Question: Prep

Answer: -Curtains

-Hand hygiene

-Wristband ID

-Raise bed

-Lower bed rails

Question: Communication

Answer: -General

-Breathing

-Cough

-Fatigue

-Pain

Question: Anterior chest

Answer: -Inspect: respiratory status (unexpected)

-Auscultate: heart sounds (unexpected), apical pulse (unexpected, also it’s the last dot on the left side of patient’s body and listen for full minute), breath sounds (unexpected)

Question: Posterior chest

Answer: -Auscultate: breath sounds (unexpected)

Question: Upper extremities

Answer: -Inspect: oxygen saturation levels (unexpected due to pulse), capillary refill (unexpected)

-Palpate: temperature (unexpected), radial pulse (expected)

Question: Lower extremities

Answer: -Inspect: skin (expected), edema (unexpected), capillary refill (unexpected), symmetry (expected)

-Palpate: edema (unexpected), temperature (unexpected), dorsalis pedis pulse (unexpected)

-Auscultate: dorsalis pedis pulse (unexpected)

Question: Wrap-up

Answer: -Intervention: client teaching

-Raise bed rails

-Lower bed

-Hand hygiene

-Curtains