025/2026 JANE
2
Assessment-Healthstream EXAM WIRH
Q&A CORRECT ANSWERS
HF Hallmark Signs - CORRECT ANSWER--SOB, orthopnea, productive cough (pink
C
frothy sputum)
-JVD, crackles, oedema, weight gain
-anxiety, restlessness, oliguria,
-Tachycardia, Tachypnea, HTN,
-Nagging cough, increased Abd girth, ascites
HF interventions - CORRECT ANSWER-Focused cardiopulmonary assessment
C
1)Check VS ( HR, RR, BP, SpO2)
2) Supplemental O2 if needed
3) Elevate HOB 45-90 degrees
4) Elevated legs to promote venous return
5) IV access
Strict Is and Os (monitor UOP)
-Daily weight
all MD and anticipate orders for:
C
CXR, diuretics, echo to evaluate EF (<50%) , labs for Bmp, and Cardiac enzymes.
ICP Hallmark signs - CORRECT ANSWER--Neuro changes: dec LOC, headaches,
confusion, vision changes, seizures, changes in behaviour
-Cushing's triad: irregular breathing (describe), bradycardia, widened pulse pressure
(systolic- diastolic)
-Vomiting (could be projectile)
-Babinski reflex,
ICP interventions - CORRECT ANSWER--Secure airway
-Perform a focused neuro assessment along with cardiopulmonary; VS (HR, RR, Spo2,
BP and temp) and a GSC
-HOB 30-45 degrees
-Maintain adequate oxygenation/elevation (supplemental O2)
-Temperature should be kept within certain limits.
, - Contact MD and anticipate orders for CT scan or MRI, CSF drainage if needed,
osmotic diuretics, and medications for blood pressure control.
KA Hallmark Signs - CORRECT ANSWER--Polydipsia (excessive thirst), Polyuria
D
(excessive urination), Polyphagia (appetite)
- Metabolic acidosis, fast/deep breathing (kussmals),
-Acetone breath, ketones
-Hyperglycemia (>300mg/dl)
-Anion gap >12
-Decreased CO2
KA interventions - CORRECT ANSWER-1) Focus assessment; neuro status, LOC
D
2) Reassess VS including BG.
-Establish IV access
3) Contact MD and anticipate orders for:
-first; Fluid resuscitation (NS/LR), administration of insulin and K+, labs such as
chemistry panel, BMP (K+, BUN, and creatine, VBG?), cardiac monitoring
I Hallmarks - CORRECT ANSWER--Crushing chest pain, pain radiating from the left
M
jaw, should and/or arm
-Heartburn/ indigestion, n/v (women)
-SOB, diaphoresis, pale cool skin, anxiety
-ST elevation, High troponin (cardiac enzymes), high RR, high BP, and low O2
I interventions - CORRECT ANSWER--Perform a focused assessment;
M
cardiopulmonary.
-Recheck VS (HR, RR, BP, O2,)
- 12 Lead EKG
-Establish IV access
-Follow ONAM (Oxygen, nitroglycerin, aspirin, morphine)
-Contact MD and anticipate orders for labs; cardiac enzymes (CPK-MB) and troponin
levels, an ECHO to check EF, CXR, check CBC.
epsis hallmark signs - CORRECT ANSWER-Identified as 2 + of the following criteria
S
PLUS a suspected infection: -Temperature <36.0C or >38.3 C
-HR >90
-Respiration >20
-WBC <4,000 or >12,000 or BANDS >10%
Blood sugar >140 in nondiabetic
2
Assessment-Healthstream EXAM WIRH
Q&A CORRECT ANSWERS
HF Hallmark Signs - CORRECT ANSWER--SOB, orthopnea, productive cough (pink
C
frothy sputum)
-JVD, crackles, oedema, weight gain
-anxiety, restlessness, oliguria,
-Tachycardia, Tachypnea, HTN,
-Nagging cough, increased Abd girth, ascites
HF interventions - CORRECT ANSWER-Focused cardiopulmonary assessment
C
1)Check VS ( HR, RR, BP, SpO2)
2) Supplemental O2 if needed
3) Elevate HOB 45-90 degrees
4) Elevated legs to promote venous return
5) IV access
Strict Is and Os (monitor UOP)
-Daily weight
all MD and anticipate orders for:
C
CXR, diuretics, echo to evaluate EF (<50%) , labs for Bmp, and Cardiac enzymes.
ICP Hallmark signs - CORRECT ANSWER--Neuro changes: dec LOC, headaches,
confusion, vision changes, seizures, changes in behaviour
-Cushing's triad: irregular breathing (describe), bradycardia, widened pulse pressure
(systolic- diastolic)
-Vomiting (could be projectile)
-Babinski reflex,
ICP interventions - CORRECT ANSWER--Secure airway
-Perform a focused neuro assessment along with cardiopulmonary; VS (HR, RR, Spo2,
BP and temp) and a GSC
-HOB 30-45 degrees
-Maintain adequate oxygenation/elevation (supplemental O2)
-Temperature should be kept within certain limits.
, - Contact MD and anticipate orders for CT scan or MRI, CSF drainage if needed,
osmotic diuretics, and medications for blood pressure control.
KA Hallmark Signs - CORRECT ANSWER--Polydipsia (excessive thirst), Polyuria
D
(excessive urination), Polyphagia (appetite)
- Metabolic acidosis, fast/deep breathing (kussmals),
-Acetone breath, ketones
-Hyperglycemia (>300mg/dl)
-Anion gap >12
-Decreased CO2
KA interventions - CORRECT ANSWER-1) Focus assessment; neuro status, LOC
D
2) Reassess VS including BG.
-Establish IV access
3) Contact MD and anticipate orders for:
-first; Fluid resuscitation (NS/LR), administration of insulin and K+, labs such as
chemistry panel, BMP (K+, BUN, and creatine, VBG?), cardiac monitoring
I Hallmarks - CORRECT ANSWER--Crushing chest pain, pain radiating from the left
M
jaw, should and/or arm
-Heartburn/ indigestion, n/v (women)
-SOB, diaphoresis, pale cool skin, anxiety
-ST elevation, High troponin (cardiac enzymes), high RR, high BP, and low O2
I interventions - CORRECT ANSWER--Perform a focused assessment;
M
cardiopulmonary.
-Recheck VS (HR, RR, BP, O2,)
- 12 Lead EKG
-Establish IV access
-Follow ONAM (Oxygen, nitroglycerin, aspirin, morphine)
-Contact MD and anticipate orders for labs; cardiac enzymes (CPK-MB) and troponin
levels, an ECHO to check EF, CXR, check CBC.
epsis hallmark signs - CORRECT ANSWER-Identified as 2 + of the following criteria
S
PLUS a suspected infection: -Temperature <36.0C or >38.3 C
-HR >90
-Respiration >20
-WBC <4,000 or >12,000 or BANDS >10%
Blood sugar >140 in nondiabetic
