Health Assistant (Nursing) Complete Review Guide 2026–2027

4. Normal blood pressure is below 120/80 mmHg. Elevated: 120–129 with diastolic below 80. Stage 1: 130–139 or 80–89. Stage 2: 140/90 or higher (AHA 2017).
5. Normal SpO2 is 95–100%. Nail polish and cold fingers can give a falsely low reading, so remove the polish or warm the hand before measuring.
6. BMI = weight (kg) ÷ height (m) squared. 18.5–24.9 is normal, 25–29.9 overweight, 30 or more obese. Weigh the patient at the same time, on the same scale, in light clothing.
7. When making a bed: hold linen away from your uniform, never shake it, pull it wrinkle-free, and put soiled linen in a designated bag. Leave the bed at its lowest level with the call light within reach.
8. Bathing order: face first (water only around the eyes), then arms, chest, abdomen, legs, back, and the perineum last. Expose only one body part at a time.
9. An unconscious patient is placed on their side for mouth care to avoid aspiration. Dentures are cleaned with cool water and stored in a labeled container with water.
10. Positions: Fowler 45–60°, semi-Fowler 30–45°, high Fowler 60–90°. Sims is left side-lying, Trendelenburg has the head lower than the body.
11. A bedridden patient is turned at least every 2 hours. The head of the bed stays at 30° or lower unless the patient is eating, to reduce sliding and friction, and the patient is lifted, not dragged, when moved.
12. Braden scale: the lower the score, the higher the pressure injury risk, and 18 or below means at risk. Stage 1 is intact skin with redness that does not blanch. Check the sacrum, heels, hips and elbows.
13. For transfers use a gait belt and good body mechanics: feet apart, knees bent, load close to the body, lifting with the legs and not the back. Lock the bed and wheelchair wheels before the transfer.
14. Units: 1 oz = 30 mL, 1 cup = 240 mL, 1 tsp = 5 mL, 1 tbsp = 15 mL. Normal urine output is at least 30 mL/hour. A catheter bag stays below bladder level and never touches the floor.
15. The patient sits upright while eating and for about 30 minutes afterward. A patient with swallowing difficulty needs food textures as directed by the responsible nurse. NPO means no food or drink by mouth.
16. The five rights of medication: right patient, drug, dose, route and time, plus documentation. Check allergies, and stay until the patient swallows an oral dose. Any medication error is reported at once.
17. Wound infection signs: redness, warmth, swelling, increasing pain, pus or foul odor, and fever. Clean from the cleanest area to the most contaminated, and change wet or soiled dressings as instructed.
18. After surgery: encourage deep breathing and coughing with the incision supported by a pillow, early movement, and watch vital signs, pain, bleeding and drainage. With children: raise crib sides, place infants to sleep on their back, and never leave them on a raised surface.

Common mistakes in this chapter

• ✕ Axillary temperature is about 0.5 °C below oral, and rectal or tympanic is about 0.5 °C above. Do not compare readings from different sites without adjusting.
• ✕ The 6-second × 10 shortcut works only for a regular pulse. An irregular pulse is counted for a full minute, and an apical pulse is always counted for a full minute.
• ✕ A cuff that is too small gives a falsely high reading and one that is too large gives a falsely low reading. Never measure on an arm with an IV, a dialysis fistula, or on the mastectomy side.
• ✕ Clean the eye from the inner corner outward with a clean part of the cloth for each stroke, and clean the perineum front to back. The reverse spreads germs.
• ✕ Do not mix up the positions: Fowler is sitting at 45–60 degrees, Sims is lying on the left side for enemas and rectal examination, and semi-Fowler is 30–45 degrees.
• ✕ Never massage reddened bony prominences, since it increases damage. Redness that does not blanch under light pressure is stage 1 pressure injury and is reported.
• ✕ In intake counts, soup, ice cream and gelatin count as fluid, and ice counts as about half its volume. Output includes urine, vomit, liquid stool and wound drainage.
• ✕ Never leave medication at the bedside, give it from an unlabeled container, or identify the patient by bed number. Use the name plus date of birth or file number.