Nursing fundamentals and clinical assessment
This domain tests systematic assessment: can you gather data in a structured order, recognise deterioration early, and act on trends rather than isolated numbers? It underpins every other domain because every scenario starts with an assessment.
Vital signs and early warning
- Respiratory rate is the earliest and most sensitive indicator of deterioration and the most frequently invented value. Count for a full minute.
- Track trends and early-warning scores rather than single readings. A NEWS2-type score rising across three observations matters more than one abnormal value.
- Measure blood pressure correctly: right cuff size, arm supported at heart level, and lying and standing values in anyone at risk of orthostatic hypotension.
Structured assessment
- ABCDE for the deteriorating patient, then a focused or head-to-toe examination. Reassess after every intervention.
- Pain: self-report is the gold standard; use a numeric or faces scale, and an observational tool such as PAINAD in advanced dementia.
- Risk screening on admission and when condition changes: Braden (pressure injury), Morse or STRATIFY (falls), MUST or NRS-2002 (nutrition), plus moving-and-handling and VTE risk.
- Fluid balance: record intake and output, weigh daily where fluid status matters, and expect urine output of at least 0.5 mL/kg/h.
Worked example
A 78-year-old on furosemide has BP 92/48 mmHg, HR 104/min, Na 129 mmol/L and reports dizziness on standing. Reasoning: the combination suggests volume depletion with orthostatic intolerance. The nurse repeats the blood pressure standing, reviews the fluid balance chart and weight, checks for postural drop greater than 20 mmHg systolic, withholds the diuretic under protocol, checks electrolytes and escalates. Tachycardia here is compensatory, not anxiety.
Traps that cost marks
Documenting a single blood pressure; estimating respiratory rate; recording a pain score without reassessing after analgesia; attributing hypotension in an older adult to age alone.
Key habit
Assess, intervene, reassess, and document the change.