NCLEX-RN Fundamental Assessment & Documentation Flashcards

Select the correct normal adult ranges for the following vital signs:

Which finding is considered the most reliable indicator of a patient's pain level?

A Glasgow Coma Scale (GCS) score of 8 or less generally requires which priority intervention?

During a neurological assessment, what does a unilateral fixed and dilated pupil most likely indicate?

The '5 P's' (Pain, Pallor, Pulselessness, Paresthesia, Paralysis) are the hallmark assessment for which orthopedic emergency?

What is the maximum normal time for capillary refill in an adult?

Match the pitting edema grade to the depth of indentation:

Which adventitious breath sound is a high-pitched inspiratory sound indicating upper airway obstruction and requires immediate intervention?

Why must the abdomen be auscultated before percussion and palpation?

What is the minimum hourly urine output for an adult that indicates adequate renal perfusion?

A sudden weight gain of 1 kg (2.2 lbs) indicates the retention of how much fluid?

Which nursing entry represents correct objective documentation?