital, reviewed their charts,
and are ready to begin your day.
You have elected to assess them in the following order based on the
information you were given from the overnight nurses:
1) Herbie Saunders
2) Gladys Parker
3) David Mueller
Initial Assessment Initial Assessment
Patient #1: Herbie Saunders
Vital Signs @ 0715 What Do You Notice? Clinical Significance:
Increased heart rate of 110 Patient’s heart is having to pump
T: 98.4 F (oral)
faster in order to adequately
P: 110 oxygenate the body’s tissues.
R: 24 Increased respiration rate of 24 Patient’s respiration rate is faster
due to pulmonary edema
BP: 132/78 (MAP 96 mmHg) secondary to CHF exacerbation.
O2 sat: 91% on room air Patient is compensating for
insufficient gas exchange in the
Pain: denies alveoli.
Daily Weight: 198.4 lb (90.2 kg) Oxygen saturations at 91% on RA Patient’s oxygen saturation is on
the low side of normal, but is
Fingerstick: 147 above 90% which is baseline for
him.
Increase in weight by 1 kg Patient may be retaining fluid due
compared to admission weight to CHF exacerbation.
Focused Patient Assessment: What Do You Notice? Clinical Significance:
Patient’s breathing is labored and SOB is indicative of poor gas
As you enter the room, Mr. Saunders is sitting in
experiencing shortness of breath exchange, hypoxia, and
the recliner breathing heavily. He states, with some
hypercapnia.
difficulty, “I can’t….believe…..how winded….I
Tachypnea of 28 respirations/min Increased respiration rate indicates
am right now. I just….had….to go….to the
poor gas exchange and
bathroom.” Respirations are 28 and his continuous
oxygenation of the body’s tissues
oxygen monitor reads 87%. He is on room air.
Oxygen saturations dropped to Low oxygen saturation indicates
87% on RA. possibly worsening pulmonary
edema, which can cause poor lung
compliance and poor gas
exchange.
Before you continue with your assessment, what nursing interventions need to be implemented right away?
Administer supplemental oxygen to keep oxygen saturations above 90%. Assist with relaxation techniques to
slow the respiration rate.
2026
, Part II: Initial Assessment/Interprofessional Communication
Herbie Saunders, 62 years old David Mueller, 71 years old Gladys Parker, 92 years old
CHF Exacerbation Below-the-Knee Amputation Weakness and Falls
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
✓ Management of Care 17-23% □
✓ Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12% □
Psychosocial Integrity 6-12%
Physiological Integrity
✓ Basic Care and Comfort 6-12%
✓ Pharmacological and Parenteral Therapies 12-18%
✓ Reduction of Risk Potential 9-15% □
✓ Physiological Adaptation 11-17% □
, It is now 7:45 am. You have received reports for each of your three patients
on the med-surg unit of Anytown General Hospital, reviewed their charts,
and are ready to begin your day.
You have elected to assess them in the following order based on the
information you were given from the overnight nurses:
1) Herbie Saunders
2) Gladys Parker
3) David Mueller
Initial Assessment Initial Assessment
Patient #1: Herbie Saunders
Vital Signs @ 0715 What Do You Notice? Clinical Significance:
Increased heart rate of 110 Patient’s heart is having to pump
T: 98.4 F (oral)
faster in order to adequately
P: 110 oxygenate the body’s tissues.
R: 24 Increased respiration rate of 24 Patient’s respiration rate is faster
due to pulmonary edema
BP: 132/78 (MAP 96 mmHg) secondary to CHF exacerbation.
O2 sat: 91% on room air Patient is compensating for
insufficient gas exchange in the
Pain: denies alveoli.
Daily Weight: 198.4 lb (90.2 kg) Oxygen saturations at 91% on RA Patient’s oxygen saturation is on
the low side of normal, but is
Fingerstick: 147 above 90% which is baseline for
him.
Increase in weight by 1 kg Patient may be retaining fluid due
compared to admission weight to CHF exacerbation.
Focused Patient Assessment: What Do You Notice? Clinical Significance:
Patient’s breathing is labored and SOB is indicative of poor gas
As you enter the room, Mr. Saunders is sitting in
experiencing shortness of breath exchange, hypoxia, and
the recliner breathing heavily. He states, with some
hypercapnia.
difficulty, “I can’t….believe…..how winded….I
Tachypnea of 28 respirations/min Increased respiration rate indicates
am right now. I just….had….to go….to the
poor gas exchange and
bathroom.” Respirations are 28 and his continuous
oxygenation of the body’s tissues
oxygen monitor reads 87%. He is on room air.
Oxygen saturations dropped to Low oxygen saturation indicates
87% on RA. possibly worsening pulmonary
edema, which can cause poor lung
compliance and poor gas
exchange.
Before you continue with your assessment, what nursing interventions need to be implemented right away?
Administer supplemental oxygen to keep oxygen saturations above 90%. Assist with relaxation techniques to
slow the respiration rate.
